BackgroundAlthough e-cigarette excise taxes have great potential to prevent the initiation and escalation of e-cigarette use, little information is available on pricing activities of online vape shops, and how well taxation is implemented during web-based sales remains unclear.ObjectivesWe examine e-liquid pricing activities in popular online vape shops that sell nationwide in the USA and present how those stores charge excise taxes based on shipping addresses in states and local jurisdictions that have e-cigarette taxation in place.MethodsWe collect e-liquid sales prices from five online vape shops using web data extraction, standardise prices for e-liquid products, and present e-liquid price distribution in the whole sample and in each store, as well as variations of excise taxes across states/local jurisdictions and between stores. The price data were scraped from the store websites from February to May in 2021.ResultsWe collected data on 14 477 e-liquid products from five stores. The average price of e-liquids is $0.25/mL, and the median price is $0.20/mL in our sample. E-liquid products sold online are very affordable and the average prices are lower compared with price estimates using other sources (eg, self-reports, sales data). In addition, online stores charge state excise taxes inconsistently and fail to comply with county-level or city-level excise taxes.ConclusionE-liquid products sold online are priced low, and stricter enforcement of e-cigarette excise tax is needed in online purchasing channels.

BackgroundA growing number of states or jurisdictions in the USA have imposed excise taxes on electronic nicotine delivery systems (ENDS). However, there is no consensus on how best to tax ENDS.ObjectivesWe specifically compare the tax incidence or burden for ENDS and cigarettes and analyse how ENDS tax incidence is associated with the choices of tax bases and rates.MethodsWe calculate ENDS excise tax incidence as the percentage of retail prices for each state or jurisdiction. Next, we use ordinary least squares to evaluate how tax incidence is associated with the choices of tax bases (eg, a specific tax base vs a value or ad valorem tax base) and rates and how these associations are moderated by product types.ResultsENDS and cigarette tax incidence is similar at the state level. Nonetheless, when federal cigarette taxes are considered, the cigarette tax incidence is higher than the tax incidence on closed-system ENDS. The proportion of states that impose value taxes is higher for open systems (65.4%) than for closed systems (46.2%). A value tax base is associated with a 7 percentage point lower tax incidence compared with a specific tax base. Product type further moderates the association between tax base and incidence.ConclusionTax incidence can be used to measure the strength of ENDS tax policies and how they are compared with cigarette taxes. Policymakers who aim to prevent youth from using ENDS may consider a value tax base to raise the tax incidence of closed systems—the product type preferred by young people.

Introduction: Electronic cigarettes are the most popular tobacco product among U.S. youth, and over 80% of current youth users of e-cigarettes use flavored e-cigarettes, with fruit, mint/menthol, and candy/sweets being the most popular flavors. A number of new e-liquid flavors are currently emerging in the online e-cigarette market. Menthol and other flavored e-cigarettes could incentivize combustible tobacco smokers to transition to e-cigarette use. Methods: From February to May 2021, we scraped data of over 14,000 e-liquid products, including detailed descriptions of their flavors, from five national online vape shops. Building upon the existing e-liquid flavor wheel, we expanded the semantic databases (i.e., key terms) to identify flavors using WordNet—a major database for keyword matching and group discussion. Using the enriched databases, we classified 14,000+ e-liquid products into the following 11 main flavor categories: “fruit”, “dessert/candy/sweets”, “coffee/tea”, “alcohol”, “other beverages”, “tobacco”, “mint/menthol”, “nuts”, “spices/pepper”, “other flavors”, and “unspecified flavor”. Results: We find that the most prominent flavor sold in the five online vape shop in 2021 was fruit flavored products, followed by dessert/candy/other sweets. Online vendors often label a product with several flavor profiles, such as fruit and menthol. Conclusions: Given that online stores market products with multiple flavor profiles and most of their products contain fruit flavor, the FDA may have issued marketing denial orders to some of these products. It is important to further examine how online stores respond to the FDA flavor restrictions (e.g., compliance or non-compliance).

Given the increase in electronic cigarette use during the past decade, the objectives of this study are to obtain comprehensive product-level information from online vape shops, which are one of the most common outlets for e-cigarette users to purchase vaping products, especially e-liquid products, and to examine the appeal of various e-liquid product attributes to consumers. We used web scraping and estimation of generalized estimating equation (GEE) models to obtain and analyze data from five popular online vape shops that sell nationwide across the US. The outcome measures are e-liquid pricing for the following e-liquid product attributes: nicotine concentration (in mg/ml), nicotine form (nicotine-free, freebase, or salt), vegetable glycerin/propylene glycol (VG/PG) ratio, and a variety of flavors. We find that the pricing for freebase nicotine and nicotine salt products are 1% (p<0.001) lower and 12% higher (p<0.001), respectively, than that for products that do not contain nicotine. For nicotine salt-based e-liquid products specifically, the pricing for a 50/50 VG/PG ratio is 10% (p<0.001) higher than the pricing for a more common 70/30 VG/PG ratio, and the pricing for fruity flavors is 2% (p<0.05) higher than that for tobacco/unflavored products. Regulating the nicotine form in all e-liquid products and fruity flavor in nicotine salt-based products will have a great impact on the market and consumers. The preference for VG/PG ratio varies by product nicotine form. More evidence on typical user patterns of a certain nicotine form (i.e., freebase or salt nicotine) is needed to assess the public health consequences of these regulations.

Objectives To evaluate disparity in service quality between second- and third-tier hospitals and explore factors that affect patients' perception of service quality in China. Design Cross sectional study. Setting Twelve hospitals in China. Participants 5714 patients. Intervention None. Main Outcome Measure Total score of the SERVQUAL scale and each of its five dimensions. Results Patients from third-tier hospitals rated significantly higher scores overall and in all the five dimensions of the SERVQUAL scale. Those with lower education, urban residents and those who had higher degree of life satisfaction and attention paid to health perceived higher service quality. Inpatients perceived higher service quality compared with outpatients. Conclusion We found a significant gap in patient's perceived service quality between second- and third-tier hospitals in China. A variety of demographic and personality factors were found to significantly influence patient's perceived service quality.