Minors, Moral Psychology, and the Harm Reduction Debate: The Case of Tobacco and Nicotine

Ethical Considerations in Substance Use Treatment for Youth: Assessing Clinical Practices and Policy Frameworks for Potential Harm

The current conceptual review highlights considerations surrounding the potential for non-beneficence and undue coercion within the practices of psychologists and other clinicians providing substance use treatment for youth. The potential for nonbeneficence and undue coercion is assessed at three key stages of treatment for youth with substance use disorders (SUDs): the informed consent process, maintaining confidentiality, and treatment planning. We explore these concerns as they relate to the ethical principles of psychologists as outlined by the American Psychological Association (American Psychological Association [APA], 2017), as well as pertinent state and national legislative guidelines. The paper culminates in actionable recommendations to resolve these inconsistencies in practice and emphasizes opportunities for professionals at all career stages to engage in ethical policy initiatives. These endeavors aim to reduce potential for undue coercion and nonbeneficence from psychologists treating youth with substance use disorders and to elucidate beneficial treatment pathways for youth navigating substance use challenges.

Smoking reduction using an electronic nicotine delivery system (ENDS) with nicotine delivery similar to combustible cigarettes

BACKGROUND

Electronic nicotine delivery systems (ENDS) offer a promising approach to tobacco harm reduction, but many people use both ENDS and combustible cigarettes ("dual use"), which undermines potential risk reduction. To explore the role of ENDS nicotine delivery in promoting switching to ENDS, we conducted a study in which people who smoked cigarettes were offered an ENDS that had previously been shown to replicate the rapid nicotine pharmacokinetics of combustible cigarettes (BIDI® Stick).

METHODS

Twenty-five cigarette smoking adults, not seeking smoking cessation treatment, but open to using ENDS as a cigarette substitute, were provided with a 12-week supply of BIDI® Stick in tobacco or menthol flavors, during a study that included seven biweekly sessions and a 6-month follow-up. Daily diaries assessed ENDS and cigarette use, and exhaled carbon monoxide (eCO) served as an objective marker of smoke intake. Subjective ratings were collected to assess the rewarding properties of ENDS and combustible cigarettes, and indices of nicotine dependence.

RESULTS

Over 12 weeks, ENDS use increased to an average of 15.8 occasions per day (SD = 20.2) and self-reported cigarette consumption decreased by 82% from 16.7 cigarettes/day (SD = 6.0) at baseline to 3.0 cigarettes/day (SD = 4.1) at week 12. The eCO level decreased by 27% from an average of 20.0 ppm (SD = 9.8) at baseline to 14.5 ppm (SD = 9.9) at week 12. Four of 25 participants completely switched to ENDS and were smoking abstinent during weeks 9-12. At 6 months one participant was confirmed to be abstinent. Ratings of subjective reward for the ENDS were very similar to those of participants' usual brands of cigarettes. Dependence level was lower for the ENDS than for combustible cigarettes.

CONCLUSIONS

In this study, the ENDS effectively replicated the subjective rewarding effects of participants' usual brands of cigarettes and led to a substantial reduction in reported cigarettes/day. Exhaled CO showed less of a decrease, possibly due to compensatory smoking behavior and/or the timing of eCO measurements that might not have reflected smoke intake throughout the day. The relatively low rate of sustained smoking abstinence at 6 months suggests that additional approaches continue to be needed for achieving higher rates of complete switching.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05855343.

Using Moralization as a Persuasion Strategy in Public Health Messages: A Cross-Sectional, Experimental Study on Vaping

Using moralization in anti-vaping public health messages as a persuasion strategy was recently recommended to address the current vaping epidemic. However, previous findings indicated this could lead to moralized attitudes in the general population, which can be very difficult to change and could severely affect social cohesion and distort risk perception. Since the safety and efficiency of using electronic cigarettes as smoking cessation devices are still being investigated, we conducted a cross-sectional, experimental study on a convenience sample of 612 Romanian never vapers, never smokers to assess how exposure to moralizing public health messages about vaping might influence their trust in future scientific results about this topic. Participants were randomized into six groups according to the type of message ("moral," "immoral," "neutral") and the type of effects of vaping on smokers' health, documented in a future fictitious study ("health benefits," "health risks"). Results showed that the type of message moderated trust in future scientific results after controlling for participants' general trust in science. When vaping was framed as immoral, trust in future scientific results showing health benefits was decreased, and vice versa. Implications are discussed for using moralization strategically in public health messaging to curtail or promote certain health behaviors.

E-Cigarettes and the Multiple Responsibilities of the FDA

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence.

