Non-tobacco nicotine E-cigarette use and flavored E-cigarette use among young adults in the United States

BACKGROUND

E-cigarette flavors can create sensations of sweetness and coolness while masking the aversiveness of nicotine. Recently, non-tobacco nicotine (NTN) products were introduced to the market, but little is known about flavors in NTN e-cigarette use. We examined associations between flavors (i.e., sweet, mint/menthol) and susceptibility to and use of NTN e-cigarettes.

METHODS

1239 US young adults (18-25 years) completed an anonymous, online survey in Fall 2021. The analytic sample included 520 participants who had used e-cigarettes and heard of NTN. Multinomial logistic regression models analyzed associations of flavored e-cigarette use (sweet and mint/menthol) with NTN e-cigarette use status (i.e., current [past-month] use, past [ever but not current] use, susceptible to use, and non-susceptible to use [reference]).

RESULTS

Overall, 46.2% of participants reported current NTN use, 14.8% reported past use, 16.7% were susceptible to use, and 22.3% reported no susceptibility. Participants reported dual-use of sweet and mint/menthol NTN e-cigarette flavors (56.5%), sweet flavors use (24.8%), and mint/menthol flavor use (1.7%). Ever dual use of sweet and mint/menthol flavors was associated with current (OR = 9.64, 95%CI: 3.21-28.98) and past NTN e-cigarette use (8.30, [2.10-32.80]). Ever sweet flavor use was associated with current NTN use (3.80, 95%CI: 1.44-10.03) and susceptibility to future use (4.25, [1.53-11.81]). Similar findings were observed for mint/menthol flavors (current: 5.03, [1.41-17.99]; susceptible: 5.65, [1.64-19.51]).

CONCLUSION

The use of sweet and mint/menthol flavors was significantly associated with NTN e-cigarette use among US young adults, highlighting the need for ongoing surveillance of flavored NTN e-cigarettes and appropriate regulations to discourage use.

Sources of exposure to non-tobacco nicotine electronic nicotine delivery systems and associations with susceptibility to use and use behaviors among young adults in the United States

INTRODUCTION

The Electronic Nicotine Delivery Systems (ENDS) industry recently introduced non-tobacco nicotine (NTN), which is not tobacco-derived and is often marketed as "tobacco-free nicotine." Given its novelty, it is important to understand where young adults learn about NTN ENDS. This study examined sources of exposure to NTN ENDS and relationships with NTN ENDS use and susceptibility.

METHODS

We analyzed online survey data collected in Fall 2021 from 642 young adults (18-25 years) who had heard of NTN ENDS. We assessed 9 sources of NTN ENDS exposure (e.g., retail stores, social media) and examined associations between sources of exposure and NTN current (past-month) use, lifetime (non-current) use, and susceptibility to use, adjusting for demographics and other tobacco product use.

RESULTS

Participants reported current NTN ENDS use (37.4%), lifetime use (12.0%), susceptibility (18.5%), or no susceptibility to use (32.1%). The most common sources of NTN ENDS exposure were retail stores (87.7%) and social media (81.0%). Exposure to NTN ENDS via social media was associated with greater odds of current NTN ENDS use (vs. no susceptibility) (aOR = 1.83, 95%CI: 1.02-3.28). Exposure via online streaming platforms was associated with greater odds of current (aOR = 1.75, 95%CI: 1.08-2.82) and lifetime NTN ENDS use (aOR = 2.42, 95%CI: 1.25-4.68).

CONCLUSIONS

Young adults were exposed to and learned about NTN ENDS from diverse sources, primarily retail shops and social media. Further, exposure via social media and streaming platforms were associated with NTN ENDS use. Future studies should explore the content of NTN information from various sources to inform prevention efforts.

Sources of Contraception Among Adolescents and Young Adults

This cross-sectional study describes the nationwide pattern of contraception access by sociodemographic characteristics and health care settings among US youth aged 15 to 24 years.

Treating Adolescent Opioid Use Disorder in Primary Care

This survey study explores primary care pediatricians’ preparedness to counsel and treat adolescents with opioid use disorder (OUD) and perceived barriers to prescribing OUD medications.

Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study

PURPOSE

Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters.

DESIGN

Observational cohort study.

SUBJECTS AND SETTING

The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children.

METHOD

Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters.

RESULTS

Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only.

CONCLUSIONS

Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

Shared and distinct parental influences on teen impaired driving in rural and suburban contexts: A mixed methods study of young drivers

OBJECTIVE

To explore shared and distinct parental influences on rural and suburban adolescents' riding with an impaired driver (RWI) and driving while impaired (DWI) behaviors during high school.

METHODS

Participants in the NEXT Generation Health Study (NEXT) were classified into four RWI/DWI trajectory classes (i.e., Abstainer, Escalator, Decliner, Persister) which described patterns of RWI/DWI from high school to emerging adulthood. A follow-up, in-depth, qualitative interview was conducted with a purposeful selection of participants from each trajectory class between March and September 2020. Guided by Ecodevelopmental Theory, the interview included questions which explored parent-teen influences on driving and RWI/DWI.

RESULTS

Imposition of a curfew was a shared parental influence in rural and suburban contexts. Unique to the rural context, parent modeling of RWI/DWI was described as normative and occurring since childhood.

CONCLUSIONS

Prevention interventions targeting parent RWI/DWI may reduce their children's risk for RWI/DWI among rural adolescents.

Do adolescent trajectories of riding with an impaired driver and driving impaired predict similar behaviors in early adulthood?

BACKGROUND

A recent study shows four trajectories of riding with an impaired driver (RWI) and driving while impaired (DWI) from adolescence to emerging adulthood. We examined prospective associations of adolescent RWI/DWI trajectory class with early adulthood RWI/DWI behavior.

METHODS

Data were from the NEXT Generation Health Study (NEXT), a nationally representative longitudinal study (N = 2783) beginning with a 10th-grade cohort completing 7 annual assessment waves (W1-W7) between 2010 and 2016 and a later follow-up mixed methods study. Four RWI and DWI trajectories derived from a recently published latent class analysis study (RWI (last 12 months); DWI (last 30 days) dichotomized as ≥ once vs. none) were used: Abstainer, Escalator, Decliner, and Persister. In the follow-up examination, a purposive subsample (N = 105, 26.3 ± 0.5 y/o, Female 50.5%) of NEXT participants were selected by trajectory (31 Abstainers, 33 Escalators, 14 Decliners, and 27 Persisters) for in-depth interviews 4 years after NEXT. In interviews, self-reported RWI events (number of times) related to alcohol (Alc-RWI) or marijuana (MJ-RWI) use in the last 12 months, and DWI events (number of times) related to alcohol (Alc-DWI) & marijuana (MJ-DWI) use in January 2020 (pre-COVID pandemic) were collected using structured surveys. General linear models were used to examine associations of adolescents' RWI/DWI trajectories with early adulthood RWI/DWI behavior, controlling for sex, health status, education attainment, and work hours.

RESULTS

The mean number (SD) of Alc-RWI and MJ-RWI events reported by Escalators (3.83(2.48), 2.43(2.77)) and Persisters (3.83(2.43), 3.57(2.54)) were higher (p≤0.05) than Abstainers (0.82(1.42), 0.77(2.04)) and Decliners (1.81 (2.69), 1.38 (2.04)). Similarly, Escalators (1.61 (2.28), 1.88(2.69)) and Persisters (1.96(2.08), 1.93(2.48)) reported more Alc-DWI and MJ-DWI events than Abstainers (0.18 (0.53), 0.42(1.38)) and Decliners (0.00 (0.00), 0.08(0.28)). Linear regression models indicated membership in Escalator and Persister classes compared to Abstainer class was associated (p≤0.01) with higher engagement in RWI/DWI in early adulthood.

