Supporting the Prevention Efforts of Youth Uptake of Vaping Products

The Canadian Institutes of Health Research in collaboration with Health Canada

Objectives

The Best Brains Exchange (BBE) will provide an opportunity for researchers, implementation experts, policy makers, health practitioners and other key stakeholders to support the Government of Canada’s legislative agenda to prevent youth under the age of 18 from incentives to use vaping products and nicotine addiction.

More specifically, the BBE will allow participants to address the following objectives:

  1. Examine current research and implementation evidence on public health prevention approaches related to risky behaviours among youth, to identify key factors that facilitate successful targeted youth prevention campaigns. Relevant areas of expertise include exploring:
    1. youth social (online) marketing,
    2. youth-targeted public health campaigns (e.g., substance use, youth smoking/vaping and others)
  2. Identify best practices in communicating evidence-based health risks to youth, parents, health care professionals and other providers in order to support Health Canada’s efforts in reducing the incidence of vaping uptake among youth.
  3. Better understand vaping marketing approaches and potential impacts on normalizing vaping and inducing increased appeal to young people.

Policy Context

The Government of Canada enacted the Tobacco and Vaping Products Act (TVPA) on May 23, 2018, which aims to regulate vaping products to protect young persons from nicotine addiction and tobacco use, while allowing adults access to vaping products as a less harmful alternative to smoking. The TVPA applies to a range of devices and substances, such as e-liquids, and vaping products, both with and without nicotine.

Health Canada recognizes that vaping products could offer public health benefits by helping smokers quit or switch completely to a less harmful alternate source of nicotine, potentially reducing tobacco related death and adverse health outcomes. However, vaping products also present public health risks. Nicotine is a potent and powerfully addictive substance that produces chemical and psychological effects that can be appealing to youth. Long-term effects of nicotine consumption could include developing dependency, tolerance for higher doses of nicotine, and withdrawal symptoms. Use of vaping products by youth also increases the risk of tobacco initiation.

While all nicotine users are at risk for developing an addiction, nicotine consumption presents a particular risk for adolescents. Approximately 86% of current adult daily smokers aged 25 or older in Canada smoked their first cigarette by 18 years of age, and adolescents are more sensitive to the addictive effects of nicotine. As well, there is a growing body of evidence that nicotine exposure during adolescence adversely affects cognitive function and brain development.

Canadian data from the 2017 Canadian Tobacco, Alcohol and Drugs Survey (CTADS) show that 3% of Canadians aged 15+ have used an e-cigarette in the past 30 days. However, this data was collected prior to the enactment of the TVPA, the introduction of a suite of new vaping products in the Canadian market, and before vaping brands significantly increased promoting their products through a variety of media channels.

In August of 2018, the United States released data showing a 78% increase in vaping prevalence in one year among high school students (12% in 2017 to 21% in 2018), which may be related to the entrance of JUUL (a new type of e-cigarette) onto the market.Footnote 1 JUUL is unique from other vaping products available on the market due to its ability to deliver high concentrations of nicotine more rapidly, which could increase risks to youth. In addition, unlike tobacco products, vaping products are offered in thousands of flavours, which may make them more appealing to youth. As well, these products also have novel designs (i.e. USB stick) which may also increase their appeal. Use of these products is also widely shared on social media.

In addition to product design, marketing strategies used by vaping product manufacturers that increase the products’ appeal among young people as well as product initiation are important to consider. The FDA in the US hypothesizes that the increase in youth vaping may be related to marketing practices undertaken by vaping product manufacturers.Footnote 2

In this context, it is essential for Health Canada to maximize the public health benefit of preventing youth from using and developing an addiction to nicotine, notably from vaping products.

Need for Evidence

Research evidence will help inform communication practices that will maximize youth prevention strategies to reduce the initiation of vaping products among youth.

