E-cigarette and combustible cigarette cessation patterns, reasons, and methods among adolescents, young adults, and adults

Research is limited regarding adolescents' and young adults' (AYA) patterns, methods of, and reasons for cigarette or e-cigarette cessation. Further, while adults may try to use e-cigarettes to quit combustible cigarettes, little is known about how adults then quit e-cigarettes. This study utilizes a national, cross-sectional online survey of 6131 diverse participants aged 13-40 years to examine reasons for quitting e-cigarettes or cigarettes, quit methods, and quit attempt outcomes among AYAs and adults. In our sample, 3137 (51.2%) had ever used an e-cigarette, of whom 2310 (37.7%) were aged 13-24 years and 827 (13.5%) were 25-40 years old; 2387 (38.9%) had ever used a combustible cigarette (1440 [23.5%] were 13-24 years old and 947 [15.4%] were 25-40 years old). Among e-cigarette ever-users, 39.4% of 13-24-year-olds intended to quit in the next 6 months, and 36.9% had a serious plan for quitting in the next 30 days; 25.2% wanted to decrease the amount they used while 34.8% wanted to quit completely. Similar rates were found among e-cigarette ever users aged 25-40 years, as well as past 30-day e-cigarette users, cigarette ever-users, and past 30-day cigarette users across all ages. "Cold turkey" (41.0%) followed by "tried to cut down slowly by vaping/smoking less often or fewer puffs" (25.5%) was the most common quit method among e-cigarette ever-users and cigarette ever-users of all ages. Further study of effective tobacco cessation methods to help both AYAs and adults successfully quit nicotine, whether from cigarettes or e-cigarettes, is urgently needed.

Sociodemographic differences in use of nicotine, cannabis, and non-nicotine E-cigarette devices

BACKGROUND

Sociodemographic differences in e-cigarette use have been documented; however, disparities in use of specific e-cigarette types with various ingredients have yet to be thoroughly investigated. This study examines ever- and past-30-day-use of nicotine, cannabis, and non-nicotine e-cigarette device types by sex, sexual orientation, race/ethnicity, and financial comfort.

METHODS

Data were drawn from a 2021 national cross-sectional survey of adolescents, young adults, and adults (N = 6131, ages 13-40 years old). Participants reported ever and past-30-day-use of (1) disposable nicotine e-cigarettes, (2) pod/cartridge-based nicotine e-cigarettes, (3) "other" nicotine e-cigarettes, (4) non-nicotine e-cigarettes, (5) e-cigarettes with THC, and (6) e-cigarettes with CBD. We constructed summary tables for each e-cigarette device type in which percentages of ever and past-30-day-use were calculated by birth year category and sociodemographic variables: (a) sex, (b) sexual orientation, (c) race/ethnicity, and (d) financial comfort.

RESULTS

Females born between 1996 and 2008 reported higher rates of past-30-day disposable e-cigarette use relative to males (females 26.4%; males 22.4%). Compared to their heterosexual counterparts, LGBTQ+ participants reported higher overall rates of past-30-day-use for disposable (LGBTQ+ 27.9%; Heterosexual 23.8%), THC (LGBTQ+ 30.8%; Heterosexual 24.1%), and CBD e-cigarettes (LGBTQ+ 20.0%; Heterosexual 16.9%). Hispanic/Latino participants generally reported higher rates of past-30-day-use across device types relative to those identifying as Black or White non-Hispanic, particularly disposable nicotine e-cigarettes.

CONCLUSIONS

Findings highlight sociodemographic disparities in e-cigarette use, though differences varied based on e-cigarette device type and participant birth year category. Tailored preventive efforts may be necessary to mitigate e-cigarette use among populations at highest risk.

Use, marketing, and appeal of oral nicotine products among adolescents, young adults, and adults

IMPORTANCE

Oral nicotine products such as pouches, lozenges, tablets, gums, and toothpicks are gaining popularity, especially among adolescents and young adults, with increased marketing.

OBJECTIVE

To estimate use patterns of oral nicotine products and likelihood of buying and liking products based on marketing, using a large group of adolescents, young adults, and adults.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, online survey among U.S. participants (n = 6,131; ages 13-40 years) was conducted in November-December 2021.

MAIN OUTCOMES AND MEASURES

Ever, past-30-day, and past-7-day use, behaviors, and flavors of oral nicotine products. Liking marketing and likelihood of buying specific oral nicotine products (Zyn pouches and Lucy gum) from marketing.