CONCLUSION

Adolescents with escalating and persistent high RWI/DWI may continue these health risking behaviors into their mid-twenties. Decliners during the transition maintained low RWI/DWI into their mid-twenties. Taken together, these findings suggest that earlier reduction may have long-term effects. Our findings can be used to inform the precision tailoring of prevention efforts aimed at effectively reducing alcohol/drug impairment crash injuries and related deaths among those in early adulthood.

Longitudinal perspectives of riding with a cannabis-impaired driver

OBJECTIVE

To explore decisions and perceptions of engaging in riding with a cannabis-impaired driver (RWI) during high school and young adulthood to build context around RWI-cannabis events.

METHODS

Participants were sampled from the NEXT Generation Health Study (NEXT), a 7-year national cohort study of adolescent health behaviors. Four RWI and driving while impaired (DWI) trajectories classes (i.e., Abstainer, Escalator, Decliner, Persister) were previously derived.A theoretical model based on ecological systems theory guidedin-depth semi-structured interviews to includecomplex, social-developmental and environmental multi-level factors affectingpersonal experiences with RWI-cannabis during high school, after high school, and during young adulthood. Participants (n = 105) were purposively selected from each trajectory class for follow-up, in-depth, qualitative interviews. All interviews were conducted via Zoom between March and September 2020.

RESULTS

Two unique themes emerged as facilitators of RWI-cannabis: "Driving Context" and "Trust in Driver". "Legal Concerns" and "Concerns with Safety Emerge with Age" were themes that described deterrents to RWI-cannabis.

CONCLUSIONS

Current data suggest that youth RWI-cannabis occurs during daytime hours and while driving to everyday activities. Youth report legal concerns as a potential deterrent to RWI-cannabis in high school and concerns for safety emerge in young adulthood. The multifaceted nature of RWI-cannabis among young drivers identifies potential complexities for programming designed to reduce RWI/DWI-cannabis.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

The first nicotine product tried is associated with current multiple nicotine product use and nicotine dependence among a nationally representative sample of U.S. youths

This study examines the demographic factors associated with youths' first product tried (i.e., cigarettes, e-cigarettes, cigars, hookah, or smokeless tobacco). This study also evaluates whether the first product tried is associated with future nicotine product use (i.e., no use, single product use, and multiple product use) and nicotine dependence. Participants were 1999 youths (ages 12-17 years) who had ever tried a nicotine product and completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments. Two separate multinomial logistic regression models examined the association between 1) demographic factors and the first product tried at Wave 1 and 2) the first product tried at Wave 1 and past-30-day product use status at Wave 4. A two-part multivariable model examined the association between the first product tried and nicotine dependence, with part 1 modeling the presence (or absence) of any symptom of dependence and part 2 modeling the degree of dependence among those with any symptom of dependence. The first product tried was associated with sex, race, urbanicity, and parent education. First trying smokeless tobacco (vs. e-cigarettes) was associated with a greater likelihood of multiple product use (vs. no use and vs. single product use). Regarding the degree of nicotine dependence (n = 713), first trying smokeless tobacco (vs. e-cigarettes) was associated with higher nicotine dependence scores among those with any symptom of dependence. Youths who first try smokeless tobacco (vs. e-cigarettes) may be at higher risk for future multiple product use and more symptoms nicotine dependence. Research should explore tailored interventions for smokeless tobacco users.

"Tobacco-free" Nicotine Pouches: Risk Perceptions, Awareness, Susceptibility, and Use Among Young Adults in the United States

BACKGROUND

Nicotine pouches containing synthetic nicotine or tobacco-derived nicotine (TDN) are available in the United States. Synthetic nicotine pouches are often marketed as "tobacco-free nicotine" (TFN), which may alter risk perceptions and product appeal. This study examined young adults' perceptions of TFN versus TDN pouches and the associations between product perceptions and TFN pouch awareness, susceptibility, and use, respectively.

AIMS AND METHODS

In total 630 young adults (18-25 years) completed an online Qualtrics panels survey in 2021. Participants were informed that TFN pouches contain synthetic nicotine as opposed to TDN. Participants reported on comparative risk perceptions for TFN versus TDN pouches and on TFN pouch awareness, susceptibility, and use. Unadjusted between-group comparisons and adjusted binary logistic regressions were run to examine relationships between product perceptions and TFN pouch awareness, susceptibility, and use.

RESULTS

Participants were aware of (37.3%), susceptible to (29.2%), or had used TFN pouches (3.8%). In unadjusted comparisons, TFN pouch awareness, susceptibility, and use were associated with disproportionately perceiving TFN pouches as less harmful or otherwise better than TDN pouches. In adjusted models, relationships between favorable perceptions and both TFN pouch awareness and susceptibility remained significant.

CONCLUSIONS

The descriptor "tobacco-free" may impact risk perceptions and the appeal of nicotine pouches among young adults. While no direct relationship was observed between TFN perceptions and TFN pouch use in the adjusted model, perceptions remained related to product awareness and susceptibility, which may be linked to future use. Continued surveillance is needed to fully determine how the term "tobacco-free" on product packaging and advertising impacts longitudinal public health outcomes.

IMPLICATIONS

Nicotine pouches originally contained TDN. Today, numerous brands of synthetic nicotine pouches, which are often marketed as "tobacco-free," are available on the market. We informed participants that "tobacco-free nicotine" pouches contain synthetic nicotine and examined comparative risk perceptions (i.e. tobacco-free vs. TDN pouches) and TFN pouch awareness, susceptibility, and use. Perceiving tobacco-free nicotine pouches as less harmful than tobacco-derived pouches was associated with product awareness, susceptibility, and use in unadjusted models and with awareness and susceptibility in adjusted models. Restricting the term "tobacco-free" may become necessary if the term inaccurately reduces product risk perceptions or increases product appeal.

Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States

BACKGROUND

Oral nicotine pouches (NPs) that contain nicotine but no tobacco leaves are rapidly gaining popularity. However, there is limited research on NPs, including within priority populations. In the current study, we examined awareness of, susceptibility to, and use of NPs in young adults as well as comparative risk perceptions with smokeless tobacco.

METHODS

In 2021, 609 young adults (18-25 years) completed an online survey. Participants reported on NP awareness, susceptibility, and use as well as on comparative product perceptions for NPs versus smokeless tobacco. We ran unadjusted between-groups comparisons and an adjusted multinomial logistic regression to identify relationships between product perceptions and NP susceptibility and use.

RESULTS

41.5% of participants had heard of NPs before. Participants were non-susceptible (66.2%), susceptible (23.5%), or had used NPs (10.3%). Comparative product perceptions between NPs and smokeless tobacco suggested that young adults, as a whole, expressed uncertainty about the relative risk/benefit of using NPs versus smokeless tobacco. However, as expected, unadjusted and adjusted findings indicated that favorable perceptions of NPs versus smokeless tobacco were disproportionately observed among susceptible participants and NP users compared to non-susceptible individuals. Demographic differences were also observed (e.g., NP users were more likely than non-susceptible and susceptible individuals to have used smokeless tobacco).

CONCLUSIONS

Young adults reported awareness of, susceptibility to, and use of NPs, with findings indicating that favorable perceptions of NPs versus smokeless tobacco may contribute to NP susceptibility and use beyond known correlates like smokeless tobacco use. However, further research is needed to understand the full range of factors that are associated with NP susceptibility and use. It will be important to disentangle factors that are associated with potential positive public health impacts (e.g., switching from smokeless tobacco to exclusive NP use) from those associated with negative public health impacts (e.g., initiation among nicotine naïve individuals).

