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Youth use and appeal of e-cigarettes and intervention development Suchitra Krishnan-Sarin, Ph.D. Professor of Psychiatry, Yale University School of Medicine Co-PI, Yale Tobacco Center of Regulatory Sciences
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Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Jun 25, 2020

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Page 1: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Youth use and appeal of e-cigarettes and intervention development

Suchitra Krishnan-Sarin, Ph.D.Professor of Psychiatry, Yale University School of Medicine

Co-PI, Yale Tobacco Center of Regulatory Sciences

Page 2: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

FDA Regulation of tobacco products

Page 3: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Family Smoking Prevention and Tobacco Control Act

The FSPTCA became law on June 22, 2009. It gives the Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution, and marketing of tobacco products to protect public health.

Page 4: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-cigarettes emerge….• First smokeless cigar invented in 1963• In 2003, Hon Lik, a Chinese pharmacist patented modern e-

Cigarette design. The company Lik worked for, Golden Dragon Holdings, developed the device and changed its name to Ruyan, which means “like smoke.”

• Today, there are over 400 e-Cigarette Brands.• E-cigarettes started appearing in the US market 2006-2009

Page 5: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

•Smoking Everywhere files a federal complaint. Smoking Everywhere contends that the FDA has no authority over electronic cigarettes, as they are a “tobacco product,” and the FDA’s attempt to regulate them infringes on Congress’s intent to withhold FDA jurisdiction over tobacco products. Smoking Everywhere contends that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C 321(g).

FDA adds electronic cigarettes to Import Alert 66-41 and directs the U.S. Customs and Border Protection to reject the entry of electronic cigarettes into the United States on the basis of them being unapproved drug delivery devices.

March 2009

April 2009

Are they a tobacco product or a drug delivery device???

Page 6: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Smoking Everywhere v. FDA, U.S. Court of Appeals in Washington rules the FDA can only regulate e-cigarettes as a tobacco product, unless therapeutic claims are made.

December 2010

US District Court (district of Columbia) prohibits the FDA from seizing e-cigarettes as drug or drug/device combinations.Jan

2010

FDA shall not detain or refuse admission into the United States of NJOY's electronic cigarette products on the ground that those products are unapproved drugs, devices, or drug-device combinations under the FDCA, absent a proffer of evidence, consistent with the Court's Memorandum Opinion, that NJOY's products are intended to have a therapeutic effect;

E-cigarettes can only be regulated as tobacco products

Page 7: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Per FSPTCA, E-cigarettes contain nicotine from tobacco and can only be regulated as tobacco

products

BUTThe FSPTCA did not cover e-cigarettes till 2016

THEREFOREFrom 2010 to Oct 2016

E-cigarettes were not regulated

Page 8: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-cigarette Evolution

Cigarette “like”Disposable (non refillable, non re-chargeable) CartridgeRefillable

Non cigarette “like”Water pipe CigarTank (active and passive delivery) ModifiedPod systems

New Design FeaturesDual coil Change Voltage Control puff duration

Page 9: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-cigarettes!!

Battery-operated devices used to inhale an aerosol, which may contain nicotine, flavorings, and other chemicals.

Page 10: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

The Present

Heat –not-butn

Page 11: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Other JUUL-like productsPhix, Suorin

Page 12: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Sales of e-Cigarettes

• Sales projected to be 27.7 billion by 2022• Source: Wells Fargo

Page 13: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Sales dollar of e-cigarettes in Nielsen-tracked retail channels: by brand 2011–2017.

Jidong Huang et al. Tob Control doi:10.1136/tobaccocontrol-2018-054382

©2018 by BMJ Publishing Group Ltd

Page 14: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Population Based

Surveys

Web-based cross-sectional survey

Retail SalesData

0%

10%

20%

30%

40%

50%

60%

70%

80%

2013 2014 2015 2016 2017 2018

Perc

ent o

f Tot

al E

-cig

aret

te D

olla

r Sa

les

YearAltria British American Tobacco Imperial Tobacco Japan Tobacco JUUL Labs… Other

2019

E-Cigarette Market Share, by Dollar Sales, US, 2013 - 2018

Source: King, Brian A, The Rise of the Pod Mod: Trends in E-Cigarette Sales in the US, 2013-2017. Paper presented at: 25th Annual Meeting of SRNT; February 2019; San Francisco, CA.

Page 15: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C
Page 16: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-Cigarettes Make Aerosol, Not Vapor

Page 17: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

What draws youth to e-cigarettes?