RESULTS

Our sample included 2,025 (33.0%) ever-users, 1,191 (19.4%) past-30-day users, and 998 (16.3%) past-7-day users of any oral nicotine product. Use patterns by age (in years): ever-users (<21: 816 (22.3%); 21-40: 1,209 (48.9%)); past-30-day users (<21: 458 (12.5%); 21-40: 733 (29.7%)); and past-7-day users (<21: 383 (10.5%); 21-40: 615 (24.9%)). Across products, 10-18% of participants reported using nicotine strength ranging from 6-10 mg. Fruit, sweet/dessert, alcohol, coffee, and mint were the most used flavors. When shown marketing, ever-users liked and were likely to buy Zyn pouches compared to never users, and participants under 21 years felt equally targeted by Lucy and Zyn marketing. Liking Zyn marketing even a little bit compared to not at all increased the likelihood of buying Zyn pouches across age groups. After observing marketing, participants < 21 years were more likely to buy Zyn if they perceived marketing to contain messages about good tasting flavors (AOR 1.43, 1.09-1.87; 0.009) and helping to feel comfortable in social situations (AOR 1.38, 1.02-1.87; 0.033), and were more likely to buy Lucy if they felt it could be used anywhere (AOR 1.57, 1.05-2.33; 0.026).

CONCLUSIONS

This study provides a foundation for estimating use, behaviors, flavors, and marketing influence of oral nicotine products in the US and globally. Adolescent and young adult use of oral nicotine products and likelihood of buying products when exposed to marketing highlights the need for expanded tobacco use surveillance, marketing regulations, and counter marketing and educational efforts.

Sources of flavoured e-cigarettes among California youth and young adults: associations with local flavoured tobacco sales restrictions

PURPOSE

This study compares access to flavoured JUUL and other e-cigarettes from retail, online and social sources among underage and young adult e-cigarette users who live in California jurisdictions that restrict sales of flavoured tobacco with the rest of the state.

METHODS

An online survey used social media advertisements to recruit participants (n=3075, ages 15-29) who lived in one of nine jurisdictions that restrict sales (n=1539) or in the rest of state, and oversampled flavoured tobacco users. Focusing on past-month e-cigarette users (n=908), multilevel models tested whether access to flavoured JUUL and other e-cigarettes from retail, online and social sources differed by local law (yes/no) and age group (15-20 or older), controlling for other individual characteristics.

RESULTS

The percent of underage users who obtained flavoured JUUL and other e-cigarettes in the past month was 33.6% and 31.2% from retail, 11.6% and 12.7% online, and 76.0% and 70.9% from social sources, respectively. Compared with underage and young adult users in the rest of California, those in localities that restrict the sales of flavoured tobacco were less likely to obtain flavoured JUUL from retail sources (Adjusted OR=0.54, 95% CI 0.36 to 0.80), but more likely to obtain it from social sources (Adjusted OR=1.55, 95% CI 1.02 to 2.35). The same pattern was observed for other brands of flavoured e-cigarettes.

CONCLUSION

Although local laws may reduce access to flavoured e-cigarettes from retail sources, more comprehensive state or federal restrictions are recommended to close the loopholes for online sources. Dedicated efforts to curtail access from social sources are needed.

School-based programs to prevent adolescent e-cigarette use: A report card

Given high rates and known health consequences of adolescent e-cigarette use as well as adolescents' susceptibility to nicotine addiction, school-based efforts to prevent and reduce adolescent e-cigarette use should continue to be developed, implemented, disseminated, and evaluated. This paper elaborates on best practices for developing and implementing prevention programs, including the importance of grounding programs in theories and frameworks that empower adolescents, including normative and interactive education, and having programs that are easily accessible and free of cost. Programs should also address key factors driving adolescent e-cigarette use, including discussing misperceptions, flavors, nicotine content, addiction, and the role that marketing plays in appealing to adolescents. The paper also discusses the gap areas of currently available prevention programs and highlights the need for evidence-based approaches and the importance of rigorous evaluation of programs.

Use Patterns, Flavors, Brands, and Ingredients of Nonnicotine e-Cigarettes Among Adolescents, Young Adults, and Adults in the United States

IMPORTANCE

Nonnicotine e-cigarettes contain chemicals, flavorants, and solvents that have known health harms and/or have not been proven safe for inhalation.

OBJECTIVE

To evaluate nonnicotine e-cigarette use patterns, including common flavors, brands, and ingredients.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a convenience sample of US residents aged 13 to 40 years who completed an online survey in November and December 2021. Quota sampling was used for an equal proportion of participants aged 13 to 17 years, 18 to 20 years, and 21 to 40 years, balanced for sex, race, and ethnicity per the latest US Census.

MAIN OUTCOMES AND MEASURES

Nonnicotine e-cigarette use (ever, past 30- and past 7-day, number of times used, time taken to finish); co-use with nicotine e-cigarettes; age at first try; and flavors, brands, and ingredients used.