Curiosity, use, and perceptions of "tobacco-free nicotine" E-cigarettes among U.S. young adults

This study determined whether young adults perceptions of how tobacco free nicotine (TFN) compared to tobacco-derived nicotine (TDN) were associated with curiosity to try or use TFN e-cigarettes. U.S. young adults aged 18-25 years (n = 1176) completed an online survey in October 2021. Survey questions assessed TFN awareness, curiosity, use, and perceptions of how flavor, taste, ease of access, cost, and harm compared between TFN and TDN. Participants were categorized into 3 groups: not curious to try TFN (n = 511, 43.5%), curious to try TFN (n = 348, 29.6%), and ever used TFN (n = 317, 27%). Multinomial logistic regression measured associations between perceptions and TFN curiosity and use (vs. not curious to try), with total number tobacco products used and demographics as covariates. Compared to young adults who were not curious to try TFN e-cigarettes, those who were curious perceived TFN as less addictive than TDN (aOR = 2.27; 95% CI =1.34-3.86). Those who had used TFN e-cigarettes perceived TFN as having flavors that tasted better (aOR = 1.80; 95% CI = 1.63-1.99), "smoother" (aOR = 1.88; 95% CI =1.18-2.99), and less like tobacco (aOR 1.94; 95% CI 1.23-3.05). Adjusted models did not show differences in perceptions between those who had tried TFN and those who were curious to try TFN. Young adults who were curious to try or had used TFN had more positive perceptions of TFN. As it is currently unclear whether synthetic nicotine carries the same health risks as TDN, ongoing surveillance of TFN uptake among young adults is warranted.

Improving Substance Use Prevention, Assessment, and Treatment Financing to Enhance Equity and Improve Outcomes Among Children, Adolescents, and Young Adults

Access to timely prevention and treatment services remains challenging for many children, adolescents, young adults, and families affected by substance use. The American Academy of Pediatrics recognizes the scope and urgency of this problem and has developed this policy statement for consideration by Congress, federal and state policy makers, and public and private payers. This policy statement updates the 2001 policy statement "Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents" and provides recommendations for financing substance use prevention, assessment, and treatment of children, adolescents, and young adults.

Clinical approach to the treatment of e-cigarette use among adolescents

E-cigarette use remains a serious public health threat for adolescents in the United States. Pediatric providers can intervene early to prevent the adverse, and sometimes life-long, health consequences of e-cigarette use. This article reviews the clinical management of e-cigarette use among adolescents using the "Ask-Counsel-Treat" model. This model was recently introduced by the American Academy of Pediatrics to help pediatric healthcare providers manage e-cigarette screening, counseling, and treatment. Behavioral treatments for e-cigarette cessation can be delivered via multiple formats, including via text, in-person, or online. Additionally, pediatric healthcare providers may consider the off-label use of nicotine replacement therapy in individuals less than 18 years of age to alleviate some of the symptoms of nicotine withdrawal. Further research is needed to inform the design and implementation of effective e-cigarette cessation strategies for adolescents.

Does it come from tobacco? Young adults' interpretations of the term "tobacco-free nicotine" in a cross-sectional national survey sample

BACKGROUND

"Tobacco-free" nicotine (TFN) e-cigarettes and nicotine pouches containing synthetic nicotine are increasingly available. The term TFN may lead to reduced risk perceptions and increased use intentions relative to tobacco-derived nicotine products. Effectively communicating messages about TFN may depend on the public's ability to differentiate TFN from tobacco-derived nicotine. Our goals were to examine knowledge about the source(s) of nicotine in commonly used products and beliefs about what TFN means.

METHODS

In 2021 we surveyed 2464 young adults (18-25 years) online. Participants reported whether cigarettes, smokeless tobacco, e-cigarettes, and nicotine pouches contain nicotine that comes from tobacco (always, sometimes, never). Correct responses were "always" for cigarettes/smokeless and "sometimes" for e-cigarettes/pouches. Participants also reported "what [they] think TFN e-cigarettes/vapes contain" (nicotine only; tobacco only; both nicotine and tobacco; neither nicotine nor tobacco). We ran unadjusted and adjusted models examining correct responses for nicotine source and TFN contents by past-month product use status (cigarettes, smokeless, e-cigarettes, pouches).

RESULTS

Rates of correctly identifying nicotine source were modest (23.6% pouches-61.9% cigarettes). Except smokeless tobacco, using a given product was associated with identifying its nicotine source correctly in unadjusted models. Participants reported "TFN" means a product contains nicotine only (57.8%), tobacco only (10.8%), both (14.1%), or neither (17.1%).

CONCLUSIONS

There is confusion about the source of nicotine in products, and many young adults incorrectly interpreted TFN to mean something other than containing nicotine but no tobacco. Regulatory efforts may be needed to restrict using the term "tobacco-free nicotine" on product labeling and advertising.

Trajectories and Outcomes of Adolescents that Ride With an Impaired Driver/Drive While Impaired

INTRODUCTION

For young drivers, independent transportation has been noted to offer them opportunities that can be beneficial as they enter early adulthood. However, those that choose to engage in riding with an impaired driver (RWI) and drive while impaired (DWI) over time can face negative consequences reducing such opportunities. This study examined the prospective association of identified longitudinal trajectory classes among adolescents that RWI and DWI with their later health, education, and employment in emerging adulthood.

METHODS

We analyzed all seven annual assessments (Waves, W1-W7) of the NEXT Generation Health Study, a nationally representative longitudinal study starting with 10^th grade (2009-2010 school year). Using all seven waves, trajectory classes were identified by latent class analysis with RWI (last 12 months) and DWI (last 30 days) dichotomized as ≥once = 1 vs. none = 0.

RESULTS

Four RWI trajectories and four DWI trajectories were identified: abstainer, escalator, decliner, and persister. For RWI and DWI trajectories respectively, 45.0% (N=647) and 76.2% (N=1,657) were abstainers, 15.6% (N=226) and 14.2% (N=337) were escalators, 25.0% (N=352) and 5.4% (N=99) were decliners, and 14.4% (N=197) and 3.8% (N=83) persisters. RWI trajectories were associated with W7 health status (χ²=13,20, p<.01) and education attainment (χ²=18.37, p<.01). Adolescent RWI abstainers reported better later health status than RWI escalators, decliners, and persisters; and decliners reported less favorable later education attainment than abstainers, escalators, and persisters. DWI trajectories showed no association with health status, education attainment, or employment.

CONCLUSIONS

Our findings suggest the importance of later health outcomes of adolescent RWI. The mixed findings point to the need for more detailed understanding of contextual and time-dependent trajectory outcomes among adolescents engaging in RWI and DWI.

Mapping the complex causal mechanisms of drinking and driving behaviors among adolescents and young adults

BACKGROUND

The proportion of motor vehicle crash fatalities involving alcohol-impaired drivers declined substantially between 1982 and 1997, but progress stopped after 1997. The systemic complexity of alcohol-impaired driving contributes to the persistence of this problem. This study aims to identify and map key feedback mechanisms that affect alcohol-impaired driving among adolescents and young adults in the U.S.

METHODS

We apply the system dynamics approach to the problem of alcohol-impaired driving and bring a feedback perspective for understanding drivers and inhibitors of the problem. The causal loop diagram (i.e., map of dynamic hypotheses about the structure of the system producing observed behaviors over time) developed in this study is based on the output of two group model building sessions conducted with multidisciplinary subject-matter experts bolstered with extensive literature review.

RESULTS

The causal loop diagram depicts diverse influences on youth impaired driving including parents, peers, policies, law enforcement, and the alcohol industry. Embedded in these feedback loops are the physical flow of youth between the categories of abstainers, drinkers who do not drive after drinking, and drinkers who drive after drinking. We identify key inertial factors, discuss how delay and feedback processes affect observed behaviors over time, and suggest strategies to reduce youth impaired driving.

CONCLUSION

This review presents the first causal loop diagram of alcohol-impaired driving among adolescents and it is a vital first step toward quantitative simulation modeling of the problem. Through continued research, this model could provide a powerful tool for understanding the systemic complexity of impaired driving among adolescents, and identifying effective prevention practices and policies to reduce youth impaired driving.