At the BBE, points of discussion related to supporting the prevention efforts of youth uptake of vaping products may include, but are not limited to:

  • Channels for effectively delivering public health messaging targeted to youth
  • Risk behaviour messaging content targeted to youth (including messaging relating to substance use or abuse)
  • The role of e-cigarette appeal for youth
  • Marketing strategies used by e-cigarette companies to increase product appeal among youth
  • Environmental factors influencing youth risky behaviour, including smoking
  • How to engage the broader public health community (i.e. parents, teachers)

Anticipated Outcomes

Recent research and implementation evidence from the BBE will provide Health Canada with best practices regarding protecting youth from nicotine addiction and incentives to use vaping products through the development of targeted messaging campaigns and strategies.

Presentation Summaries

The BBE was facilitated by Dr. Shoo Lee, (Scientific Director, Institute of Human Development, Child and Youth Health (IHDCY), Canadian Institutes of Health Research (CIHR)/ Professor of Paediatrics, Obstetrics & Gynaecology and Public Health at University of Toronto). Below is a summary of the evidence presented by the BBE presenters:

The rising popularity of e-cigarettes among youth and young adults

Jessica Barrington-Trimis, Epidemiologist; Assistant Professor of Preventive Medicine, Keck School of Medicine, University of Southern California

In the United States and in many developed countries, e-cigarettes have gained rapid popularity among youth and young adults over the last decade, and rates of use continue to rise. E-cigarettes have evolved substantially over this time, with the most recent generation of products delivering very high levels of nicotine to the user. This talk highlighted concerns regarding youth vaping, and concluded with preliminary evidence on regulations that may help reduce the adverse public health impact of adolescent and young adult vaping. Specifically, this talk addressed the following points: 1) E-cigarettes drawing in new low-risk youth who are unlikely to have otherwise used combustible tobacco products. 2) Youth and young adults who use e-cigarettes are substantially more likely to subsequently initiate use of combustible cigarettes and other combustible tobacco products; this risk is strongest for youth at low risk of initiating combustible tobacco use. 3) Certain e-cigarette product characteristics – including level of nicotine and type of e-cigarette device – increase the risk of more frequent vaping and cigarette use at follow-up. 4) Local regulatory policies regarding the sale of tobacco products to youth that are adequately funded to conduct frequent enforcement efforts may reduce youth initiation of e-cigarettes and other tobacco products.

Components and characteristics of e-cigarette devices and e-liquids which enhance their appeal to youth

Suchitra Krishnan-Siran, Professor of Psychiatry; Chair, Human Investigations Committee II & IV, Human Research Protections Program, School of Medicine, Yale University

This presentation focused on the components and characteristics of e-cigarette devices and e-liquids which enhances their appeal to youth. The appeal of e-cigarettes appears to be related to their innovative design which allows them to be used for administering substances like nicotine, marijuana and flavors, and for a variety of other alternative behaviors like dripping and cloud chasing. Dr. Krishnan-Sarin will discuss the short and long-term concerns related to the exposure to these components. She will also discuss the need for strong e-cigarette education programs directed at youth and parents focused on the harms of nicotine, and for prevention and cessation programs for youth.

Impact of e-cigarette messaging on beliefs and behaviors

Andrea Villanti, Associate Professor of Psychiatry and Psychology, Department of Psychological Science, University of Vermont

This presentation provided an overview of the e-cigarette market with a focus on the types of e-cigarettes advertised in the U.S., the messages used in advertisements, and the impact of exposure to advertising messages on e-cigarette beliefs, harm perceptions, and behaviors in young people. It will also describe the ways in which e-cigarettes are portrayed in the media and document trends in harm perceptions of e-cigarettes at the population level. To more directly inform Canada’s efforts to prevent the uptake of youth vaping, this presentation will review studies on the impact of e-cigarette warning labels and e-cigarette prevention messages on harm perceptions, intention to use, and use of e-cigarettes in youth and young adults. In addition to presenting recent data on young people’s harm perceptions of nicotine, Dr. Villanti will present preliminary evidence from a pilot randomized trial on the impact of brief nicotine educational messaging on nicotine-related beliefs, norms about nicotine use, behavioral control regarding cigarette/tobacco use, and intention to use nicotine products in the next 12 months.