RESULTS

Overall, 6131 participants (mean [SD] age, 21.9 [6.8] years; range, 13-40 years; 3454 [56.3%] identifying as female) completed the survey (55.1% completion rate). Among all participants, 1590 (25.9%) had ever used a nonnicotine e-cigarette, 1021 (16.7%) used one in the past 30 days, and 760 (12.4%) used one in the past 7 days. By age group, 227 of 1630 participants aged 13 to 17 years (13.9%), 497 of 2033 participants aged 18 to 20 years (24.4%), 399 of 1041 participants aged 21 to 24 years (38.3%), and 467 of 1427 participants aged 25 to 40 years (32.7%) had ever used nonnicotine e-cigarettes. Among 1590 participants who had ever used a nonnicotine e-cigarette, 549 (34.5%) had used one more than 10 times; 1017 (63.9%) finished 1 nonnicotine e-cigarette in less than 1 week. Co-use of nonnicotine with nicotine e-cigarettes was reported by 1155 participants (18.8%), 1363 (22.2%) exclusively used nicotine e-cigarettes, and 431 (7.0%) exclusively used nonnicotine e-cigarettes. Most-used flavors were sweet, dessert, or candy (578 [36.3%]); fruit (532 [33.4%]); and mint or menthol (321 [20.2%]); similar flavor patterns were observed for the top 2 flavors among those who used nonnicotine e-cigarettes in the past 30 days, followed by combinations of coffee, alcohol, flower, plant, and mint or menthol flavors by age group. Participants most reported using tetrahydrocannabinol (587 [36.9%]), cannabidiol (537 [33.7%]), melatonin (438 [27.5%]), caffeine (428 [26.9%]), and essential oils (364 [22.9%]) in their nonnicotine e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study of adolescents, young adults, and adults, a sizeable proportion reported having used nonnicotine e-cigarettes and co-using them with nicotine e-cigarettes. Surveillance studies should further assess nonnicotine e-cigarette use patterns and regulations, and prevention should be developed to address youth appeal, unsubstantiated health claims, and possible health harms.

E-cigarette devices, brands, and flavors attract youth: Informing FDA's policies and priorities to close critical gaps

PURPOSE

Identify e-cigarette devices, brands, and flavor types used by adolescents and young adults soon after the enactment of flavor restrictions, youth access laws, FDA's enforcement prioritization against some flavored pod/cartridge-based e-cigarettes, and during COVID-19 pandemic-related school closures.

METHODS

National cross-sectional online survey (N = 4,351) in May 2020 assessed popularity, ever- and past-30-day use of e-cigarette device types (pod/cartridge-based, disposables, others), brands, flavor types and flavor-enhancers, by age group (under age 21 and 21 and over).

RESULTS

While pod/cartridge-based e-cigarettes had the highest ever-use (82.7% <21; 69.8% ≥21) and were most often-used (41.9% <21; 41.4% ≥21), most past 30-day-users (50.8% <21; 61.9% ≥21) and 7-day-users (36.0% <21; 56.7% ≥21) used disposables. Mint/menthol was the most-used flavor type (pod/cartridge-based: 48.2% <21, 48.1% ≥21; disposables: 51.6% <21, 56.4% ≥21), followed by fruit (pod/cartridge-based: 37.4% <21, 35.5%≥ 21; disposables: 51.6% >21, 46.2% ≥ 21), and sweet/dessert/candy flavor types (pod/cartridge-based: 24.4% <21, 24.7% ≥21; disposables: 29.7% <21, 33.8% ≥21). Participants reported using add-on e-cigarette flavor-enhancers (pod/cartridge-based: 24.6%; disposables: 31.3%).

CONCLUSION

Soon after FDA's January 2020 announcement of prioritized enforcement against flavored pod/cartridge-based e-cigarettes and during the pandemic lockdown, adolescents' and young adults' past 30-day use included mostly flavored disposables rather than pod/cartridge-based e-cigarettes, mint/menthol flavors, and some used add-on flavor enhancers. To reduce youth use, comprehensive regulation of e-cigarette devices and flavors should be enacted and enforced at federal, state, and local levels.

Development and Reach of the Stanford Tobacco Prevention Toolkit: Implementation of a Community-Based Participatory Approach

BACKGROUND

We developed the Tobacco Prevention Toolkit (Toolkit) to enhance the impact of school-based tobacco education. This study describes the process of developing the Toolkit, its contents, and reach.