A Person-Centered Approach to Moralization-The Case of Vaping

Using e-cigarettes for smoking cessation is a controversial topic among health experts. Evidence suggests that vaping might have been moralized among the general public. Despite the detrimental consequences of moralizing health behaviors on social cohesion and health, some argue for using moralization strategically to prevent and combat vaping. We aim to add to the body of literature showing the dangers of moralization in health by proposing a person-centered approach to the moralization of anti-vaping attitudes. Our cross-sectional survey explores the moralization of anti-vaping attitudes and its predictors on a convenience sample of 348 Romanian never-vapers, before the final vote to severely restrict vaping. By fitting a hierarchical regression model on our data, we found support for a unique contribution of negative prototypes (β = 0.13) and opinions of vapers (β = 0.08) in predicting moralization, with significant contributions of piggybacking on moralized self-control, on moralized attitudes toward smoking and on sanctity/degradation, disgust, anger, harm to children, and gender. Together, these variables explained 56% of the variance of the moralization of anti-vaping attitudes. Our findings add to our knowledge of motivated moralization and advise against using moralization in health, suggesting that people may weaponize it to legitimize group dislike.

Tribes of Trust or Distrust, "Attitude Roots" and Encouraging Scientific Participation in the Tobacco Harm-Reduction Debate

Implications This commentary provides an analysis of non-scientific influences on the tobacco harm reduction debate. It makes use of the "attitude roots" model and the issue of misplace trust and distrust. Greater participation in the debate by experts is encouraged, along with efforts to minimize the effects of non-scientific, biasing effects on judgments.

Tobacco Harm Reduction as a Path to Restore Trust in Tobacco Control

The controversy of tobacco harm reduction in the United States persists despite evidence that an important audience of tobacco prevention and control, i.e., the people who use or are likely to use nicotine and tobacco products, are engaging in practices that may be considered harm reduction. Despite this, a significant proportion of the US tobacco control and prevention field continues to be guided by a precept that there is "no safe tobacco," therefore failing to acknowledge practices that may be used to reduce the harms associated with consuming combustible forms of nicotine and tobacco. In this commentary, we argue that ignoring the potential benefits of harm reduction strategies may unintentionally lead to an erosion of trust in tobacco control among some members of the public. Trust in tobacco control as an institution is crucial for the success of tobacco control efforts. To ensure trust, we must return to our basic principles of doing no harm, developing programs that are responsive to people's experiences, and providing resources in assisting people to reduce the harms that may be associated with practices, such as smoking, which adversely affect health. Only by respecting an individual's priorities can we cultivate trust and develop tobacco prevention efforts that are grounded in the realities of people's lives and responsive to their needs.

Pathways of Nicotine Product Use: A Qualitative Study of Youth and Young Adults in California

INTRODUCTION

Existing research on youth's adoption of alternative nicotine delivery systems (ANDS) has focused on identifying pathways of nicotine product use, specifically examining whether vaping encourages progression to smoking. Few studies have considered other pathways of initiation. Qualitative studies suggest that meanings of vaping vary significantly, suggestive of the need for a more nuanced understanding of the role of vaping for youth with different pathways into vaping and smoking.

METHODS

We conducted in-depth qualitative interviews with 49 Californian youth between 15 and 25 years old who reported ever vaping nicotine to gain a deeper understanding of their initiation pathways of vaping and smoking, paying special attention to youth's experiences and reasons for ANDS initiation and use. Categorizing participants into initiation pathways by self-reported use and age of initiation of ANDS and cigarettes, we then compared the meaning and role of vaping across three distinct pathways of use: (1) smoking to vaping, (2) vaping to smoking, and (3) vaping only.

RESULTS

The most common pathway reported was smoking to vaping (74%), eight participants began vaping before smoking, and five participants reported only vaping but never smoking. Analysis of participants' narratives emphasized that youth in our study, regardless of initiation pathway, were generally aware of the health consequences of smoking and negotiated their use of nicotine products considering relative risks.

CONCLUSION

Findings from this study suggest that ANDS serve as a transitional tool for youth who are keenly aware of the health consequences of smoking, thus challenging conventional discourses about ANDS as a threat to youth's health.

IMPLICATIONS

This qualitative study queries concerns about the potential of alternative nicotine delivery systems (ANDS) to serve as a gateway into cigarette smoking for youth and young adults. Findings suggest that most of the youth participants discussed and considered relative risks in their pathways of initiation, highlighting the need to acknowledge harm reduction in constructing public health messaging and policies for smoking cessation.