Understanding the cultural trends of youth vaping

Tyler Janzen, Senior Director of Client Services, Rescue Agency

With teen vaping on the rise in Canada, it is important to understand what is causing this rapid increase, which youth are at highest-risk, and how we can develop targeted interventions to reach them most efficiently. While research on teen vaping patterns is still limited, some evidence is emerging that indicates the newest wave of teen vaping is being driven by a teen subculture that is traditionally at low to moderate risk for tobacco use. The “Popular” teen Peer Crowd is always one of the largest teen subcultures in the markets where Rescue has conducted research with teens, including multiple provinces in Canada. They value having a lot of friends, being popular amongst their peers, being fashionable, and attractiveness. They often come from above average income families and wear the most popular clothing brands, listen to top-40 music, and stay up-to-date with current trends and celebrities.

To better understand where the increase in teen vaping is coming from, Rescue analyzed data from three representative teen surveys in the U.S.: 1) The CDC’s Youth Risk Behavior Survey; 2) The Monitoring the Future Survey (MTFS); and 3) The Virginia Youth Survey (VYS). All three surveys show a decrease in teen vaping from 2015 to 2017, but the MTFS survey shows a dramatic increase in 2018. To explore this odd prevalence pattern, we looked to the VYS, which included Rescue’s peer crowd segmentation tool on both the 2015 and 2017 surveys. Although vaping among all teens decreased from 16.3% to 11.9%, a different picture emerged when we viewed the data through a peer crowd lens. The decrease in teen vaping was concentrated among the teens usually at greatest risk of tobacco use: Hip Hop, Alternative, and Country teens. The only peer crowd that saw an increase was the Popular Peer Crowd.

Based on these data, we hypothesize that the first wave of teen vaping peaked in 2015 and was driven mainly by Hip Hop, Alternative, and Country teens. The vaping products used during this first wave included Gen 1-3 ENDS devices, including cigarette-like devices, vape pens and larger MODS. With the entry of Juul into the marketplace and their youth-focused marketing in 2015, Popular teens were exposed to something that appealed specifically to them. Juul’s marketing was clean, fashionable, trendy, and positioned the brand as a healthy, technological revolution like an iPhone. Although Juul was forced to change its marketing to limit its appeal to youth, the brand had already cemented its position with Popular teens who further normalized Juuling through social media.

To learn how to combat this new wave of vaping, Rescue conducted focus groups with high-school aged teens in multiple US states to understand the perceived risks of vaping and discuss the messages most likely to change behaviour. In terms of addiction, teens only responded to messages that specifically compared the nicotine in vapes and cigarettes. Teens were less motivated by messages that focused on the tobacco industry’s manipulation, or the similarities between cigarette and vape marketing strategies. Teens were generally interested in specific facts about ingredients that could be harmful, even if a specific long-term health consequence was not provided. Many teens expressed they had a sense that vapes were dangerous, but didn’t have any facts to back up that assumption. Once provided with facts about harmful ingredients or addictiveness, teens were open to reconsidering their use. However, commercials that generally suggested vaping was dangerous without providing a specific ingredient or health consequence were not motivating and seen as not credible.

To turn the tide on teen vaping, we must first understand what is motivating the recent surge, which teens are driving this increase, and what they think about the product. While vaping is not proven to cause the same health consequences of combustible tobacco use, we found multiple hard-hitting facts and messages that motivated teen vape users and those susceptible to reconsider their behavior. Focusing on specific facts that align with Popular teen values and are delivered in a way that these teens relate to could help turn the tide of teen vaping in the U.S. and Canada.