Page 18: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Connecticut focus groups and surveys

Longitudinal surveys and focus groups (2014-onwards)4-6 high schools in Southeastern CT

Dfferent CT District Reference Groups

Page 19: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-cigarette use reasons among youth users Wave 1 (Fall 2013) Surveys in CT

0

10

20

30

40

50

60

70

Perc

enta

ge

MiddleSchool(n=41)

High School(n=912)

Kong et al. (2014) NTR

Page 20: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Multiple Innovative devices!!

Page 21: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

E-cigarette Evolution

Cigarette “like”Disposable (non refillable, non re-chargeable) CartridgeRefillable

Non cigarette “like”Water pipe CigarTank (active and passive delivery) ModifiedPod systems

New Design FeaturesWattage ControlPuff control

Page 22: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Appeal of customizable product features among susceptible non-users and current users

(2015)26

.5

12.9

6.7

5.2

2.0 3.4

10.8

3.7

73.4

3.1

23.0

9.9

5.5

5.2

3.7

2.9

10.2

3.1

49.3

1.8

55.9

36.9

21.5

22.3

16.0

10.8

19.7

9.9 15

.9

5.8

0

10

20

30

40

50

60

70

80

90

100

Perc

ent

Susceptible, Tobacco-Naive Never-Users Susceptible, Tobacco-Exposed Never-usersCurrent E-cigarette Users

Camenga et al. (2018) TRS

Page 23: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Youth are using different devices (2017)

25.4

60.664.2

71.2

7.3

18.7

47.1

33.1

0

10

20

30

40

50

60

70

80

90

100

CIG-A-LIKE VAPE/HOOKAH PEN JUUL MODS

Perc

ent

Ever Current

Krishnan-Sarin et al. (2019) DAD

Page 24: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Youth are using multiple devices (2017)

VAPE/HOOKAH PEN + JUUL + MODS24%

JUUL + MODS20%

All17%

VAPE/HOOKAH PEN + MODS

16%

DISP + VAPE/HOOKAH PEN + MODS8%

VAPE/HOOKAH PEN + JUUL7%

DISP + VAPE/HOOKAH PEN2.6%

DISP + VAPE/HOOKAH PEN + JUUL2.6%

DISP + JUUL + MODS1.6% DISP + JUUL

0.8%

DISP + MODS0.8%

Krishnan-Sarin et al. (2019) DAD

Page 25: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Over 15000 Flavors!!

Page 26: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

> 15,000 flavorsFlavors Made up of multiple chemicals with known toxicity profiles

(inflammation, free radical generation, oxidative stress…)

BenzaldehydeCinnamaldehydeAcroleinFurfuralDiacetylβ-damascone,δtetradecalactoneγ-decalactonecitraldipenteneethyl maltolethyl vanillin ethyl vanillin PG acetallinalool piperonal DipenteneETC….

Page 27: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavorants and toxicityVanillinAcetoinDiacetylPentanedioneCinnamaldehydeFurfural (chocolate)Maltol (cotton candy)CoumarinBenzaldehyde (fruity flavors, esp. cherry)

(Allen et al., 2016; Tierney et al., 2016; Muthumalage et al., 2018)

Page 28: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Cytotoxicity of Flavor chemicals

Page 29: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavorants and toxicity

Erythropel HC, Jabba SV, De Winter TM, Mendizabal M, Anastas PT, Jordt SE, Zimmerman JB. Nicotine & Tobacco Research 2018. DOI: 10.1093/ntr/nty192

Page 30: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavors used by Youth in E-cigarettes (2017)

Page 31: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavors used by Youth vs Adults in E-cigarettes (2017)

Morean ME, Butler ER, Bold KW, Kong G, Camenga DR, et al. (2018) Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults. PLOS ONE 13(1): e0189015. https://doi.org/10.1371/journal.pone.0189015https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189015

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189015
Page 32: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Table 2. Predictors of e-cigarette use frequency in adults and adolescents.

Morean ME, Butler ER, Bold KW, Kong G, Camenga DR, et al. (2018) Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults. PLOS ONE 13(1): e0189015. https://doi.org/10.1371/journal.pone.0189015https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189015

Total flavors preferred predict e-cigarette use frequency in youth but not in adults

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189015
Page 33: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavorants in Electronic Cigarettes

Pharmacological effects Modulate somatosensory responses and nicotine

irritancy perception

Affect nicotine intake

Page 34: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Menthol (High dose) reduces Sensory Irritant Responses from Nicotine (High dose)

• Human Sensory Testing Paradigm

• E-cigarette vapor exposure in young adult users

Rosbrook and Green, Nicotine Tob Res, 2016

Page 35: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Menthol improves the taste of E-liquids