Patterns of E-Cigarette Use Among Youth and Young Adults: Review of the Impact of E-Cigarettes on Cigarette Smoking

There is concern that e-cigarette use among youth and young adults (YAs) may lead to future cigarette or other combustible tobacco product use. A synthesis of the literature on this topic is needed because existing longitudinal studies are limited in number and not consistent in their conclusions. We conducted a search in PubMed through December 31, 2017 for peer-reviewed studies related to e-cigarette patterns of use. Of 588 relevant studies, 26 had a youth or YA sample, were longitudinal in design, and assessed e-cigarette use at baseline and cigarette smoking at follow-up. Most studies followed a sample over time and compared cigarette smoking at follow-up between baseline e-cigarette users and nonusers. Other studies examined the difference at follow-up in cigarette smoking status among smokers according to e-cigarette use at baseline. Results suggest that, among never smokers, e-cigarette use is associated with the future (6 months to 2.5 years) cigarette trial; however, firm conclusions cannot be drawn because of limitations including small sample size, measurement of experimental use (ie, ever use, past 30-day use) rather than established use, and inadequate controls for potentially confounding variables. Conclusions also cannot be drawn from studies examining the impact of e-cigarette use among smokers due to the limited number of studies and additional limitations. A comprehensive understanding of this literature is needed to inform policy makers and consumers for evidence-based decision-making and to guide future research on e-cigarette use among youth and young adults.

IMPLICATIONS

The present article provides a review of the impact of e-cigarette use on subsequent cigarette smoking among youth and YAs. Studies presented here suggest that e-cigarette use among nonsmokers is associated with subsequent cigarette smoking, but study designs are subject to numerous limitations. Future research should focus on addressing the characteristics that put youth and YAs at the risk of using either product and how appeal and accessibility of these products are related to product use in order to inform future policy-making.

Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society-An Observational Study over a 16 Year Period

Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003⁻2018), 13,381 respondents (aged 16⁻79 years) answered questions about risk perceptions in Statistics Norway's nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: "We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful". Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14⁻79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.

Origins in the USA in the 1980s of the warning that smokeless tobacco is not a safe alternative to cigarettes: a historical, documents-based assessment with implications for comparative warnings on less harmful tobacco/nicotine products

BACKGROUND

Before the 1980s in the USA, smokeless tobacco carried no health warnings, was not judged to cause disease, and was a declining practice. In 1986, the federal government passed legislation requiring rotating warnings on "mouth cancer," "gum disease and tooth loss," and "This product is not a safe alternative to cigarettes." This paper explores the history of the establishment of these warnings with emphasis on the 'not a safe alternative' warning and the bases for claiming that smokeless was 'not safe' (absolute harm) versus 'not safer than cigarettes' (relative harm).

METHODS

Results of searches of Truth Tobacco Industry Document archives and transcripts of legislative hearings were analyzed. Critical assessments were made of the evidence-base.

RESULTS

New evidence of oral cancer causation emerged along with a much-publicized case of a teenager dying of oral cancer. Public health concerns also arose over a widespread, successful marketing campaign implying smokeless was a safe alternative to cigarettes. Industry wanted pre-emptive federal warnings, to prevent a diversity of pending state warnings. To avoid an addiction warning, the industry accepted a compromise 'not a safe alternative' warning, which had not been initially proposed and which the cigarette industry may have sought in order to constrain the smokeless tobacco industry. The evidence presented supported smokeless only as 'not safe' and not 'as harmful as cigarette smoking.'

CONCLUSIONS

The comparative warning was a compromise to prevent an addiction warning and consistent with the preferences of cigarette companies. Prior surveys indicated that the public generally did not view smokeless tobacco as harmless, but they did generally report smokeless as less harmful than cigarettes despite expert interpretations to the contrary. As would not have been appreciated by public health supporters at the outset, subsequent research has shown that the 'not a safe alternative' message is misinterpreted by consumers to indicate that smokeless is 'not safer' than cigarettes-which was not established and has been disconfirmed by subsequent assessments of that question. Though many countries have banned smokeless tobacco (but not cigarettes), where smokeless is legally available accurate information on the nature of harms and differential harms needs to be developed.

Universal School-Based Implementation of Screening Brief Intervention and Referral to Treatment to Reduce and Prevent Alcohol, Marijuana, Tobacco, and Other Drug Use: Process and Feasibility

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to reducing substance use in adolescents. An emerging literature shows the promise of school-based SBIRT. However, most school-based SBIRT has only targeted substance-using adolescents and used school-based health clinics, which most schools lack. This project aimed to describe the following: a model for implementing universal SBIRT in high schools without school-based clinics, reasons students most commonly endorsed for reducing or avoiding substance use, students’ perceptions of SBIRT, and students’ intentions to change substance use or remain abstinent following SBIRT. Participants were N = 2513, 9th to 10th grade students in 10 high schools. Students rated SBIRT positively and indicated substantial intentions to reduce or delay substance use following SBIRT. Results support SBIRT’s potential to delay substance use among current abstainers in addition to reducing substance use among current users. This project demonstrates SBIRT’s feasibility as a universal method in high schools without in-school clinics.