The National Heart, Lung, and Blood Institute (NHLBI), in partnership with the National Institutes of Health (NIH) Office of Disease Prevention (ODP), National Cancer Institute (NCI), Office of Behavioral and Social Sciences Research (OBSSR), National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Mental Health (NIMH), National Institute of Child Health and Human Development (NICHD), and the Food and Drug Administration (FDA) Center for Tobacco Products, held a workshop on E-Cigarette Prevention and Cessation in Youth and Young Adults on March 2-3, 2020 in Bethesda, MD. The goal of this workshop was to convene stakeholders from federal agencies, public health organizations, and the research community to discuss the state of the science and where research gaps exist in developing and testing e-cigarette prevention and cessation strategies for youth and young adults.
This workshop aligns with NHLBI Strategic Vision objective 6 (Optimize clinical and implementation research to improve health and reduce disease).
Public health data over the last few years have shown dramatic increases in the number of youth and young adults who use e-cigarettes (also called vapes or electronic nicotine delivery systems (ENDS)). Health effects of using e-cigarettes alone or in combination with combustible cigarettes are not well known in these age groups where the cardiovascular and respiratory systems are still developing. In addition, the brain continues developing in adolescence and young adulthood making this population particularly susceptible to the effects of nicotine, including addiction. However, research shows that many youth do not perceive significant risk from using e-cigarettes. E-cigarette prevention and cessation interventions focused specifically on youth and young adults are emerging, and research efforts to determine effectiveness of various strategies are urgently needed.
Twenty-eight invited experts from the fields of tobacco, alcohol, and substance use research were invited to discuss the gaps, barriers, and opportunities related to prevention and cessation of e-cigarette use in youth and young adults. Two of these experts participated in the planning workgroup and co-chaired the workshop. Participants shared current experience and lessons learned in the context of existing school-based and media-based prevention programs and discussed research needs in policy-based prevention research and in cessation interventions.
Research Gaps and Opportunities:
This workshop identified the following gaps and research opportunities related to prevention and cessation of e-cigarette use in youth and young adults:
Gaps: Tobacco surveillance methods are limited to annual surveys that are inadequate to monitor rapidly changing trends in the use of a wide variety of new and emerging e-cigarette products by youth and young adults.
- Rapid surveillance of e-cigarette and other tobacco product use, and other substance use, could improve monitoring and may provide more timely and accurate measures of the impact of intervention efforts.
- Continuous surveillance of which social media platforms are being used by youth and young adults could facilitate identification of new venues, since digital tools used by youth and young adults change quickly.
- Comprehensive ongoing data collection from retail environment locations (both physical and online), type, density and ease of access for youth and young adults could complement current surveillance of youth and young adult behavior. Such an effort would be complicated by the fact that some states and communities require tobacco retailers to be licensed and tracked while others do not.
- Methodologic Considerations for Interventions
Gaps: For current e-cigarette use prevention programs, the effectiveness of the intervention has not been well studied and the optimal frequency and dose of the intervention is unknown. The potentially harmful impact of e-cigarette prevention interventions on other tobacco use including cigarettes and combustible tobacco products has not been evaluated.
- An understanding of how behavioral interventions can adapt their messaging as products evolve and youth behaviors change could inform intervention effectiveness.
- Studies of multi-component interventions should use research designs that can assess which components are effective (e.g., factorial designs).
- Studies determining the appropriate “dose” of interventions (i.e., number of sessions) and frequency of exposure are important in order to more effectively replicate and implement proven interventions.
- Ongoing testing and refining of content that is appropriately tailored to youth could enhance the value of intervention research. Recent work suggests that messages that resonate with youth are factual, believable, and appealing. Messages that empower youth to counter messages received from the tobacco industry have been effective. Another powerful message for kids is that nicotine has harmful effects on the brain; long-term health consequences are a less concerning message for kids than irreversible brain effects.
- Studies testing the effectiveness of interventions to prevent and treat e-cigarette use should include methods and analyses to monitor for unintended consequences (e.g., uptake of other tobacco products, effects on use of other substances).