METHODS

Qualitative community-based participatory research (CBPR), including focus group discussions (N = 152) and working groups with parents, educators, researchers, and youth (N = 87) were used to develop the Toolkit and design its implementation. Toolkit reach was assessed through number of trained educators using the Toolkit, estimated number of youth recipients of the Toolkit resources, and using Google Analytics for online engagement.

RESULTS

The Toolkit is a free, online resource aimed at preventing tobacco use by middle and high school students. Toolkit content addresses varied forms of tobacco including electronic cigarettes, hookah, smokeless tobacco, and cigarettes; addiction; and positive youth development; and is available in multiple interactive formats such as real-time quizzes, factsheets, activities, and presentations. The Toolkit is mainly delivered by trained educators, who adapt its content and duration to tailor their drug prevention teaching to student needs. As of April 2020, when data for this paper were collected, 4,750 educators have reached an estimated 1.3 million youth. The Toolkit website has 186,116 users and 802,602 page views, growing steadily since 2016. As of August 2021, additional students have been reached, for now a total of 1.85 million students reached.

CONCLUSION

The Toolkit resources are evidence-based, comprehensive, responsive, interactive, easily accessible, and flexible. Applying CBPR was instrumental in developing the Toolkit and expanding its reach.

JUUL and other e-cigarettes: Socio-demographic factors associated with use and susceptibility in California

This study examined which socio-demographic factors are associated with susceptibility (lack of commitment to avoid future use), past-12-month and past-30-day use of JUUL and other e-cigarettes, and reasons for and against using JUUL. An online survey of 3,075 Californians ages 15-29, including 24.3% who identified as LGBTQ, were recruited via social media in January-March 2019. Multi-level weighted logistic regression models suggest that LGBTQ participants were more likely to be susceptible to JUUL [AOR = 2.11 (1.60, 2.79) (parentheses include 95% Confidence Intervals)] and other e-cigarettes [AOR = 2.31 (1.75, 3.05)], and more likely to use JUUL [AOR = 1.27 (1.02, 1.58)] and other e-cigarettes [AOR = 1.66 (1.35, 2.05)] in the past 12 months. Susceptibility to using JUUL was more likely among adolescents (ages 15-17) [AOR = 1.72 (1.30, 2.28)] and young adults (ages 18-20) [AOR = 1.26 (1.00,1.58)] than adults (ages 21-29). At the community level, living in jurisdictions with higher median household income was associated with a higher likelihood of being susceptible to using JUUL and other e-cigarettes. Compared to non-Hispanic Whites, Asian/Pacific Islanders were less likely to use JUUL [AOR = 0.68 (0.54, 0.86)] and other e-cigarettes [AOR = 0.60 (0.48, 0.76)] in the past 12 months. Past-30-day JUUL use was more likely among males than females [AOR = 1.44 (1.11, 1.88)]. Common reasons for using JUUL were: friends' use, flavors, "safer" than cigarettes, no one will notice, and nicotine rush is greater than other devices. Common reasons against using JUUL were: harmful to self/others, contains nicotine and is addictive. E-cigarette prevention and cessation efforts should include tailored messaging for people who identify as LGBTQ and reinforce reasons for not vaping nicotine.

Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis

BACKGROUND

Educational interventions engage youth using visual, literary and performing arts to combat stigma associated with mental health problems. However, it remains unknown whether arts interventions are effective in reducing mental-health-related stigma among youth and if so, then which specific art forms, duration and stigma-related components in content are successful.

METHODS

We searched 13 databases, including PubMed, Medline, Global Health, EMBASE, ADOLEC, Social Policy and Practice, Database of Promoting Health Effectiveness Reviews (DoPHER), Trials Register of Promoting Health Interventions (TRoPHI), EPPI-Centre database of health promotion research (Bibliomap), Web of Science, PsycINFO, Cochrane and Scopus for studies involving arts interventions aimed at reducing any or all components of mental-health-related stigma among youth (10-24-year-olds). Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Data were extracted into tables and analysed using RevMan 5.3.5.

RESULTS

Fifty-seven studies met our inclusion criteria (n = 41,621). Interventions using multiple art forms are effective in improving behaviour towards people with mental health problems to a small effect (effect size = 0.28, 95%CI 0.08-0.48; p = 0.007) No studies reported negative outcomes or unintended harms. Among studies using specific art forms, we observed high heterogeneity among intervention studies using theatre, multiple art forms, film and role play. Data in this review are inconclusive about the use of single versus multiple sessions and whether including all stigma components of knowledge, attitude and behaviour as intervention content are more effective relative to studies focused on these stigma components, individually. Common challenges faced by school-based arts interventions included lack of buy-in from school administrators and low engagement. No studies were reported from low- and middle-income countries.