• Human E-cigarette Exposure Paradigm

• E-cig puff exposure in young adult e-cig users

Krishnan-Sarin et al., Drug and Alcohol Dependence, in press

0

5

10

15

20

25

30

No Menthol Low Menthol High Menthol

Disli

ke/L

ike

Tast

e of

E-c

igar

ette

s (-

100

to 1

00)

Like Taste of E-cigarettes(Menthol main effect, p<0.001)

Page 36: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Menthol increases liking for E-liquids with nicotine

• Human E-cigarette Exposure Paradigm

• E-cig puff exposure in young adult e-cig users-20

-10

0

10

20

30

40

50

No Menthol Low Menthol High Menthol

Disli

ke/L

ike

Tast

e of

E-c

ig (-

100

to

100)Like Taste of E-cigarettes

(Menthol*Nicotine, p<0.05)

0 mg Nicotine 6 mg/ml Nicotine 12 mg/ml Nicotine

p<0.05

Krishnan-Sarin et al., Drug and Alcohol Dependence, in press

Page 37: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

“Youth believe ads for flavored e-liquids target individuals about their age, not older adults”

McKelvey et al., 2019

Page 38: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavor Ads activate Brain Reward PathwaysGarrison et al., 2017

+

Ratings/restSweet/fruit e-cigor menthol cig

Tobacco e-cigor regular cig

Ratings/rest

How much do you like this product?

1 2 3 4

How likely is it that youwill try this product in the future?

+

How much do you like this product?

1 2 3 4

How likely is it that youwill try this product in the future?

WARNING

WARNING

Post-scan memory task

Control images

Eye tracking

Have you seen this message before?

Do Flavor Ads activate Brain Reward Pathways?Garrison et al., 2017

Page 39: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Flavor ads activate brain reward circuitrysweet/fruit v. tobacco stimuli

NAc

Con

trast

Val

ue

Control Sweet/fruit Tobacco-1.1

-0.6

-0.1

0.4

0.9

* *

* p<.05

Garrison et al., 2018

Page 40: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Do Flavor ads change attention paid to E-cig warning labels on risks of nicotine and toxic

chemicals?

• Content taken from U.S. gov. websites (FDA, CDC, NIH) and www.thetruth.com

• E-cig warnings concerned potential risks of nicotine and chemical constituents

http://www.thetruth.com/
Page 41: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

NAc

con

trast

val

ue

Warning label memory score

NAc response correlated with memory for warning labels

Greater activation of brain reward circuitry is related to poorer memory for warnings

r=-.43, p=.03

Page 42: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C
Page 43: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine and Addiction!!

Page 44: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine concentration Used by Youth (2015)

Camenga et al. (2018) TRS

Page 45: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Do youth use nicotine in their ecigs? (2017)

Krishnan-Sarin et al. (2019)

Page 46: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine delivery can be changed by device power

Adapted from Wagener TL, Floyd EL, Stepanov I, Driskill LM, Frank SG, Meier E, Leavens EL, Tackett AP, Molina N, Queimado L. Tob Control. 2017 Mar;26(e1):e23-e28. doi: 10.1136/tobaccocontrol-2016-053041. Epub 2016 Oct 11.

Third GenerationN = 11�̅�𝑥 = 71.6 W�̅�𝑥 = 4.1 mg/ml

Second GenerationN = 9�̅�𝑥 = 8.6 W�̅�𝑥 = 22.3 mg/ml

Pre Post0

5

10

15

20

25

*

Third Gen.Second Gen.

Plasma Nicotine Concentration (N = 20)

Time relative to 10 puffs

ng/

ml

Page 47: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Benzoic Acid

00Nicotine Salts

Free Base

Nicotine

Nicotine delivery can be changed by use of nicotine salts

Page 48: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Reasons for Liking JUUl among youth current e-cigarette users (2018)

Kong et al., 2020

Page 49: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Reasons for Disliking JUUL among youth current e-cigarette users (2018)

Kong et al., 2020

Page 50: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Reasons for Liking JUULs and frequency of JUUL use among current e-cig users

Unadjusted Models Adjusted ModelB (SE) β B (SE) β

Reasons for likingPharmacological effects 22.87 (1.67) 0.42 9.49 (1.59) 0.17Product characteristics 13.81 (1.18) 0.36 3.47 (1.24) 0.09Peer influences -3.59 (0.79) -0.15 -2.43 (0.61) -0.10Comparative perceptions to other e-cigs 6.91 (1.45) 0.16 -1.14 (1.20) -0.03Ability to hide 9.37 (1.04) 0.29 1.26 (0.97) 0.04“Other” reason for liking 3.67 (2.16) 0.06 2.86 (1.56) 0.04