Demographic and substance use-related differences among high school adolescents who vape cannabis versus use other cannabis modalities

BACKGROUND

Vaping is the second most common modality of using cannabis following smoking. We examined differences in demographics and substance use behaviors between adolescent cannabis vapers and those exclusively using other cannabis modalities.

METHODS

In 2019, 4875 students from six Connecticut high schools completed school-wide, online surveys. Past-month cannabis users (n = 931; 52.8% female, 16.38(1.27) years old, 44.9% non-Hispanic White) reported on cannabis modalities used (e.g., combustible, vaporizable, edible) and were classified as cannabis vapers or non-vapers. Cannabis vapers reported on device type used to vape cannabis: a cannabis-specific device or modified/hacked e-cigarette. Unadjusted and adjusted relationships were examined to identify demographic and substance-related differences between cannabis vapers and non-vapers.

RESULTS

56.3% of past-month cannabis users reported vaping cannabis. Cannabis vapers reported using both cannabis-specific vaporizers (91.9%) and modifying/hacking e-cigarettes (23.7%). Cannabis vapers, relative to other cannabis users, were more likely to be male, White, initiate cannabis use at a younger age; endorse past-month use of all cannabis modalities, alcohol, and e-cigarettes; and report smoking and dabbing cannabis more frequently; consuming more drinks per drinking day; and using e-cigarettes at a younger age and more frequently.

CONCLUSIONS

Relative to other cannabis modalities, vaping was associated with increased use of several cannabis products and other substances. Adolescent past-month cannabis users reported modifying e-cigarettes to vape cannabis. Findings suggest that regulations should be implemented to prevent e-cigarettes from being modifiable for use with cannabis and highlight the importance of assessing different cannabis use modalities, as vaping was associated with distinct substance-related risks.

Simulated and self-reported driving among young adults with and without prenatal cocaine exposure

Objective: This exploratory study aimed to examine associations between executive function and simulated and self-reported driving behavior among young adults with and without a history of prenatal cocaine exposure (PCE).Methods: Young adult drivers with PCE (n = 38) and with no drug exposure (NDE; n = 25) were recruited from an ongoing longitudinal birth cohort study assessing effects of PCE on development (Mean age = 23.7; 60.3% male; 61.9% with a valid U.S. driver's license, 38.1% report independent driving without a license). Participants completed executive function tasks (i.e., the Stop Signal Task and Groton Maze Learning Task) and self-reported driving measures (i.e., Checkpoints Risky Driving Scale (C-RDS)) outside the cab. Average stop signal reaction time(s) measured inhibitory control, number of exploratory errors measured visuo-spatial working memory, and the total C-RDS score measured self-reported risky driving. Participants completed a high-fidelity driving simulation scenario in a miniSim™ ½ cab National Advanced Driving Simulator (NADS) that yielded indicators of driving performance shown in previous research to correlate with inhibitory control (e.g., average speed, standard deviation lane position (SDLP)) and working memory (minimum headway time, lane departures). Multivariate linear regression models tested whether PCE status, licensure status and executive function measures were associated with simulated driving measures or C-RDS, controlling for sex.Results: Multivariate regression models demonstrated inhibitory control, working memory and PCE group status was not significantly associated with driving outcomes. Licensure was significantly associated with total lane departures (β = -0.66, SE = 0.19; p < 0.01) and C-RDS (β = 5.86, SE = 1.4; p ≤ 0.001).Conclusions: This exploratory study suggests that young adults with PCE have similar neurocognitive performance and driving behaviors as their non-drug exposed (NDE) peers. These findings add to the growing literature demonstrating that the effect of PCE on cognitive functions in childhood may not persist to young adulthood. Further research with similar groups of young drivers in a naturalistic driving context (i.e., instrumented vehicles) is needed to more definitively translate and confirm our findings.

Supporting Patient-centered Communication on Adolescent Sexual and Reproductive Health-Perspectives to Build an Appointment Planning Tool

STUDY OBJECTIVE

Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings.

DESIGN

In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8.

SETTING

An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic.

PARTICIPANTS

Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10).

MAIN OUTCOME MEASURES

Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool.

RESULTS

Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress.

CONCLUSIONS

Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.

Riding with an impaired driver and driving while impaired among adolescents: Longitudinal trajectories and their characteristics

PURPOSE

The purpose of this study was to identify and characterize trajectory classes of adolescents who ride with an impaired driver (RWI) and drive while impaired (DWI).

METHODS

We analyzed all 7 annual assessments (Waves W1-W7) of the NEXT Generation Health Study, a nationally representative longitudinal study starting with 10th grade (2009-2010 school year). Using all 7 waves, latent class analysis was used to identify trajectory classes with dichotomized RWI (last 12 months) and DWI (last 30 days; once or more = 1 vs. none = 0). Covariates were race/ethnicity, sex, parent education, urbanicity, and family affluence.

RESULTS

Four RWI trajectories and 4 DWI trajectories were identified: abstainer, escalator, decliner, and persister. For RWI and DWI trajectories respectively, 45.0% (n = 647) and 76.2% (n = 1,657) were abstainers, 15.6% (n = 226) and 14.2% (n = 337) were escalators, 25.0% (n = 352) and 5.4% (n = 99) were decliners, and 14.4% (n = 197) and 3.8% (n = 83) persisters. Race/ethnicity (χ² = 23.93, P = .004) was significantly associated with the RWI trajectory classes. Race/ethnicity (χ² = 20.55, P = .02), sex (χ² = 13.89, P = .003), parent highest education (χ² = 12.49, P = .05), urbanicity (χ² = 9.66, P = .02), and family affluence (χ² = 12.88, P = .05) were significantly associated with DWI trajectory classes.

CONCLUSIONS

Among adolescents transitioning into emerging adulthood, race/ethnicity is a common factor associated with RWI and DWI longitudinal trajectories. Our results suggest that adolescent RWI and DWI are complex behaviors warranting further detailed investigation of the respective trajectory classes. Our study findings can inform the tailoring of prevention and intervention efforts aimed at preventing illness/injury and preserving future opportunities for adolescents to thrive in emerging adulthood.

Trends in various e-cigarette devices used by high school adolescents from 2017-2019

BACKGROUND

Adolescent e-cigarette use has increased recently; however, little is known about trends in use of specific devices by youth. This study aims to 1) compare rates of e-cigarette device use over time, 2) examine changes in frequency of device use, and 3) identify predictors of device use.

METHODS

Cross-sectional surveys were distributed school-wide across 4 diverse Connecticut high-schools in 2017, 2018, 2019 and assessed current (i.e., past-30-day) use of various e-cigarette devices: disposables/cig-a-likes, vape pens, mods, JUULs, and other rechargeable pod devices (added in 2018 and 2019). Analyses compared rates of device use and frequency (i.e., number of days used in past 30) over time. Multivariable logistic regression models examined demographic and tobacco use characteristics (e.g., age first trying e-cigarettes) as predictors of current use of each device type in 2019.

RESULTS

From 2017-2019, rates of using JUUL, disposables/cig-a-likes, and vape pens increased significantly, while use of mods and other pod devices decreased (ps<.001). Over 59 % of youth reported using more than one e-cigarette device in 2019. Over time, more youth were frequent users (using ≥20 out of 30 days) of disposable/cig-a-likes (32 % to >46 %) and JUUL (28 % to >35 %) devices. In multivariable models, first trying e-cigarettes at a younger age was associated with current use of disposable/cig-a-like, vape pens, mods, and other rechargeable pod devices.

CONCLUSIONS

From 2017-2019, JUUL, disposable/cig-a-like, and vape pens increased in popularity and were used frequently. Tobacco regulations designed to reduce youth use should consider various device types.