CONCLUSION

Arts interventions are effective in reducing mental-health-related stigma to a small effect. Interventions that employ multiple art forms together compared to studies employing film, theatre or role play are likely more effective in reducing mental-health-related stigma.

Measures of both perceived general and specific risks and benefits differentially predict adolescent and young adult tobacco and marijuana use: findings from a Prospective Cohort Study

Health behavior theorists and prevention researchers use a variety of measures of adolescent and young adult (AYA) risk and benefit perceptions to predict tobacco-use and marijuana-use behaviors. However, studies have not examined whether and how perception measures that ask about likelihood of more general outcomes such as "harm" versus ask about specific risk or benefit outcomes compare or whether they differentially predict AYA willingness to use if one of your best friends were to offer it and intentions to use in the next year; and if these measures have differential ability to predict actual use of tobacco and marijuana. We used data from a prospective cohort of California AYAs to create and test new scales to measure perceptions of specific health and social outcomes related to risks (e.g., smell bad) and benefits (e.g., look cool) related to tobacco and marijuana, and then addressed three questions: (1) Whether and how measures of perceptions of specific social and health risks and benefits (for our purposes "specific measures") and measures of perceived general harm are differentially associated with measures of willingness, social norms, and intentions to use? (2) Are specific versus general measures differentially associated with and predictive of tobacco and cannabis use behavior? (3) Are specific perceptions measures differentially predictive of behavior compared to measures of willingness, social norms, and behavioral intentions? Our results demonstrate that to better predict AYA tobacco and marijuana use, measures that address general outcomes, such as harmfulness, as well as willingness and behavioral intention should be used. We also found that measures of specific perceived risks (short-term, long-term, social) and benefits were unrelated and correlated differently with different products. For example, adolescents perceived both risks and benefits from using products like e-cigarettes, and perceived greater risk from smokeless tobacco compared to combustible cigarettes. These findings indicate that measures of specific perceived social and health outcomes can be useful to discern nuanced differences in motivation for using different substances. Study implications are important for survey dimension-reduction and assessing relationships among perceptions, motivations, and use of tobacco and marijuana products.

School-based e-cigarette education in Alabama: Impact on knowledge of e-cigarettes, perceptions and intent to try

BACKGROUND AND OBJECTIVES

Educational programs are needed to combat the sharp rise in adolescent e-cigarette use. We assessed adolescent knowledge about e-cigarettes, perceptions of harmfulness and addictiveness and intent to try e-cigarettes before and after an e-cigarette educational session.

METHODS

We conducted a one-group pre- and post-test study among middle and high school students in Alabama in 2019. The intervention included a 30-minute educational session based on the Stanford Tobacco Prevention Toolkit on e-cigarette types, contents, marketing and advertising, health effects and nicotine addiction. McNemar tests of paired proportions and multi-level, mixed-effects logistic regression models were used to analyze intervention effects.

RESULTS

Surveys were completed by 2,889 middle and high school students. The intervention was associated with significantly increased knowledge about e-cigarettes and perceptions that e-cigarettes are harmful and addictive, and with significantly lower intent to try e-cigarettes. At pre-test, middle school students had lower knowledge, believed that e-cigarettes were not as addictive and showed higher intent to try both e-cigarettes and cigarettes compared to high school students. Groups that were associated with lower perceived harmfulness and addictiveness were: ever-users of e-cigarettes, ever-users of both e-cigarettes and cigarettes and prior users of mint/menthol flavored e-cigarettes.

CONCLUSIONS

A school-based educational session was significantly associated with improved adolescent knowledge about e-cigarettes, increased the perceived harmfulness and addictiveness of e-cigarettes, and reduced intent to try e-cigarettes. E-cigarette education should be prioritized for middle school students due to lower levels of knowledge and higher intent to try tobacco compared to high school students.

Underage Youth and Young Adult e-Cigarette Use and Access Before and During the Coronavirus Disease 2019 Pandemic

IMPORTANCE

Understanding patterns of e-cigarette use and access during the coronavirus disease 2019 (COVID-19) pandemic is important because e-cigarettes may put users at risk for more severe respiratory effects and other health problems.

OBJECTIVE

To examine whether underage youth and young adults who ever used e-cigarettes self-reported changes in access and use of e-cigarettes since the COVID-19 pandemic began.

DESIGN, SETTING, AND PARTICIPANTS

A national, cross-sectional online survey study was conducted from May 6 to May 14, 2020. This sample of 4351 participants aged 13 to 24 years across the US included 2167 e-cigarette ever-users. Quota sampling was used to balance for age, sex, race/ethnicity, and 50% having ever used e-cigarettes.

