Interventions for Preventing E-Cigarette Use Among Children and Youth: A Systematic Review.

INTRODUCTION: Many nonregulatory interventions targeting children and youth have been implemented at three levels: directed at the individual (e.g., interactive video games), delivered to students at school (e.g., campus bans), and launched in the community (e.g., mass media campaigns). This systematic review aims to synthesize the evidence on the effectiveness of interventions aimed at preventing e-cigarette initiation among children and youth. METHODS: MEDLINE, CINAHL, Embase, APA PsycINFO, and Web of Science Core Collection were searched for papers published between January 1, 2004 and September 1, 2022 that reported more than one outcome on vaping prevention among individuals aged less than 21-years-old: vaping prevalence/incidence, initiation intentions, knowledge/attitudes, and other tobacco product use prevalence/initiation intentions. Interventions were at the individual, school, or community level. The risk of bias was assessed using ROBINS-I and RoB 1. RESULTS: Thirty-nine publications met the eligibility criteria. Fourteen individually-based (4 parental monitoring, 3 video games, 2 text messages, 3 graphic message themes, 2 healthcare), 19 school-based (14 educational and skill interventions, 5 vape-free policies/bans), and 6 community-based (3 social media, 3 mass media campaigns) interventions were reported. E-cigarette initiation prevention was observed with high perceived parental monitoring; however, the cross-sectional study designs precluded causal claims. There was promising but limited evidence that social-emotional skills curricula and peer leader programming prevented vaping initiation. DISCUSSION: Some individual- and school-based interventions showed promise for preventing e-cigarette initiation among children and youth.

Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review.

INTRODUCTION: Many jurisdictions have implemented different regulatory strategies to reduce vaping among youth. The objective of this systematic review is to synthesize the evidence of the effectiveness of different regulatory strategies for preventing and reducing nicotine vaping among youth. METHODS: Five electronic databases were searched from January 1, 2004 to July 17, 2022 for primary studies examining state/provincial or national regulations targeting vaping among youth (aged 12-21 years) in high-income countries. The primary outcome was vaping prevalence. Included studies were qualitatively synthesized through systematic review. RESULTS: The systematic review included 30 studies. There was insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping. Included studies had moderate-to-serious risks of bias. DISCUSSION: Although several regulatory interventions have been shown to be effective at reducing vaping among youth, evidence is insufficient to recommend a specific type of regulation. Regulatory authorities could implement various regulations targeting the price, accessibility, and desirability (i.e., flavors and packaging) of E-cigarettes.

Adapting E-cigarette prevention programming to reach the latinx community.

PURPOSE: E-cigarettes are the most commonly used tobacco product among youth in the United States. Yet evidence-based prevention programming is limited due to the rapid onset of this threat. Community-based efforts to address vaping largely target youth in school settings. Although parents can play an important role in youth tobacco control efforts, messages about the dangers of vaping, use among adolescents, and strategies for intervening have not reached many Spanish-speaking parents in low-income Latinx communities. Our community-academic team developed e-cigarette prevention programming for use by promotor/as de salud to address this unmet need. METHODS: During the 1-year project, the team worked closely with a Project Advisory Committee to: review existing evidence-informed materials; conduct focus groups with parents, youth and promotor/as to guide program development; develop a curriculum to prepare promotor/as to educate low-literacy, Spanish-speaking parents about vaping; craft Spanish language resources for promotor/as to use in community education sessions; train 61 promotor/as to deliver the program; and support program delivery to 657 community members. RESULTS: Focus groups with promotor/as and community members, key-informant interviews, and brief surveys informed program development and assessment. Community member feedback was essential to development of appropriate materials. Promotor/as demonstrated significant pre- to post- training increases in e-cigarette knowledge and confidence in delivering vaping prevention education. Community members demonstrated a mastery of basic e-cigarette concepts and expressed intention to discuss vaping with their children. CONCLUSIONS: Promotor/a-led programming for parents represents a promising approach to vaping prevention and control in the Latinx community.

Vaping harms awareness messaging: exploring young South Australians' responses to vaping prevention campaign materials.