First tobacco product tried among adolescents based on race/ethnicity and socioeconomic status

In recent years, the tobacco use landscape among youth has changed greatly, underscoring a need to understand current tobacco product initiation patterns. This study aimed to examine if adolescents' first tobacco product tried differs by race/ethnicity and socioeconomic status (SES). Cross-sectional survey data were collected from 6 Connecticut high schools in Spring 2019 (N = 4875). The analytic sample comprised ever users of tobacco products who reported on the first tobacco product they tried (N = 2530; 53.6% female). Of ever tobacco product users, 64.6% reported that their first tobacco product tried was an e-cigarette, 24.4% reported blunts, 6.5% reported another tobacco product, and 4.5% reported cigarettes. A multinomial logistic regression model examined race/ethnicity and SES as predictors of the first tobacco product tried with cigarettes as the reference group. Compared to Non-Hispanic (NH) White students, NH Black students (OR = 0.38, 95%CI = 0.17-0.82), Hispanic students (OR = 0.44, 95%CI = 0.27-0.71), and students of other NH races (OR = 0.30, 95%CI = 0.18-0.52) were less likely to report initiating tobacco product use with e-cigarettes. Additionally, compared to NH White students, NH Black students were more likely to report using blunts as their first tobacco product (OR = 3.01, 95%CI = 1.38-6.56). Compared to low SES, middle SES (OR = 1.62, 95%CI = 1.04-2.52) was associated with greater odds of reporting e-cigarettes as the first tobacco product. These findings suggest that youth of different backgrounds initiate tobacco use with different tobacco products and tailored prevention strategies are needed.

Social Processes Informing Toileting Behavior Among Adolescent and Adult Women: Social Cognitive Theory as an Interpretative Lens

Little is known about social processes shaping adolescent and adult women's toileting behaviors. The "Study of Habits, Attitudes, Realities, and Experiences" (SHARE) examines adolescent and adult women's experiences related to bladder health across the life course. Forty-four focus groups with 360 participants organized by six age groups were conducted across seven sites. A transdisciplinary team used social cognitive theory as an interpretive lens across a five-stage analysis. The act of observing was identified as the overarching social process informing women's toileting behaviors in three ways: (a) observing others' toileting behavior, (b) being aware that one's own toileting behaviors are monitored by others, and (c) observing oneself relative to others. We found that underlying processes of toileting behaviors, seemingly private are, in fact, highly social. We suggest, given this social embeddedness that health promotion efforts should leverage interpersonal networks for "social norming" interventions and policies to promote healthy toileting behaviors.

Feasibility of text messaging to augment brief advice and nicotine replacement therapy for smoking cessation in college students

To test the feasibility of a university health center-delivered smoking cessation intervention that adds a 6-week course of text messaging to brief advice and nicotine patch therapy. Participants: Young adult cigarette smokers (n = 40) from 2 universities from January 2015 to May 2016. Methods: Randomized controlled trial comparing brief advice, nicotine patch therapy and: (1) a 6-week text messaging intervention (n = 20); or (2) no text messaging (n = 20). Primary outcomes included enrollment, retention and satisfaction. Results: Forty participants enrolled (38% of those screened). Retention rates were 98% and 92.5% at 6 and 12 weeks. Of those who completed the text intervention (n = 16), 64.3% felt the texts were "helpful", however they reported desire for tailoring and concern that texts triggered smoking. Biochemically confirmed abstinence rates did not significantly differ between text and control arms. Conclusions: These feasibility data suggest that text messaging may need to be modified to better engage and motivate college-age smokers.

High school students' use of JUUL pod flavors before and after JUUL implemented voluntary sales restrictions on certain flavors in 2018

Objectives

In November 2018, JUUL, Inc. restricted sales of mango, fruit medley, crème brûlée, and cucumber pods to its website. Physical/online sales of tobacco, menthol, and mint pods continued. We examined rates of adolescent JUUL device and flavored pod use before and after restrictions were implemented to examine their potential impact.

Methods

Students from 4 Connecticut high schools completed cross-sectional surveys in 2018 (N = 3170) and 2019 (N = 3074).

Results

Compared to 2018, current (past-month) JUUL use decreased in 2019 (30.2–25.6%). Among current JUUL users, restricted flavor use (mango [62.8–36.9%]; cucumber [27.7–11.9%]; fruit [23.5–11.4%]; crème brûlée [12.3–5.0%]) and the total number of flavors used (2.09[SD = 1.71]-1.51[SD = 1.33]) decreased (p-values < .001), while mint pod use increased (62.0–68.6%, p < .01). Tobacco and menthol pod use remained stable.

Conclusions

Following voluntary sales restrictions implemented by JUUL, Inc., restricted flavor use and the total number of flavors used decreased among JUUL users while mint use increased. Results suggest flavor restrictions may impact adolescents’ e-cigarette use. While 2020 Food and Drug Administration restrictions on mint pods may further limit youth JUUL use, research is needed to determine where youth acquire restricted flavors and if restrictions prompt increased popularity of unrestricted devices/e-liquids.

Querying About the Use of Specific E-Cigarette Devices May Enhance Accurate Measurement of E-Cigarette Prevalence Rates Among High School Students

INTRODUCTION

Prevalence estimates of electronic cigarette (e-cigarette) use may underestimate actual use in youth. Confusion resulting from the fact that a multitude of devices (eg, vape pens, JUULs) fall under the umbrella term "e-cigarettes," the use of different names to refer to e-cigarettes (eg, vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (eg, "vaping," "JUULing"), may lead some young e-cigarette users to incorrectly indicate nonuse. Therefore, we compared rates of endorsing lifetime e-cigarette use when adolescents were asked about lifetime e-cigarette use in two different ways.

METHODS

In May to June 2018, a total of 1960 students from two high schools in Connecticut completed a computerized, school-based survey. Participants first reported on lifetime "e-cigarette" use and, subsequently, on lifetime use of five different e-cigarette devices: disposables, cig-a-likes, or E-hookahs; vape pens or Egos; JUULs; pod systems other than JUULs such as PHIX or Suorin; and advanced personal vaporizers or mods.

RESULTS

In total, 35.8% of students endorsed lifetime "e-cigarette" use, whereas 51.3% endorsed lifetime use of at least one e-cigarette device. The kappa statistic indicated only 66.6% agreement between the methods of assessing e-cigarette use. Overall, 31.5% of adolescents who endorsed lifetime device use did not endorse lifetime "e-cigarette" use, although rates of discordant responding varied across subgroups of interest (eg, sex, race).

CONCLUSIONS

Assessing adolescents' use of specific e-cigarette devices likely yields more accurate results than assessing the use of "e-cigarettes." If these findings are replicated in a nationally representative sample, regulatory efforts requiring all e-cigarette devices to be clearly labeled as "e-cigarettes" may help to reduce confusion.

IMPLICATIONS

Different prevalence estimates of lifetime e-cigarette use were obtained depending on the way that prevalence was assessed. Specifically, fewer adolescents (35.8%) endorsed lifetime e-cigarette use when they were asked "Have you ever tried an e-cigarette, even one or two puffs?" than when they were queried about lifetime use of five different e-cigarette devices (51.3%). Among those who endorsed lifetime use of at least one specific e-cigarette device, 31.5% did not endorse lifetime "e-cigarette" use. These findings suggest that when assessing adolescents' lifetime e-cigarette use, using of terms referring to specific devices likely produces more accurate prevalence estimates than using the term "e-cigarettes."

E-cigarette devices used on school grounds

INTRODUCTION

Preliminary evidence suggests adolescents use e-cigarettes in school. However, little is known about the types of devices that are used in schools, where they are used, and who uses them. Knowledge about these issues is critical to inform school regulations.