MAIN OUTCOMES AND MEASURES

Change in e-cigarette use (increase, decrease, quit, no change, and switch to another product) and access to e-cigarettes (easier or harder, and change in point-of-purchase) before and after the COVID-19 pandemic began, reasons for change, number of times e-cigarettes were used, nicotine dependence, and sociodemographic data.

RESULTS

This study focused on 2167 e-cigarette ever-users among 4351 participants who completed the survey. Among 2167 e-cigarette users, a total of 1442 were younger than 21 years and 725 were aged 21 years or older; 1397 were female (64.5%) and 438 identified as lesbian, gay, bisexual, transgender, queer (20.2%). The survey completion rate was 40%. Since the COVID-19 pandemic began, 1198 of 2125 e-cigarette users (56.4%) changed their use: 388 individuals (32.4%) quit, 422 individuals (35.3%) reduced the amount of nicotine, 211 individuals (17.6%) increased nicotine use, 94 individuals (7.8%) increased cannabis use, and 82 individuals (6.9%) switched to other products. Participants reported that not being able to go to vape shops and product unavailability were the reasons accessing e-cigarettes was difficult after the pandemic began. Since the COVID-19 pandemic began, individuals reported purchasing from alternative retail stores (disposables, 150 of 632 [23.7%]; pod-based, 144 of 797 [18.1%]; and other e-cigarette, 125 of 560 [22.3%], ie, between 18.1% and 23.7%), purchasing online instead of retail (disposables, 115 of 632 [18.2%]; pod-based, 156 of 797 [19.6%]; and other e-cigarette, 111 of 560 [19.8%], ie, between 18.2% to 19.8%), and shifted to retail instead of online (disposables, 11 of 632 [1.7%]; pod-based, 17 of 797 [2.0%]; and other e-cigarette, 13 of 560 [2.3%], ie, between 1.7%-2.3%). Other individuals reported no change: from retail stores (disposables 262 of 632 [41.5%]; pod-based 344 of 797 [43.2%]; and other e-cigarette, 223 of 560 [39.8%], ie, between 39.8% and 43.2%) and online (disposables 94 of 632 [14.9%]; pod-based 136 of 797 [17.1%]; and other e-cigarette, 88 of 560 [15.8%], ie, between 14.9% and 17.1%). Underage youth reported e-cigarette deliveries from vape shops and/or dealers or friends who received such deliveries, and 63 of 229 (27.5%) self-reported accessing e-cigarettes without age verification. e-Cigarette users were 52% less likely to quit or reduce their use if they previously used e-cigarettes between 11 and 99 times (adjusted odds ratio, 0.48; 95% CI, 0.30-0.78), 68% less likely to quit if they previously used e-cigarettes more than 100 times (adjusted odds ratio, 0.32; 95% CI, 0.20-0.51), and 51% were less likely to quit if they were nicotine dependent (adjusted odds ratio, 0.49; 95% CI, 0.35-0.70).

CONCLUSIONS AND RELEVANCE

During the COVID-19 pandemic, youth e-cigarette users reported changes in e-cigarette use, point-of-purchase, and ability to purchase e-cigarettes without age verification. The US Food and Drug Administration and local policy makers may find these data useful to inform policies to prevent e-cigarette sales to underage youth.

Stigma associated with mental health problems among young people in India: a systematic review of magnitude, manifestations and recommendations

BACKGROUND

Globally, 20% of young people experience mental disorders. In India, only 7.3% of its 365 million youth report such problems. Although public stigma associated with mental health problems particularly affects help-seeking among young people, the extent of stigma among young people in India is unknown. Describing and characterizing public stigma among young people will inform targeted interventions to address such stigma in India, and globally. Thus, we examined the magnitude and manifestations of public stigma, and synthesised evidence of recommendations to reduce mental-health-related stigma among young people in India.

METHOD

A systematic review and meta-analysis of observational studies was conducted. Nine electronic databases were searched and 30 studies (n = 6767) met inclusion criteria.

RESULTS

Most studies (66%) focused on youth training to become health professionals. One-third of young people display poor knowledge of mental health problems and negative attitudes towards people with mental health problems and one in five had actual/intended stigmatizing behavior (I2>=95%). Young people are unable to recognize causes and symptoms of mental health problems and believe that recovery is unlikely. People with mental health problems are perceived as dangerous and irresponsible, likely due to misinformation and misunderstanding of mental health problems as being solely comprised of severe mental disorders (e.g. schizophrenia). However, psychiatric labels are not commonly used/understood.

CONCLUSION

Public education may use symptomatic vignettes (through relatable language and visuals) instead of psychiatric labels to improve young people's understanding of the range of mental health problems. Recommended strategies to reduce public stigma include awareness campaigns integrated with educational institutions and content relevant to culture and age-appropriate social roles.