- Consider precision, adaptive trials to test the effectiveness of e-cigarette prevention and cessation interventions.
- Individual, Peer and System-Based Prevention
Gaps: Existing interventions to prevent e-cigarette use often rely on self-reported data and measure only knowledge, attitudes, and intentions. There is a need for research designs that can effectively assess the impact of an intervention’s impact on e-cigarette use behavior.
- Design interventions for e-cigarette prevention by building on the evidence base of peer leader and social network approaches to cigarette and other tobacco product prevention.
- Determine the best strategies to engage parents and other important adult influencers in prevention efforts.
- Develop multi-component prevention strategies that involve credible adult influencers (including parents, coaches, school nurses) who can deliver these messages in multiple settings.
- Determine whether existing evidence-based tobacco prevention programs may be adapted for e-cigarette prevention. Determine the optimal strategy to improve scalability and implementation of effective programs.
- Develop and test interventions that focus on improving decision-making skills to resist e-cigarette use in the context of multiple tobacco products.
- Design interventions to promote healthy behaviors while targeting multiple tobacco products and substances (including co-use of cannabis) while avoiding unintended consequences.
- Develop better outcome measures in addition to intent to use e-cigarettes) in order to understand the intervention’s impact on behavior.
- Develop and test e-cigarette prevention interventions for adolescent and young adult populations in non-school settings (e.g., community-based settings, medical settings, workplace).
- Population-Based Prevention Through Media-Based Interventions
Gaps: There is a need for evaluative and formative research related to mass media campaigns and health communications aimed at preventing e-cigarette use and promoting cessation among youth and young adults. Media messages should be age-appropriate and may need to be tailored to use status (non-users who may be susceptible to future use, current infrequent users/experimenters, and regular/daily users).
- Develop and evaluate health communication approaches that can be delivered via technology-based applications that are most often utilized by youth and young adults (e.g., texting, social media, mobile apps).
- Studies are needed to understand best practices in conducting rigorous health communication prevention research via digital media platforms, addressing gaps such as:
- How to measure the totality of social media e-cigarette prevention messages from multiple sources;
- How to measure the effectiveness of e-cigarette prevention messaging approaches on e-cigarette use behavior, not just antecedents like intentions;
- Understanding which kinds of health warnings are most effective for e-cigarette prevention among youth and young adults (e.g., is it effective to counter messages from industry that normalize nicotine and compare it to caffeine?).
- Policy-Based Prevention Research
Gaps: There are relatively few studies examining the effect of retail environment policies, price, tax, and product promotions on e-cigarette product perceptions, appeal, and use by youth and young adults.
- Research is needed to understand different taxation and price approaches for e-cigarette products and the resulting effects on e-cigarette and other tobacco product purchase behavior.
- Research is needed to identify the most effective policies for state and local governments to implement in the retail environment, including bans on advertising and promotion.
- Evaluate how exemptions and loopholes in retail policies weaken public health benefits and/or exacerbate inequities.
- Conduct research to further understanding of age verification methods and compliance for online purchases of tobacco products.
- Investigate industry strategies to co-market tobacco and marijuana and the impact on social norms, risk perceptions, and dual use among youth and young adults.
- Cessation Interventions for E-Cigarette Use
Gaps: Few evidence-based e-cigarette cessation interventions (behavioral or pharmacologic) are available to youth and young adults. In addition, few e-cigarette cessation studies incorporate biochemical verification of e-cigarette and other tobacco product abstinence.
- Determine predictors and correlates of effective cessation interventions (i.e., which treatments work for different age groups, which treatments work for specific tobacco products (e-cigarettes alone, or with other tobacco products, or with cannabis), which treatments work for various use patterns (non-daily or intermittent vs daily use)).
- Determine youth and young adult motivations for quitting and how to employ those in cessation interventions.
- Determine appropriate outcome measures for cessation intervention trials (e.g., biochemical verification of smoking status vs. participant self-report, cessation of e-cigarette use only vs. cessation of all tobacco products).
