More than half of young people with past-month nicotine vaping reported purchasing vaping products at a retail location, including vape/smoke/head shops that are restricted to adults in some cities. To our knowledge, this study was the first to examine associations between city-level tobacco retail policy and individual young people’s e-cigarette risk perceptions. We proposed that risk perceptions are a plausible means by which tobacco retail policy could decrease underage e-cigarette use. Adolescents’ e-cigarette risk perceptions are sensitive to societal changes, such as the 2019 outbreak of e-cigarette and vaping-associated lung injury , and higher risk perceptions are associated with lower likelihood of ecigarette use . If flavored products were not widely available for purchase, use of such products may seem less normative and less acceptable, thereby increasing support for flavored tobacco policy and decreasing susceptibility to use among non-users. However, this study did not find support for a link between e-cigarette flavor policy and young people’s thoughts about e-cigarettes.Current events may have increased young people’s risk perceptions across cities. Data were collected after the 2019 EVALI outbreak and during the COVID-19 pandemic. Prior to COVID-19, a prospective cohort survey of Philadelphia high school students found that youth with past-month nicotine vaping prior to the EVALI outbreak had a greater increase in risk perceptions during the outbreak than youth who had not vaped . Findings suggest that personal relevance of EVALI may have influenced young people’s response to new information about the risks of vaping. Moreover, a May 2020 U.S. survey of young people found that 25% of participants who decreased or quit their nicotine vaping cited concerns about lung health as a reason for decreasing vaping . Results of the present study should be interpreted in the context of the unique time period in which data were collected,grow cannabis in containers during which the importance of respiratory health was highly salient to young people. Lack of associations between e-cigarette flavor policy and e-cigarette risk perceptions, policy attitudes, and past-month vaping do not indicate that e-cigarette retail policy is ineffective.
New evidence from Massachusetts showed that local flavored tobacco sales restrictions were associated with reduced likelihood of vaping among youth . Policy must be consistently and effectively enforced in order to prevent underage access to products. A 2016- 2018 investigation of the FDA compliance inspection database found widespread sales of vaping products to minors, especially flavored products and especially in urban areas . Policy may not impact young people’s risk perceptions if it is not consistently enforced. Young people may evade restrictions by purchasing products online or outside their city of residence, and retailers may sell flavorings and nicotine separately. In this study, data were collected during the COVID-19 pandemic, when tobacco control resources were redirected to manage the pandemic. Additionally, e-cigarette flavor policy may impact young people through mechanisms other than risk perceptions. Simply decreasing access may discourage youth use, without strong effects on perceptions of e-cigarettes. Importantly, all participants were under age 21, the legal age to purchase vaping products nationally. Federal policy may have had a stronger effect on vaping-related perceptions and behavior than local flavor policy, though the current study cannot address questions of the relative strength of federal and local policies. Characteristics of young people who vaped nicotine in the past month were largely consistent with the extant literature. Consistent with a systematic review of the demographic characteristics of youth who vape, past-month nicotine vapers in this study were older and were more likely to be non-Hispanic white than Black, with no clear pattern regarding socioeconomic status . Contrary to the systematic review, males were not more likely to vape nicotine . A recent study found greater prevalence of ever vaping among sexual minority youth, but consistent with the present study, past-month vaping was not associated with sexual identity . Current vaping was associated with greater likelihood of exposure to e-cigarette ads in convenience stores, supermarkets, and gas stations. Consistent with this finding, a systematic review concluded that exposure to e-cigarette marketing is associated with e-cigarette use among young people . Also consistent with prior research , young people with current vaping reported greater use of e-cigarettes and approval of e-cigarettes in their social environments. As expected, participants with current nicotine vaping had lower harm perceptions and believed less strongly in the effectiveness of flavored tobacco policy, although they did not differ in perceived ease of accessing vaping products. Notably, half of participants with past-month nicotine vaping reported purchasing flavored products from a vape, smoke, or head shops, despite being under the legal vaping age. This finding is consistent with the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey. Vape shops were the most common purchase location of vaping products among underage users in the U.S, with more than half of underage, past-year users reporting purchasing vaping products from a vape shop in the past year .
Taken together, findings suggest that U.S. youth are able to access vaping products at specialty shops. In this study, a sizable proportion of youth with past-month vaping reported purchasing vaping products from a store that was not a vape, smoke, or head shop. Adolescents who regularly visit convenience stores regularly or stop at retail stores before or after school are more likely to use e-cigarettes, potentially due to point-of-sale marketing exposure . Convenience stores greatly outnumber vape shops in metropolitan areas and both may expose youth to vaping ads and purchase opportunities. In this study, youth in cities both with and without a sales restrictions on flavored e-cigarettes reported purchasing vaping products from retail sources. Those who purchased vaping products from a store were more likely to use fruit- and menthol-flavored vaping products than those who did not purchase their products in the retail environment, suggesting that fruit- and menthol-flavored products were appealing and available in stores. Compared to the 2020 National Youth Tobacco Survey, fewer participants with past-month vaping in this study received their vaping products from a friend , and more participants purchased vaping products from vape shops and online . Discrepancies may be due to all participants in this study residing in urban areas, as well as slight differences in item wording and differences in age group . This study over sampled e-cigarette users in order to examine interactions between ecigarette use and policy. Therefore, this study could not examine differences in lifetime ecigarette use prevalence by policy. Future research could examine lifetime e-cigarette use prevalence in addition to risk perceptions and policy attitudes. Other data sources, such as the FDA compliance inspection database , are needed to fully understand underage purchasing of vaping products.