Demographic Sex (Ref. = Female) 1.12 (0.75) 0.05 -0.78 (0.58) -0.03Race (Ref. = Non-White) 1.43 (0.87) 0.06 1.85 (0.66) 0.07Age 1.67 (0.30) 0.18 0.43 (0.24) 0.05

JUUL use characteristics Use my own JUUL 13.78 (0.63) 0.58 9.27 (0.64) 0.39

Past-30-day use of other tobacco products 9.39 (0.69) 0.40 3.49 (0.65) 0.15Past-30-day use of other e-cigarette devices 9.11 (0.75) 0.37 4.38 (0.66) 0.18

Kong et al., 2020

Page 51: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine is highly addictive and the adolescent brain is sensitive to even low levels of nicotine

• Adolescent animals get more easily addicted to nicotine than adults

• Most human cigarette smoking starts prior to the age of 18

• Smokers who start prior to the age of 18 have greater chronic disease burden and find it harder to quit smoking

Page 52: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine is a neurotoxin in the adolescent brain

In adolescent animals nicotine is a well established neurotoxin• Pruning and brain development• Changes neural pathways and behaviors related to

learning, memory, attention processes • Leads to hyperactivity. • Makes it easier to get addicted to other substances

• produces epigenetic changes (genes involves in asthma and depression)

Adolescent humans who smoke also experience memory and attention deficits after using cigarettes, and have greater rates of depression and anxiety

Page 53: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Nicotine has an effect on almost all processes in the human body

Page 54: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Alternative Use Behaviors!!

Page 55: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Dripping/Vape Tricks

In June 2017, 0f 1047 high school e-cigarette ever users, 35.7% had tried vape tricks

In June 2017, 0f 1047 high school e-cigarette ever users, 22.5% had tried dripping

Page 56: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Dripping/Vape Tricks (2017)Past 30 day rates among e-cigarette users

26.1%

14.9%

18.6%20.0%

27.0%

20.2%18.8%

21.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0 days 1-3 days 4-14 days 15-30 days

Days of Dripping among Adolescents Who Tried Dripping (N=215)

Days of Vape Tricks Conducted among Adolescents Who Tried Vape Tricks (N=575)

Page 57: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Vape Cannabis

Morean et al., (2015) Pediatrics

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Total Samplen = 3,847

All Lifetime E-cigarette users

n = 1,075

Lifetime DualUsers (E-

cigarettes andCannabis)

n = 724

Vaporizing Cannabis using E-cigarettes

2014

Page 58: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

What can we do to reduce youth e-cig use?

• Product regulation• Reduce or limit flavors?• Reduce nicotine concentrations?• Include nicotine content labels that are easy to understand• Remove youth appealing packaging ( e.g. flavors)?• Create efficient devices that cannot be manipulated• Dealing with marijuana vaping?

• Other regulatory efforts that have shown benefit for reducing cigarette smoking• Restricting youth sales and access• Restricting advertising• Taxation

Page 59: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

What can we do to reduce youth e-cig use?

• Education and Prevention• Teachers, parents, children• Change harm perceptions about Nicotine • Change harm perceptions about Flavors.

• Cessation• Develop interventions based on behavioral and pharmacological

methods that have worked for cigarette smoking• Understand ecigarette cues• Understand e-cigarette and nicotine dependence and withdrawal

• Develop interventions for marijuana vaping

Page 60: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Treatment Modalities used with Youth

• 5 A’s (USDHHS, 2012)• Cognitive Behavioral Therapy

• Goal setting, self-monitoring, cognitive reframing, problem solving, coping skills• Motivational Interviews or Enhancement

• Addressing resistance with confrontation, strengthening desire to quit, reducing ambivalence about quitting, supporting self-efficacy

• Behavior Change based on Transtheoretical Model of Change• Identifying stage (precontemplation, contemplation, preparation, action, maintenance)

and facilitating behavior change using ME• Pharmacological Interventions

Nicotine patch and inhaler, bupropion, varenicline • Novel Interventions

• Behavioral Reinforcement (Contingency Management, Quit and win)• Approach Avoidance Training (Habitual approach tendencies)• Behavioral Activation Training (for smokers with Depression)

Page 61: Youth use and appeal of e-cigarettes and intervention ...that electronic cigarettes are not “drugs,” “drug delivery systems,” or “drug device combinations” under 21 U.S.C

Treatment settings

• Schools/Colleges• Ideal setting to access youth• Confidentiality problems in schools

• Health Care Settings• Great Teaching moment when with Pediatrician/Primary care doc• Lack of provider time • Lack of Follow up

• Internet and mobile phones• Great reach• Lower efficacy• Hard to keep youth motivated and engaged


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