“Puffs per month” provide a more accurate picture of adolescents’ exposure to nicotine from e-cigarettes

BOSTON – Current measures that track youth e-cigarette use (or vaping) typically assess how many days in the past month individuals used e-cigarettes.

A recent study indicates that assessing the number of puffs of e-cigarettes taken per month provides a more accurate picture of adolescents’ exposure to nicotine.  The research, which was published in Nicotine and Tobacco Research and led by investigators at Massachusetts General Hospital (MGH), a founding memeber of the Mass General Brigham healthcare system, suggests that “puffs per month” can more accurately capture the nature of e-cigarette binging and the extent of youth tobacco addiction.

Tracking how many days in the past month an individual has used e-cigarettes does not represent the intensity of use, the researchers say.

Someone who uses five days a week could only be puffing once every day, while someone who uses once every week could be getting a hundred puffs on that one day.

“Their nicotine exposure could be vastly different and unexpected if only days of use are considered,” says senior author Jonathan P. Winickoff, MD, MPH, a pediatrician in the division of General Academic Pediatrics at Mass General for Children and a professor of pediatrics at Harvard Medical School.

To test the potential of puffs per month as an alternative measure, Winickoff and his colleagues analyzed 1,051 adolescents’ responses to the Population Assessment of Tobacco and Health (PATH) Youth survey from 2018–2019.

PATH is a collaboration between the National Institutes of Health, the National Institute on Drug Abuse, and the US Food and Drug Administration that collects data every year on why people use tobacco, quit using, and start using again, and how different tobacco products affect health.

The team compared intensity (puffs per month) among youth nicotine e-cigarette users with frequency (the number of days of use in the past month).

Number of puffs per month among adolescent e-cigarette users ranged from 1 to 300,000. Most users were considered low-frequency users, using e-cigarettes on one to nine days per month, but 14.9% of low-frequency users were using as much per month as daily users.

Compared with days of use in past month, puffs per month had a stronger association with different measures of nicotine addiction, including greater cravings, less of a desire to quit e-cigarettes, and fewer concerns about addiction to e-cigarettes.

“Our findings could help target interventions to the most vulnerable e-cigarette users who have the highest risk of addiction with the lowest perceived risk of addiction,” says co-author Abra M. Jeffers, PhD, a data analyst in the Health Policy Research Center at the Mongan Institute at MGH and the division of General Academic Pediatrics at MGH. “The puffs per month metric can also be helpful for highlighting youth who may be early in their use pattern, but not yet addicted and willing to quit.”

The metric may also have implications for regulatory approval policies and protective legislative approaches to e-cigarette products. “Some disposable e-cigarette products currently on the market have thousands of hits of nicotine and promote youth binging behaviors. A measure like puffs per month can better detect binging and better shine a regulatory spotlight on these dangerous products,” Winickoff explains.

The investigators plan to present ongoing data using this better measure of e-cigarette use to the US Food and Drug Administration, other regulatory bodies, and legislatures so that officials have a better understanding of the extent of the harms of e-cigarettes for youth.

Catherine Xie, of the University of Rochester, is the study’s first author.

This work was supported by the University of Rochester Research Innovation Grant.

About the Massachusetts General Hospital

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. MGH is a founding member of the Mass General Brigham healthcare system.