This study did not assess participants’ awareness of e-cigarette flavor policy in their city. Future research could examine whether policy differentially affects young people who are aware versus unaware of the policy. Although the sample was diverse in geographic location, gender, and race/ethnicity, it is not representative of adolescents in the urban United States. This study focused on e-cigarette use because of its popularity among young people. Future research could examine e-cigarette risk perceptions in association with use of other tobacco products . Studies of how neurobiological systems are linked to the transdiagnostic endophenotypic and phenotypic expression of psychopathology are particularly relevant to trauma-related psychopathology, as three of the most common trauma-related disorders—post traumatic stress disorder , major depressive disorder , and generalized anxiety disorder —are highly comorbid and share common transdiagnostic dimensions of threat and loss symptomatology . Trauma-related threat symptomatology includes intrusive thoughts and memories, and hyperarousal symptoms such as sleep disturbance and hypervigilance, whereas trauma-related loss symptomatology includes emotional numbing and depressive/dysphoric and generalized anxiety symptoms. Elucidation of neurobiological systems implicated in trauma-related endophenotypes can inform etiologic models of trauma related psychopathology,pot for cannabis as well as the development of more targeted, mechanism-based prevention and treatment strategies. Attentional bias to threat is one of the core endophenotypic characteristics of trauma-related psychopathology . Attentional biases to threatening information, such as faces and words, which are often assessed using a dot-probe paradigm, have been found to contribute to and maintain the persistence of trauma-related threat symptomatology, even months to years after trauma exposure . Greater attentional bias to threat is also associated with exaggerated fear expression and impaired extinction in individuals with PTSD .Hyperarousal symptoms, such as exaggerated startle response during fear learning, in particular, have been found to contribute to attentional bias to threat in symptomatic trauma survivors . Recent functional neuroimaging work has implicated increased amygdala activation in relation to attentional bias to threat among individuals with PTSD , suggesting that the amygdala modulates the orientation of attention toward and processing of threatening information in this population. Although cannabinoid type 1 receptors are widely distributed in the human brain , they are found in particularly high concentrations in the amygdala, and have been associated with the processing and storage of threat-related memories, as well as the coordination of threat-related behaviors . Recently, we reported in vivo evidence of abnormal CB1 receptor-mediated endocannabinoid signaling in individuals with PTSD and suggested that increased CB1 receptor availability may be a molecular adaptation to reduced endocannabinoid availability. In addition to this work, a large body of preclinical studies has found strong support for a major role of the endocannabinoid anandamide and CB1 receptor signaling in the amygdala in modulating stress-induced threat behaviors . Understanding how key neuroreceptor systems such as CB1 relate to intermediate endophenotypic and phenotypic expression of trauma-related psychopathology may thus provide insight into molecular targets that could inform the development of mechanism-based treatment approaches.
To date, however, human data evaluating this possibility are lacking. In the current study, we aimed to address this gap in the literature by using the CB1 receptor antagonist radiotracer [11C]OMAR, which measures volume of distribution linearly related to CB1 receptor availability, to evaluate the relationship between CB1 receptor availability in the amygdala, and objectively assessed attentional bias to threat, and the transdiagnostic and dimensional expression of trauma-related threat and loss symptomatology. To obtain a sample that encompassed the full-dimensional range of study measures , we employed an inclusive sampling approach by recruiting a sample of individuals who represented a broad transdiagnostic and dimensional spectrum of trauma-related psychopathology, ranging from healthy, nontrauma-exposed individuals to trauma-exposed individuals with severe trauma-related psychopathology. On the basis of prior work linking CB1 receptor availability in the amygdala to threat processing and threat symptomatology to attentional bias to threat , we hypothesized that greater CB1 receptor availability in the amygdala would be associated with greater attentional bias to threat, as well as increased severity of threat symptomatology, particularly hyperarousal. We then evaluated a mediational model to examine whether attentional bias to threat mediated the relationship between CB1 receptor availability in the amygdala and trauma-related psychopathology.Lifetime traumatic events were assessed using the Traumatic Life Events Questionnaire and psychiatric diagnoses were established using DSM-IV-TR criteria and the Structured Clinical Interview for DSM-IV that was administered by an experienced master- or doctorallevel psychiatric clinician. Only traumatic events that met criteria A1 and A2 for a DSM-IV-TR-based diagnosis of PTSD were counted toward participants’ trauma histories in this study. Nontrauma-exposed healthy adults did not report any trauma exposures on the TLEQ and did not have any lifetime psychiatric diagnosis, including substance abuse or dependence or nicotine dependence. Severity of trauma-related threat and loss symptomatology was assessed using the Clinician-Administered PTSD Scale for DSM-IV ; the Hamilton Rating Scale for Depression to assess depressive symptoms; and the Hamilton Rating Scale for Anxiety to assess nonspecific anxiety symptoms. Scores on these structured clinician-administered measures of trauma-related psychopathology represented a transdiagnostic and dimensional spectrum of trauma-related psychopathology, ranging from nontrauma-exposed asymptomatic adults to traumaexposed adults with severe trauma-related psychopathology . All participants were evaluated by physical examination, electrocardiogram, standard blood chemistry, hematology laboratory testing, toxicology testing, and urinalysis. All but two participants were psychotropic medication naive, and two took antidepressants for less than a week before the study but were medication free for at least 6 months before the study. Participants with significant medical or neurologic conditions, with substance abuse within 12 months of the scan, lifetime history of intravenous substance dependence, or with history of head injury that involved loss of consciousness were excluded from the study.