Nicotine vaping products (NVPs) pose health risks associated with nicotine dependence and increased likelihood of tobacco consumption. Despite having a secondary role in smoking cessation, recreational NVP use is increasing among younger people. Vaping prevention campaigns aim to influence views on the health risks of vaping. This study examined perceptions of Australian and international vaping prevention campaigns among 27 young South Australians aged 16-26 years who do and do not use NVPs, to inform targeting and framing of vaping risk messaging. Participants viewed example materials from three vaping prevention campaigns: 'Epidemic', 'Do you know what you're vaping' and 'Unveil what you inhale'. Focus groups and interviews assessed whether materials were easily understood, appropriate, relevant, credible and effective in health communication. Participants indicated that all campaigns would influence their thoughts and actions related to vaping. The 'Do you know what you're vaping' campaign prompted thoughts about uncertainty about individual health risks, though participants did not indicate that this was enough to motivate vaping cessation. Participants considered the 'Unveil' campaign effective, with those who did not vape indicating they would click through to access resources, and those who did vape responding well to the 'challenge' aspect of the messaging. The 'Epidemic' campaign fear appeal did not clearly prompt change in vaping views or behaviours. Campaigns using a challenge approach may generate conversation about vaping harms, while fear appeals can be dismissed by younger audiences. Evidence-based short messages and the presentation of multiple versions of content were considered effective approaches.

Vaping industry participation standards in health organizations: an exploratory policy content analysis.

The vaping industry has been found to employ similar tactics to tobacco industry actors to seek credibility and distort the scientific evidence base around the health harms of nicotine vaping products. As vaping industry interests undermine vaping control efforts, safeguards are necessary to protect against this influence. We aimed to examine health organizations' policies on vaping industry participation in their activities in Australia. A descriptive approach integrating policy analysis and key informant surveys was used to obtain vaping industry participation information from health research stakeholders. Descriptive statistics on organization type, policy document type, policy document industry focus (tobacco or vaping) and respondent role and responsibility were collected. We used framework analysis to identify themes describing organizational allowances, constraints, and rationale for vaping industry research participation. Relevant health organizations were identified within Australia for policy searching (n = 156), which identified 47 unique policy documents. After contacting 267 key stakeholders from eligible organizations, 31 survey responses were analysed. Research organizations and universities were highly represented in both the policy and survey data. Most health research stakeholders recognized that vaping industry interests counteract public health priorities and opposed vaping industry participation. However, many organizations lacked clear, vaping industry-specific participation policies. To protect the integrity of the emerging evidence base around vaping harms which inform vaping policy, health organizations require strong, comprehensive policies to resist vaping industry participation in research.

Public health interventions to prevent adolescent vaping: a scoping review protocol.

OBJECTIVE: The objective of the review is to systematically examine the emerging literature related to public health interventions aimed at preventing adolescent vaping. INTRODUCTION: The prevalence of vaping among adolescents is a rising concern worldwide. A thorough investigation of existing public health interventions to prevent vaping among adolescents is imperative to reduce serious and avoidable vaping-related health risks for this cohort. Many vaping-prevention interventions have been described in the literature, but their key components and outcomes have not been summarized. INCLUSION CRITERIA: All English literature related to public health interventions preventing adolescent (aged 10 to 18 years) vaping from all countries will be included. METHODS: This review will follow the JBI methodology for scoping reviews. A comprehensive search of academic and gray literature using MEDLINE (Ovid), CINAHL (EBSCOhost), Embase (Ovid), PubMed, PsycINFO (Ovid), ProQuest (Health and Medicine and Sociology Collections), and Web of Science Core Collection will be performed. Articles will be screened for inclusion by 2 independent reviewers. Results will be extracted using customized tools and summarized in a final report using narrative synthesis and presented in table format.

Tobacco Policy and ENDS Policy Influences on Adolescent Vaping Across the U.S. States.

INTRODUCTION: Although the use of tobacco has declined among youth, ENDS has the potential to disrupt or reverse these trends. Policies for tobacco and ENDS may have an impact on adolescent ENDS use. The impacts of state-level policies were examined for both tobacco and ENDS indoor use bans, excise taxes, and age-of-purchase laws on past-month adolescent ENDS use from 2013 to 2019. METHODS: This study used cohort data from the Population Assessment of Tobacco and Health study and policy data from the Americans for Nonsmokers' Rights Foundation repository-3 policies for ENDS and 2 policies for tobacco products. Policies included comprehensive indoor vaping/smoking bans, purchase-age restrictions, and excise taxes. Hybrid panel models were estimated in 2022 using data merged from the 2 longitudinal sources on past-month vaping. The analytic sample (observations=26,008) included adolescents aged 12-17 years, yielding a total of 72,684 observations. RESULTS: The odds of adolescent ENDS use were 21.4% lower when the state had an ENDS purchase-age restriction and 55.0% lower when the state had a comprehensive tobacco smoking ban than in the years when the state did not have the ban. CONCLUSIONS: During a period of significant growth in ENDS use among U.S. youth, ENDS purchase-age restrictions and smoking bans reduced the odds of past-month vaping among adolescents. Wider implementation of policies may help intervene in youth vaping.