A Breath of Knowledge: Overview of Current Adolescent E-cigarette Prevention and Cessation Programs

Purpose

Adolescent use of electronic cigarettes (e-cigarettes) has risen rapidly, which is concerning given the health effects of e-cigarettes and youth susceptibility to nicotine addiction. It is critical that efforts to educate, prevent, and reduce adolescent use of e-cigarettes are developed and evaluated. The purpose of this paper is to review available current prevention and cessation programs.

Findings

A web-based search of currently available e-cigarette prevention and cessation/treatment programs was conducted using Google in May of 2020. Programs were then reviewed on whether they included theory- and evidence-based practices of effective adolescent prevention and cessation programs. Eight prevention programs, seven cessation programs, and one program that addressed both prevention and cessation were identified and included in this review. Most prevention programs included the importance of understanding flavored e-cigarette products, addressed industry-targeted marketing, included social learning activities to develop refusal skills, delivered free-of-cost, available online, and explicitly stated their incorporation of theory. Five prevention programs and two cessation programs had empirically evaluated their e-cigarette-related components.

Conclusions

Although the programs reviewed largely incorporated theory and included key components known to be effective, there are some gaps in the programs’ overall ability to prevent and stop adolescents from using e-cigarettes, such as lack of dedicated e-cigarette materials. More evidence-based tools, resources, and evaluations are needed to best inform adolescent e-cigarette cessation. Addressing the gaps that existing prevention and cessation programs present requires intervening at multiple systematic levels, conducting more rigorous program evaluations, and bolstering the availability of cessation programs.

'No time for health:' exploring couples' health promotion in Indian slums

Joint involvement of couples is an effective strategy to increase contraceptive use and improve reproductive health of women. However, engaging couples to understand how their gender attitudes affect their personal and family health is an idea in search of practice. This mixed-methods study explores opportunities and barriers to couples' participation in health promotion in three slums of Delhi. For each couple, surveys and semi-structured interviews were conducted with husbands and wives individually to contrast self and spousal work, time, interest in health, sources of information related to health and depth of knowledge (n = 62). Urban poverty forces men to work long hours and women to enter part-time work in the informal sector. Paid work induces lack of availability at home, lack of interest in health information and in performing household chores and a self-perception of being healthy among men. These factors inhibit men's' participation in community-based health promotion activities. Women's unpaid work in the household remains unnoticed. Women were expected to be interested in and to make time to attend community-based health-related activities. Men recalled significantly less sources of health information than their spouse. Men and their wives showed similar depth of health-related knowledge, likely due to their spousal communication, with women acting as gatekeepers. Health promotion planners must recognize time constraints, reliance on informal interpersonal communication as a source of health information and the need to portray positive masculinities that address asymmetric gender relations. Innovative, continuous and collaborative approaches may support couples to proactively care about health in low-resource settings.

Association Between Youth Smoking, Electronic Cigarette Use, and COVID-19

PURPOSE

This study aimed to assess whether youth cigarette and electronic cigarette (e-cigarette) use are associated with coronavirus disease 2019 (COVID-19) symptoms, testing, and diagnosis.

METHODS

An online national survey of adolescents and young adults (n = 4,351) aged 13-24 years was conducted in May 2020. Multivariable logistic regression assessed relationships among COVID-19-related symptoms, testing, and diagnosis and cigarettes only, e-cigarettes only and dual use, sociodemographic factors, obesity, and complying with shelter-in-place.

RESULTS

COVID-19 diagnosis was five times more likely among ever-users of e-cigarettes only (95% confidence interval [CI]: 1.82-13.96), seven times more likely among ever-dual-users (95% CI: 1.98-24.55), and 6.8 times more likely among past 30-day dual-users (95% CI: 2.40-19.55). Testing was nine times more likely among past 30-day dual-users (95% CI: 5.43-15.47) and 2.6 times more likely among past 30-day e-cigarette only users (95% CI: 1.33-4.87). Symptoms were 4.7 times more likely among past 30-day dual-users (95% CI: 3.07-7.16).

CONCLUSIONS

COVID-19 is associated with youth use of e-cigarettes only and dual use of e-cigarettes and cigarettes, suggesting the need for screening and education.

Public Health Considerations for Adolescent Initiation of Electronic Cigarettes

Adolescent use of electronic cigarettes (e-cigarettes) has increased dramatically, with younger and nicotine-naive adolescents starting to use these devices and use them more frequently than combustible cigarettes. In emerging evidence, it is shown that e-cigarettes are not effective in helping adult smokers quit and that youth using e-cigarettes are at risk for becoming nicotine dependent and continuing to use as adults. Important gaps in our knowledge remain regarding the long-term health impact of e-cigarettes, effective strategies to prevent and reduce adolescent e-cigarette use, and the impact of provider screening and counseling to address this new method of nicotine use.