METHODS

Cross-sectional surveys were conducted in 6 Connecticut high schools in 2019. Adolescents reported on current use (past 30-day use) of the following e-cigarette devices inschool: JUUL, any pod system other than JUUL, vape pens, disposables, mods, and on deviceuse in different locations: class, bathroom, hallways, outside on school grounds, and other school locations. Separate binary logistic regressions investigated predictors of use (demographics and past month use frequency of each device) in school for each device.

RESULTS

Overall, 45.0% of current users (N = 1447) used e-cigarettes at school. Among users of each device, prevalence of current use at school varied by device with 45.7% reporting JUUL use, 41.3% other pod use, 34.6% vape pen use, 38.3% disposables use and 27.3% mod use. Current users used devices in bathrooms (75.1%), followed by outside on school grounds (52.2%), classrooms (45.7%), hallways (38.8%) and other school locations (11.7%). Greater e-cigarette past month use frequency for each device was associated with device use in school.

CONCLUSIONS

This study is the first to examine use of specific e-cigarette devices in schools and demonstrates that e-cigarette use frequency predicts school use. Despite rules against vaping, e-cigarette use remains prevalent in many school locations, suggesting alternative strategies such as prevention and e-cigarette education are needed.

The Association of Sleep Hygiene and Drowsiness with Adverse Driving Events in Emergency Medicine Residents

Introduction

Prior research shows that physicians in training are at risk for drowsy driving following their clinical duties, which may put them in danger of experiencing adverse driving events. This study explores the relationship between sleepiness, overall sleep hygiene, level of training, and adverse driving events following an overnight shift in emergency medicine (EM) residents.

Methods

Throughout the 2018–2019 academic year, 50 EM residents from postgraduate years 1–4 completed self-administered surveys regarding their sleepiness before and after their drive home following an overnight shift, any adverse driving events that occurred during their drive home, and their overall sleep hygiene.

Results

Fifty out of a possible 57 residents completed the survey for a response rate of 87.7%. Sleepiness was significantly associated with adverse driving events (beta = 0.31; P < .001). Residents with high sleepiness levels reported significantly more adverse driving events. Residents reported significantly higher sleepiness levels after completing their drive home (mean = 7.04, standard deviation [SD] = 1.41) compared to sleepiness levels before driving home (mean = 5.58, SD = 1.81). Residency training level was significantly associated with adverse driving events (beta = −0.59, P < .01). Senior residents reported significantly fewer adverse driving events compared to junior residents.

Conclusion

Emergency physicians in training are at risk for drowsy driving-related motor vehicle crashes following overnight work shifts. Trainees of all levels underestimated their true degree of sleepiness prior to initiating their drive home, while junior residents were at higher risk for adverse driving events.

Alcohol use patterns and their association with sober driver vehicle control in high fidelity driving simulation

OBJECTIVE

To examine the relationship between patterns of alcohol use, as determined by the Alcohol Use Disorders Identification Test, and vehicle control measures in high fidelity driving simulation among adult sober drivers.

METHODS

Baseline data (BAC = 0.00%; N = 108) from a larger study aimed at using high-fidelity driving simulation (National Advanced Driving Simulator) to evaluate the feasibility of vehicle-based sensors to identify alcohol impairment were analyzed. Driving simulation scenarios included driving on urban, interstate, and rural roadways. The independent variable was the pattern of alcohol use measured with the Alcohol Use Disorder Identification Test (AUDIT). Dependent variables included one lateral vehicle control measure (i.e., standard deviation of lane position (SDLP)) and one longitudinal vehicle control measure (i.e., average speed relative to the speed limit) in high fidelity driving simulation. Multivariable linear regression was used to examine the associations between patterns of alcohol use and vehicle control measures.

RESULTS

Total AUDIT scores ≥8 was positively associated with SDLP. Increased frequency of drinking was associated with decreased SDLP and increased average speed relative to the speed limit. Increased reports of blackouts and alcohol-related injury were associated with increased average speed relative to the speed limit. Driver performance (SDLP, average speed relative to the speed limit) was related to additional factors such as driver experience, age, marital status, and driving context.

CONCLUSIONS

The findings support our hypothesis that the AUDIT score and responses to individual AUDIT questions, among sober drivers, relates to vehicle control measures. Overall, our data highlight two important themes: 1) a need to further integrate alcohol use metrics with high-fidelity driving simulation studies to understand how drinking experience can relate to driver behavior and vehicle control and 2) the opportunity to integrate clinical perspectives with driving simulation research to strengthen clinically oriented alcohol-misuse prevention efforts.

Marijuana Vaping in U.S. Adults: Evidence From the Behavioral Risk Factor Surveillance System

INTRODUCTION

As of February 18, 2020, states have reported 2,807 cases of e-cigarette, or vaping, product use-associated lung injury to the Centers for Disease Control and Prevention. Most cases involved cannabinoids. This study identifies current risk factors for adult marijuana vaping by analyzing 2017 and 2018 Behavioral Risk Factor Surveillance System data.

METHODS

Data on 8,255 people who recently used marijuana were analyzed in September 2019. Sample-weighted multivariate logistic regressions considered a binary indicator for vaping as the primary method of marijuana use. Adjusting for demographic controls, regressions assessed the association between marijuana vaping and marijuana use for medical purposes (versus nonmedical only), current conventional cigarette use, current nicotine e-cigarette use, and 2 mental health variables. Demographic controls were binary indicators for female sex, Hispanic ethnicity, race, and having completed ≥1 year of college.

RESULTS

Odds of marijuana vaping were higher among those who reported using for medical purposes (AOR_{age18-24years}=3.8, 95% CI=1.91, 7.67; AOR_{age25-54years}=1.8, 95% CI=1.02, 3.08; AOR_{age55-64years}=2.3, 95% CI=0.75, 7.07) and lower among people who smoked combustible cigarettes (AOR_{age18-24years}=0.2, 95% CI=0.06, 0.65; AOR_{age25-54years}=0.2, 95% CI=0.10, 0.26; AOR_{age55-64years}=0.1, 95% CI=0.05, 0.34). Vaping nicotine e-cigarettes was associated with greater odds of vaping marijuana for adults aged 25-54 years (AOR=4.6, 95% CI=2.70, 7.78) but not those aged 18-24 years (AOR=0.9, 95% CI=0.33, 2.26).

CONCLUSIONS

Among people who use marijuana, adults reporting medical marijuana use were more likely to vape as their primary mode of consumption, whereas conventional cigarette smokers were less likely to do so. Use of nicotine e-cigarettes was associated with a greater likelihood of vaping marijuana for adults aged 25-54 years.

Brain-based limitations in attention and secondary task engagement during high-fidelity driving simulation among young adults

Distracted driving remains a leading factor in fatal motor vehicle crashes, particularly in young drivers. Due to ongoing neuromaturation, attention capabilities are changing and improving throughout young adulthood. Here, we sought to bridge neuroscience with driving simulation by evaluating the effects of driving on attention processing through a selective auditory attention task. Participants (18-25 years old) engaged in an auditory attention task during LOAD (driving a high-fidelity simulator) and No-LOAD conditions (sitting in the parked simulator). For the auditory task, participants responded to a target auditory tone in a target ear. The event-related potential components, collected from frontal and posterior regions, P2 and P3, were used to evaluate attention processing across LOAD and No-LOAD conditions for attended and unattended stimuli. Data from 24 participants were evaluated in repeated measures ANOVAs, considering interactions between load and attention conditions for the P2 and P3 components of the cortical region. We observed a significant difference between response to attended and unattended stimuli for posterior P2 and P3 responses at the frontal and posterior midline sites. Comparing LOAD and No-LOAD conditions, there was a significant difference for P2 response at the posterior site and P3 response at the frontal site. A significant interaction between load and attended stimuli was found for P3 response at the posterior site. These data document differences in neural processing of auditory stimuli during high-fidelity simulated driving versus sitting parked in the simulator. Findings suggest the cognitive load of driving affects auditory attention.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women

AIMS

Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts.