- Develop methods within health systems to identify youth and young adults who need help with e-cigarette cessation. Data collection using electronic health records may facilitate cessation efforts.
- Cross-Cutting Themes
- Interventions that target all tobacco products and co-use with other substances (e.g., cannabis, alcohol) instead of e-cigarettes alone are needed.
- Understand how social and environmental context impact effectiveness of interventions.
- Qualitative research is needed to find out what youths’ and young adults’ preferences are for types of e-cigarette prevention/cessation interventions (e.g., pharmacologic vs. behavioral, group vs. individual, school vs. social media).
- Policy research might be enhanced by availability of a national tobacco licensing registry; studies on the impact of e-cigarette advertising, retail environment, taxation, and pricing; and collaboration with public health law centers to gather and exchange information.
- Interdisciplinary team approaches and rapid research approaches to surveillance are needed.
- Testing of multi-component interventions is needed.
A white paper is in preparation that will expand on workshop deliberations and detailed research opportunities.
NIH Office of Disease Prevention
National Cancer Institute
Vandana Sachdev, MD, Division of Cardiovascular Sciences
Catherine Stoney, PhD, Division of Cardiovascular Sciences
Lisa Postow, PhD, Division of Lung Diseases
NIH and Federal Partners
Cathy Backinger, PhD, MPH, Center for Tobacco Products, FDA
Mary Garcia-Cazarin, PhD, Office of Disease Prevention, NIH
Elizabeth Ginexi, PhD, Office of Behavioral and Social Sciences Research, NIH
Rachel Grana Mayne, PhD, MPH, National Cancer Institute, NIH
Mary Kautz, PhD, National Institute on Drug Abuse, NIH
Heather Kimmel, PhD, National Institute on Drug Abuse, NIH
Rosalind King, PhD, National Institute of Child Health and Human Development, NIH
Helen Meissner, ScM, PhD, Office of Disease Prevention, NIH
Eve Reider, PhD, National Institute of Mental Health, NIH
Mariela Shirley, PhD, National Institute on Alcohol Abuse and Alcoholism, NIH
Belinda Sims, PhD, National Institute on Drug Abuse, NIH
Kevin Walton, PhD, National Institute on Drug Abuse, NIH
Kay Wanke, PhD, MPH, Office of Disease Prevention, NIH
Suchitra Krishnan-Sarin, PhD, Yale University School of Medicine
Lisa Henriksen, PhD, Stanford University School of Medicine
Tesfa Alexander, PhD, Food and Drug Administration
Carla Berg, PhD, George Washington University
Frank Chaloupka, PhD, University of Illinois at Chicago School of Public Health
Suzanne Colby, PhD, Brown University
Karina Davidson, PhD, MASc, US Preventive Services Task Force
A. Eden Evins, MD, MPH, Massachusetts General Hospital
Matthew Farrelly, PhD, RTI International
Shivani Gaiha, PhD, Stanford University School of Medicine
Amanda Graham, PhD, Truth Initiative
Steven Kelder, PhD, MPH, University of Texas School of Public Health
Brian King, PhD, MPH, Centers for Disease Control and Prevention
Grace Kong, PhD, Yale University School of Medicine
Mary Larimer, PhD, University of Washington
Pamela Ling, MD, MPH, University of California, San Francisco School of Medicine
Seth Noar, PhD, University of North Carolina-Chapel Hill
Mary Ann Pentz, PhD, University of Southern California
Yvonne Prutzman, PhD, MPH, National Cancer Institute, NIH
Danielle Ramo, PhD, Hopelab
Karla Sneegas, MPH, Centers for Disease Control and Prevention
Glory Song, MPH, Massachusetts Department of Public Health
Erin Sutfin, PhD, Wake Forest School of Medicine
Donna Vallone, PhD, Truth Initiative
Jeffrey Willet, PhD, American Heart Association
Thomas Ylioja, PhD, National Jewish Health