{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T02:40:09Z","timestamp":1792636809055,"version":"4.5.0"},"reference-count":68,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001921","name":"Public Health Research programme","doi-asserted-by":"publisher","award":["NIHR130292"],"award-info":[{"award-number":["NIHR130292"]}],"id":[{"id":"10.13039\/501100001921","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:sec id=\"abs1-1\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Youth vaping prevalence varies across countries and may be related to differing regulations\/products. The emergence of cheap disposable vapes and high-concentration nicotine salts heightened concerns related to youth\u2019s ease of access, dependence and potential health risks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-2\">\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>We examined youth in England versus Canada and the United States and:<\/jats:p>\n                    <jats:list list-type=\"order\">\n                      <jats:list-item>\n                        <jats:p>how patterns of vaping\/smoking varied, given the countries\u2019 different regulatory frameworks<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>nicotine and potential toxicant exposure in youth who vape, smoke or do neither<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>in youth who use salt and free-base nicotine<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>respiratory symptom reporting.<\/jats:p>\n                      <\/jats:list-item>\n                    <\/jats:list>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-3\">\n                    <jats:title>Design, methods, setting and participants<\/jats:title>\n                    <jats:p>\n                      Objectives 1 and 4: Repeated cross-sectional surveys (International Tobacco Control Youth Tobacco and Vaping Surveys), England, Canada, United States, 2017\u201322,\n                      <jats:italic>N<\/jats:italic>\n                      \u2005=\u20051355\u201339,214, 16- to 19-year-olds, or 16- to 29-year-olds, depending on analysis.\n                    <\/jats:p>\n                    <jats:p>\n                      Objectives 2 and 3: International Tobacco Control Biomarker Sub-Study, England, Canada, United States, 2019\u201322, 16- to 19-year-olds,\n                      <jats:italic>N<\/jats:italic>\n                      \u2005=\u2005364 and England-only Biomarker Sub-Study, 2022\u20133, 16- to 19-year-olds,\n                      <jats:italic>N<\/jats:italic>\n                      \u2005=\u2005201. Past-week users and past 30-day non-users were tested.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-4\">\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>None, comparisons based on vaping\/smoking status.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-5\">\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>Objective 1: Vape flavours, nicotine concentration, product types, brands used.<\/jats:p>\n                    <jats:p>Objectives 2 and 3: Urinary biomarkers, normalised for creatinine; tobacco-specific nitrosamine NNK (NNAL); volatile organic compounds (VOCs): acrolein (3HPMA), acrylamide (2CaHEMA), acrylonitrile (2CyEMA), benzene (PhMA), toluene (BzMA), xylene (24MPhMA); nicotine: cotinine, trans-3\u2019-hydroxycotinine (3-HC), total nicotine equivalents.<\/jats:p>\n                    <jats:p>Objective 4: Self-reporting any of 5 past-week respiratory symptoms (e.g. cough and dyspnoea).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-6\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Objective 1: Usual flavours were unchanged after 2020 United States pod-based vape flavour restrictions. Youth used exempt brands\/products. Simultaneously, disposable vape use increased. In England, in 2022, 48% of 16- to 29-year-olds who vaped in past 30 days used Elf Bar brands, mainly for subjective responses (e.g. flavour\/taste), rather than quitting smoking. Nicotine concentrations varied cross-country.<\/jats:p>\n                    <jats:p>Objectives 1, 2 and 3: Compared to smoking tobacco (exclusive or alongside vaping), exclusive vaping was associated with: similar nicotine exposure (those using nicotine salts had higher levels of nicotine metabolites vs. free-base\/unknown); lower exposure to NNK, acrolein, acrylamide and acrylonitrile, but higher toluene exposure (than dual use). Compared with not vaping\/smoking, exclusive vaping was associated with similar exposure to acrolein and acrylonitrile and higher exposure to toluene and acrylamide (past 24-hour sensitivity analysis). Benzene and xylene biomarkers were detected in &lt;\u20055% of urine samples. Some country-level biomarker differences were observed.<\/jats:p>\n                    <jats:p>Objective 4: Vaping was associated with higher respiratory symptom reporting than not vaping\/smoking. Youth who smoked and vaped had higher odds of symptoms than those only vaping. Using fruit, multiple or \u2018other\u2019 flavours was associated with higher odds of symptoms than tobacco flavours. Nicotine salt use was frequently unknown but may be associated with symptoms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-7\">\n                    <jats:title>Limitations<\/jats:title>\n                    <jats:p>Recall, misunderstandings and misreporting are possible. A subset of biomarkers was included, not all potential confounders were assessed and categorisation into vaping\/smoking groups based on past-week behaviour does not fully account for past smoking exposure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-8\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Pod flavour restrictions were ineffective. Youth were increasingly using disposable vapes containing nicotine salts. Those who vape were exposed to lower levels of toxicants than those who smoke, but a few toxicants were higher compared to youth who did not vape\/smoke. Self-reported past-week respiratory symptoms were also higher in those who vaped than those not vaping\/smoking and were related to flavours.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-9\">\n                    <jats:title>Future work<\/jats:title>\n                    <jats:p>The rapidly evolving nicotine vape market needs ongoing survey\/biomarker research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-10\">\n                    <jats:title>Funding<\/jats:title>\n                    <jats:p>This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR130292.<\/jats:p>\n                  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