Pod use and Potential for Nicotine Addiction in Adolescents

Rachel Boykan, MD, Associate Professor of Pediatrics, Renaissance School of Medicine at Stony Brook University

Adolescent use of high content nicotine vaporizers, ’pods’, has risen dramatically in the past year. Little is known about nicotine dependence from these products in teenagers. This talk focused on data from a pilot study conducted between April, 2017 and April, 2018. Teenagers completed an anonymous questionnaire about their use of e cigarettes, including specific product types and brands, and provided a spot urine sample. Nicotine exposure in participants who reported exclusive use of pods and non-pod e-cigarettes (with no combusted tobacco use) was determined by measuring cotinine in collected urine samples. Past week pod users had cotinine levels comparable to cotinine levels in tobacco users and in dual (e-cigarette and tobacco) users, and significantly higher cotinine than non-pod e-cigarette users. Additionally, pod users had more positive responses on questions regarding nicotine dependence than users of other types of e-cigarettes. Individuals endorsing positive dependence symptoms had higher cotinine levels than those not reporting such symptoms. Such usage patterns and high urinary cotinine levels raise concerns about the potential for nicotine addiction in teens.

Recommended Readings

  1. Barrington-Trimis, J. L., Kong, G., Leventhal, A. M., Liu, F., Mayer, M., Cruz, T. B., Krishnan-Sarin, S., & McConnell, R. (2018). E-cigarette use and subsequent smoking frequency among adolescents. Pediatrics, 142(6), e20180486.
  2. Barrington-Trimis, J. L., & Leventhal, A. M. (2018). Adolescents’ use of “Pod Mod” e-cigarettes—urgent concerns. New England Journal of Medicine, 379(12), 1099-1102.
  3. Collins, L., Glasser, A. M., Abudayyeh, H., Pearson, J. L., & Villanti, A. C. (2018). E-cigarette marketing and communication: how e-cigarette companies market e-cigarettes and the public engages with e-cigarette information. Nicotine and Tobacco Research, 21(1), 14-24.
  4. Goldenson, N. I., Leventhal, A. M., Stone, M. D., McConnell, R. S., & Barrington-Trimis, J. L. (2017). Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA pediatrics, 171(12), 1192-1199.
  5. Huang, J., Duan, Z., Kwok, J., Binns, S., Vera, L. E., Kim, Y., Szczypka, G., & Emery, S. L. (2019). Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tobacco control, 28(2), 146-151.
  6. Janzen, T. (2016). RESCUE The Behavior Change Agency [Using social branding to reduce young adult tobacco use: Evidence of a promising new approach].
  7. Jordan, J. W., Stalgaitis, C. A., Charles, J., Madden, P. A., Radhakrishnan, A. G., & Saggese, D. (2019). Peer crowd identification and adolescent health behaviors: results from a statewide representative study. Health Education & Behavior, 46(1), 40-52.
  8. Moran, M. B., Walker, M. W., Alexander, T. N., Jordan, J. W., & Wagner, D. E. (2017). Why peer crowds matter: Incorporating youth subcultures and values in health education campaigns. American journal of public health, 107(3), 389–395.
  9. Soneji, S., Barrington-Trimis, J., Wills, T. A., & Adam Leventhal, U. J. (2017). E-cigarette use and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr, 17, 788-797.
  10. Villanti, A. C., Rath, J. M., Williams, V. F., Pearson, J. L., Richardson, A., Abrams, D. B., Niaura, R. S., & Vallone, D. M. (2015). Impact of exposure to electronic cigarette advertising on susceptibility and trial of electronic cigarettes and cigarettes in US young adults: a randomized controlled trial. Nicotine & Tobacco Research, 18(5), 1331-1339.
  11. Wagner, D. E., Fernandez, P., Jordan, J. W., & Saggese, D. J. (2019). Freedom from chew: Using social branding to reduce chewing tobacco use among country peer crowd teens. Health Education & Behavior, 46(2), 286–294.
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