Physical Activity Among Adolescents in India: A Qualitative Study of Barriers and Enablers

Inadequate physical activity (PA) levels are reported in Indian youth, with lowest levels among adolescents, particularly girls. We aimed to identify barriers to and enablers of PA among school children in New Delhi and examine potential differences by gender and school type (government vs. private). A total of 174 students (private school students = 88, 47% girls; government school students = 86, 48% girls) aged 12 to 16 years from two Delhi schools participated in 16 focus group discussions (FGDs) conducted by bilingual moderators. We conducted FGDs separately for girls and boys, for students in Grades VIII and IX, and for private and government schools. We conducted FGDs among government school students in Hindi and translated the transcriptions to English for analysis. We coded transcriptions using a combination of inductive and deductive approaches, guided by the "youth physical activity promotion model." We identified various personal, social, and environmental barriers and enablers. Personal barriers: Private school girls cited body image-related negative consequences of PA participation. Social barriers: Girls from both schools faced more social censure for participating in PA. Environmental barriers: Reduced opportunity for PA in schools was commonly reported across all participants. Personal enablers: All participants reported perceived health benefits of PA. Social enablers: Several participants mentioned active parents and sports role models as motivators for increasing PA. Few environmental enablers were identified. This study highlights the need for further investment in physical activity within schools and for gender-sensitive policies for encouraging PA participation among adolescents in India.

Global treatment costs of breast cancer by stage: A systematic review

Background

Published evidence on treatment costs of breast cancer varies widely in methodology and a global systematic review is lacking.

Objectives

This study aimed to conduct a systematic review to compare treatment costs of breast cancer by stage at diagnosis across countries at different levels of socio-economic development, and to identify key methodological differences in costing approaches.

Data sources

MEDLINE, EMBASE, and NHS Economic Evaluation Database (NHS EED) before April 2018.

Eligibility criteria

Studies were eligible if they reported treatment costs of breast cancer by stage at diagnosis using patient level data, in any language.

Study appraisal and synthesis methods

Study characteristics and treatment costs by stage were summarised. Study quality was assessed using the Drummond Checklist, and detailed methodological differences were further compared.

Results

Twenty studies were included, 15 from high-income countries and five from low- and middle-income countries. Eleven studies used the FIGO staging system, and the mean treatment costs of breast cancer at Stage II, III and IV were 32%, 95%, and 109% higher than Stage I. Five studies categorised stage as in situ, local, regional and distant. The mean treatment costs of regional and distant breast cancer were 41% and 165% higher than local breast cancer. Overall, the quality of studies ranged from 50% (lowest quality) to 84% (highest). Most studies used regression frameworks but the choice of regression model was rarely justified. Few studies described key methodological issues including skewness, zero values, censored data, missing data, and the inclusion of control groups to estimate disease-attributable costs.

Conclusions

Treatment costs of breast cancer generally increased with the advancement of the disease stage at diagnosis. Methodological issues should be better handled and properly described in future costing studies.

Enhancing mental health literacy in India to reduce stigma: the fountainhead to improve help-seeking behaviour

Purpose

– Lack of understanding around mental illness and stigma are an overwhelming barrier in help-seeking behaviour for mental health concerns. The purpose of this paper is to examine mental health literacy and social attitudes as instrumental factors in building capacity of the demand-side to support and access mental health care at the community level in India.

Design/methodology/approach

– Knowledge, Attitude and Practice surveys were administered to 521 persons from the general population, distributed equally in the age range of 15-60 years. The study included 52 respondents per district from ten districts across five states in India, namely Andhra Pradesh, Assam, Delhi, Gujarat and Uttar Pradesh. The responses were collected and analysed thematically, keeping in mind the relevance of these findings as contributors to knowledge of mental health and to the construct of stigma.

Findings

– Pervasive socio-cultural factors, especially stigma inhibit access to basic mental health information and care, despite knowledge that mental illness is treatable. Degrading treatment, loss of personal liberty and social exclusion, i.e. compromised human rights at the community level are widespread. Self-reported attitudes when encountering a person with mental illness show that respondents act out of fear and are guided by misinformation and myths. Extant knowledge on mental health is attributed predominantly to informal networks, as a potential resource to be strengthened.

Practical implications

– Realising mental health care, including help-seeking behaviour calls for greater knowledge-sharing, sensitisation and community engagement.

Originality/value

– This paper fulfils an identified need to study current levels of mental health literacy and underlying perceptions that contribute to the persistent treatment gap.