METHODS

Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span.

RESULTS

Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research.

CONCLUSIONS

This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

Association between preference for using alcohol beverage-named e-liquids and alcohol use among high school youth

BACKGROUND

There are thousands of e-liquid flavors available, and some are named after alcohol beverages (e.g., "pina colada"). It is unclear whether use of e-liquids with alcohol beverage names is associated with adolescent alcohol use. E-cigarettes and alcohol are co-used in adolescents; therefore, it is important to investigate these associations.

METHODS

Eight Southeastern Connecticut high schools were surveyed in Spring 2015 (N = 7045). We examined the association between preference for using e-liquid flavors and alcohol drinking status (i.e., no past month alcohol use, past month alcohol use but no binge drinking, and past month binge drinking) in ever e-cigarette users (N = 1311).

RESULTS

Among ever e-cigarette users who preferred using e-liquids with alcohol beverage names (N = 111), 30.6 % had no past month alcohol use, 19.8 % had past month alcohol use but did not binge drink in the past month, and 49.5 % binge drank in the past month. Multinomial logistic regression (controlling for demographics and including other e-cigarette flavors that were highly endorsed, i.e., fruit and candy) revealed that the preferences of alcohol beverage-named-e-liquid (OR: 2.84, CI: 1.70-4.75) and fruit flavored e-liquids (OR: 1.55, CI: 1.14-2.11), but not candy flavored e-liquids was associated with past-month binge drinking compared to no past-month alcohol use.

CONCLUSION

This evidence suggests that the preference for using alcohol beverage- and fruit-named e-liquid flavors is associated with past-month binge drinking among adolescents. Understanding the associations between alcohol beverage-named e-liquids and alcohol use in adolescents may help inform tobacco regulatory strategies that aim to decrease the use/appeal of e-cigarettes.

High school students' use of flavored e-cigarette e-liquids for appetite control and weight loss

BACKGROUND

Although weight-related reasons for smoking and vaping have been examined in adults, research in adolescents is lacking. Thus, we examined the prevalence and correlates of using flavored e-liquids for appetite control or weight loss in high school adolescents.

METHODS

The analytic sample included 529 students who completed a school-based survey in Connecticut in Spring 2017 (50.6% female, 79.5% White, mean age 16.27 [SD = 1.18], range 13-19 years). Inclusion criteria were past-30-day vaping, using ≥ 1 flavored e-liquid (past month), and having non-missing data on flavored e-liquid use for appetite control and weight loss. Participants reported on sex, age, race, past-30-day vaping and smoking frequency, nicotine e-liquid use, flavored e-liquid use (e.g., tobacco, mint, fruit, candy), and flavored e-liquid use for appetite control and/or weight loss.

RESULTS

Adolescent e-cigarette users (past 30-days) reported vaping flavored e-liquids for appetite control (13.8%) and weight loss (9.3%). Using flavored e-liquids for appetite control or weight loss, respectively, was associated with more frequent vaping (OR = 1.21; 1.21) and using more flavored e-liquids (OR = 1.33; 1.28, p-values < 0.01). Vaping candy-flavored e-liquids (OR = 1.16, p = 0.02) uniquely was associated with vaping for appetite control.

CONCLUSIONS

A subset of adolescents reported using flavored e-liquids for weight-related reasons. These adolescents reported vaping more frequently than their counterparts, raising concerns about increased nicotine exposure. Research is needed to understand where adolescents learn about weight-motivated vaping (e.g., friends, social media) and whether weight-related motives promote e-cigarette initiation among e-cigarette naïve individuals or continued/escalating use among current users.

I never knew anyone who peed on themselves on purpose: Exploring adolescent and adult women's lay language and discourse about bladder health and function

AIMS

This analysis explored and characterized adolescent and adult women's lay language and discourse related to bladder health/function.

METHODS

Forty-four focus groups were conducted across seven United States research centers with 360 adolescents and adult women, organized by six age categories. Multilevel content analyses classified emergent themes. A transdisciplinary lens and inductive approach guided data interpretation. Interpretive insights were validated by a community engagement panel.

RESULTS

A repertoire of bladder function terms emerged, including explicit functional terms, formal and polite euphemistic terms, and informal familiar terms, as well as cultural and regional metaphors and idioms. Terminology usage was historically grounded, developmental, and cumulative across the life course. Lay discourse was contextual and affectively valent, suggesting unspoken, commonly understood, situation-based "rules" for talking about bladder function. Discourse appeared to be siloed within family and friendship circles. Adolescents and adult women often described, rather than named, bladder sensations or problems. Terminology for bladder issues tended to minimize severity and frequency, with medical language only relevant to extreme examples and not applicable to mild episodes.

CONCLUSIONS

A definitional discordance between medical and lay views of bladder problems was identified, signifying a need to clarify the meaning of medical terms for lay persons. Adolescents and adult women do not have or use standardized precise terminology for bladder health and function, relying instead on social convention and interpersonal context. Findings can be used to foster shared understandings between lay persons and health professionals, informing development of clinical, research, and public health initiatives to promote bladder health.

Appeal of JUUL among adolescents

INTRODUCTION

JUUL is a closed-system e-cigarette that uses disposable pods with high concentrations of nicotine. JUUL use among youth arose exponentially since 2015, thus, it is essential to understand youths' reasons for liking/disliking JUUL to inform the regulation of the product.

METHODS

A cross-sectional survey was conducted in 4 high schools in Connecticut in 2018 (N = 3170). The survey assessed JUUL use in the past month and reasons for liking/disliking JUUL, which included pharmacological effects (e.g., subjective nicotine and/or flavor effects), product characteristics (e.g., flavors, nicotine, shape), peer influence (e.g., friends' use), comparisons to other e-cigarettes (e.g., lower harm), and concealability (e.g., hide from authority).

RESULTS

30.2% (N = 956) were past-month users who used a JUUL on an average of 13.6 days (SD = 11.7; 25% reported daily use). The top reasons for liking JUUL were: "it gives me a buzz" (52%), "I like the flavors" (43%), and "my friends use it" (36%). The top reasons for disliking JUUL were: "the pods are expensive" (57%), "nicotine is too high" (20%), and "it gives me a headache" (18%). Regression models indicated that liking JUUL because of the buzz, ability to help concentrate, nicotine level, and ease of hiding it from teachers were associated with more days of use in the past month, while peer influence was negatively associated. Furthermore, disliking the high cost of pods was associated with more frequent use.

CONCLUSIONS

Comprehensive policies that regulate device characteristics that appeal to youth (e.g., nicotine level, flavors) are needed to prevent JUUL use among youth.

Novel (Multilevel) Focus Group Training for a Transdisciplinary Research Consortium

Health researchers are increasingly turning to qualitative research for a nuanced understanding of complex health phenomena. The quality and rigor of qualitative research relies on individual data collector skills, yet few guidelines exist for training multidisciplinary, multi-institution qualitative research teams. Specific guidance is needed on qualitative research practices that ensure scientific rigor by optimizing diverse experience and expertise across research centers. We describe our systematic approach to training a cohort of 15 focus group moderators from seven universities in the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium's Study of Habits, Attitudes, Realities, and Experiences (SHARE). SHARE's aim was to explore women and girls' experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. Drawing on adult education and action-learning best practices, a three-phase curriculum was designed to maximize moderator proficiency and qualitative research expertise. The phases involved online, interactive web-based education, in-person didactic training with experiential components, and tailored supplemental online training. Evaluative feedback was collected before, during, and after the training. Feedback was used to identify emergent training needs. This training approach may be used by transdisciplinary research teams conducting multisite research to assure qualitative research credibility and trustworthiness.

U.S. Adolescent and Adult Women's Experiences Accessing and Using Toilets in Schools, Workplaces, and Public Spaces: A Multi-Site Focus Group Study to Inform Future Research in Bladder Health

The World Health Organization recognizes access to clean and safe toilets as crucial for public health. This study explored U.S. adolescent and adult cisgender women's lived experiences accessing toilets in schools, workplaces, and public spaces. As part of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, we conducted 44 focus groups with female participants (n = 360; ages 11-93). Focus groups were stratified by age (11-14, 15-17, 18-25, 26-44, 45-64, 65+) and conducted across 7 geographically diverse U.S. sites from July 2017-April 2018. Using a transdisciplinary approach, we conducted conventional qualitative coding informed by our PLUS conceptual framework and used content analysis processes to identify salient themes. Across settings, toilet access was restricted by "gatekeepers" (i.e., individuals who control access to toilets). In contrast, self-restricting toilet use (deciding not to use the toilet despite biologic need to urinate) was based on internalized norms to prioritize school and job responsibilities over urination. In public spaces, self-restricting use was largely in response to lack of cleanliness. Across the life course, participants perceived gender disparities in the ability to easily access public toilets. Further research is needed to determine if and how these factors impact bladder health across the life course.

Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health

AIM

The study purpose is to explore adolescent and adult women's experiences, perceptions, beliefs, knowledge and behaviors related to bladder health across the life course using a socioecological perspective. Lower urinary tract symptoms affect between 20-40% of young adult to middle-aged women, with symptoms increasing in incidence and severity with aging. There is limited evidence to address bladder health promotion and prevention of dysfunction. This first study of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is designed to address gaps in existing qualitative research in this area.

DESIGN

This focus group study will be implemented across seven geographically diverse United States research centers using a semi-structured focus group guide informed by a conceptual framework based on the socioecological model.

METHODS

The study was approved in July 2017. A total of 44 focus groups composed of 6-8 participants representing six different age categories (ranging from 11 to over 65 years) will be completed. We aim to recruit participants with diverse demographic and personal characteristics including race, ethnicity, education, socioeconomic status, urban/rural residence, physical/health conditions and urinary symptom experience. Up to 10 of these focus groups will be conducted in Spanish. Focus group transcripts will undergo content analysis and data interpretation to identify and classify themes and articulate emerging themes.

DISCUSSION

This foundational qualitative study seeks to develop an evidence base to inform future research on bladder health promotion in adolescent and adult women.

IMPACT

This study has the potential to provide new insights and understanding into adolescent and adult women's lived experience of bladder health, the experience of lower urinary symptoms and knowledge and beliefs across the life course. This article is protected by copyright. All rights reserved.

Alcohol Use by Youth

Alcohol use continues to be a major concern from preadolescence through young adulthood in the United States. Results of recent neuroscience research have helped to elucidate neurobiological models of addiction, substantiated the deleterious effects of alcohol on adolescent brain development, and added additional evidence to support the call to prevent and reduce underage drinking. This technical report reviews the relevant literature and supports the accompanying policy statement in this issue of Pediatrics.

Medications for Maintenance Treatment of Opioid Use Disorder in Adolescents: A Narrative Review and Assessment of Clinical Benefits and Potential Risks

OBJECTIVE

Methadone, buprenorphine, and naltrexone are evidence-based treatments for opioid use disorder (OUD). A large body of evidence supports their effectiveness in adults with OUD. However, few studies have tested their efficacy in adolescents. This study summarizes the clinical benefits and risks of three medications for the treatment of OUD in adolescents.

METHOD

We review and synthesize the published evidence about the efficacy and potential risks (including safety concerns) associated with methadone, buprenorphine, or naltrexone for the treatment of OUD in adolescents and compare their benefits and risks with that of no treatment or treatment without medications. We also discuss adolescent-specific treatment needs and strategies to overcome potential challenges in prescribing medications for adolescents with OUD.

RESULTS

Methadone appears to be effective in promoting treatment retention among adolescents with heroin use disorder. Data from three randomized controlled trials suggest that buprenorphine treatment improves the likelihood of opioid abstinence and treatment retention. Although these medications have a potential risk of overdose when misused or used illegally, evidence suggests this risk is much lower for buprenorphine than methadone. Emerging data also suggest that naltrexone is a safe and feasible option for adolescents. Vast evidence demonstrates that the risks of untreated OUD far outweigh the risks of any of the previously discussed medications.

CONCLUSIONS

Little published evidence specifically examines the efficacy and safety of using medications for OUD in adolescents, and more research is needed. It is essential for healthcare professionals to determine whether their adolescent patients may benefit from medications for the treatment of OUD.

Youth generated prevention messages about electronic cigarettes

Rates of e-cigarette use are high among youth, and there is little known about the long-term health effects of e-cigarettes. Since peer influence is a powerful determinant of tobacco use, we aimed to identify message themes about e-cigarettes that youth would use to encourage or discourage peers from using e-cigarettes. We conducted 10 focus groups (N = 69) with non-smokers and smokers from one middle school, high school and college in Connecticut. Participants engaged in a discussion about e-cigarettes, and each participant created one written message to encourage e-cigarette use and one to discourage use among peers. We content-analyzed the messages and identified three main themes and 12 encouraging and discouraging sub-themes. Encouraging themes included health benefits of e-cigarettes relative to cigarettes, attractive product characteristics (e.g. flavors) and social advantages (e.g. positive social image) of using e-cigarettes. Discouraging messages included health risks of e-cigarettes relative to cigarettes, unattractive product characteristics (e.g. cost) and social disadvantages (e.g. negative social image of using an e-cigarette). Overall, there were no differences by sex, age group or smoking status in generation of encouraging and discouraging message themes. This study identified youth-generated themes that may aid in e-cigarette prevention among youth.

E-cigarette devices used by high-school youth

Background E-cigarette use rates are high among youth, but there is limited information on the types of e-cigarette devices that are used by youth. Methods During Spring 2017, students from 4 high schools completed surveys on use of e-cigarette devices (cig-a-like, vape/hookah pen, modified devices or mods, and JUUL). Among youth who endorsed ever (lifetime) use of an e-cigarette and of at least one device (n = 875), we assessed 1) prevalence rates of ever and current (past-month) use of each device, 2) use of nicotine in each device, and 3) predictors [age, sex, race, socioeconomic status (SES), other tobacco use] of ever use of each device and of use of single versus multiple devices. Results Cig-a-likes were used least frequently (Ever use: cig-a-likes: 25.4%; vape/hookah pens: 60.6%; JUUL: 64.2%; mods: 71.2%; Current use: cig-a-likes: 7.3%; vape/hookah pens; 18.7%; mods: 33.1%; JUUL: 47.1%;). Nicotine use was highest for JUUL (JUUL: 80.3%; mods: 56.3%; cig-a-likes: 51.4%; vape/hookah pens: 46.8%). Among ever users of single devices, use of JUUL was highest (JUUL: 43%; mods: 32%; vape/hookah pens: 21%; cig-a-likes: 4%). Ever use of all devices, except JUUL, was associated with other tobacco product use. Ever use of JUUL was associated with higher SES. Ever use of multiple devices (two: 34.7%; three: 25.8%; four: 11.7%) compared with a single device (27.8%) was associated with other tobacco product use. Conclusions Targeted regulatory and prevention efforts that consider the use of multiple e-cigarette devices are needed to lower youth e-cigarette use rates.

The Role of Integrated Care in a Medical Home for Patients With a Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe preventable birth defects and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure. The American Academy of Pediatrics has a previous clinical report in which diagnostic criteria for a child with an FASD are discussed and tools to assist pediatricians with its management can be found. This clinical report is intended to foster pediatrician awareness of approaches for screening for prenatal alcohol exposure in clinical practice, to guide management of a child with an FASD after the diagnosis is made, and to summarize available resources for FASD management.