Looking Cool, Doing Tricks, Managing Stress, and Nicotine Addiction: Youth Perspectives on Nicotine Vaping and Implications for Prevention.

PURPOSE: To understand the contextual and psychosocial factors associated with youth vaping in Colorado, the state with the highest youth vaping rates in 2019, and to propose strategies for prevention interventions. DESIGN: Focus groups. SETTING: In-person. PARTICIPANTS: 24 youth aged 11-17, including youth who had vaped (n = 11) and who had never vaped (n = 13). METHOD: Qualitative responses using a semi-structured focus group guide were analyzed using a matrix approach with a mixed deductive/inductive content analysis. RESULTS: Analysis revealed the highly social nature of vaping initiation and use; the use of vaping to control negative emotions; and the acquisition of vaping products through retail outlets, friends, family, and other youth who sell a variety of substances and devices to youth. Youth provided insight into how vaping is concealed from parents and teachers, and their attitudes about the health risks and benefits of vaping. CONCLUSION: When considered with other studies, our findings suggest a universality in the youth vaping experience that is highly social. Interventions should include peer-to-peer messaging with an emphasis on changing social norms and highlighting undesirable outcomes of vaping such as negative reactions by friends and close adults, adverse effects on athletic success and future aspirations, expense, addiction, and punishment. Parent education is also recommended. Rigorous research is needed to test interventions to reverse the growing trend of youth vaping.

Asian American adolescent e-cigarette use and associated protective factors: Heterogeneity in a statewide sample.

OBJECTIVES: This study characterized variation in e-cigarette use patterns and related protective factors by ethnicity among Asian American adolescents. METHODS: Multivariable logistic regressions modelled associations between ethnic group, 6 protective factors (college aspirations, internal developmental assets, positive teacher engagement, family caring, and peer and parent anti-smoking norms), and past 30-day e-cigarette use, adjusting for covariates among 10,482 8th, 9th, and 11th grade Asian American respondents to the 2019 Minnesota Student Survey. Interaction terms (protective factor × ethnic group) were used in 6 subsequent regression models to examine whether the association between each protective factor and e-cigarette use differed as a function of ethnic group. RESULTS: Respondents included 9.0% Indian, 0.3% Burmese, 7.9% Chinese, 2.5% Filipino, 25.0% Hmong, 3.2% Karen, 4.6% Korean, 2.7% Laotian, 8.2% Vietnamese, 7.5% other, 7.5% multi-ethnic, and 21.6% multi-racial adolescents. E-cigarettes were the predominant form of tobacco use. Laotian and multi-racial groups reported the highest e-cigarette use (16.6% and 16.3%), whereas Chinese and Asian Indians reported the lowest (4.7% and 5.0%). Strong peer anti-smoking norms, higher internal developmental assets scores, and positive teacher engagement were associated with lower odds of e-cigarette use across groups, with significant interactions for internal developmental assets by ethnicity. CONCLUSIONS: E-cigarettes are the most prevalent tobacco product used by Asian adolescents in Minnesota, with notable heterogeneity by ethnicity. While most established protective factors appeared to function similarly for Asian adolescents, others differed, underscoring the importance of disaggregating data by ethnicity to inform the tailoring of prevention and control strategies for these ethnic groups.

Can Extant Vaping Prevention Message Experiments Tell Us Something About What Works? A Response to O'Keefe.

In his commentary, O'Keefe raises some interesting questions about the meaning of effect sizes in meta-analyses of experiments, focusing on our recent meta-analysis on vaping prevention messages. In this commentary, we respond to O'Keefe's comments and make several points. First, it is not uncommon to include experiments with different control conditions in a meta-analysis. Second, the set of studies in our meta-analysis were relatively homogenous, all being experiments testing messages to discourage vaping among adolescents and young adults. Third, the control conditions in each of the studies in the meta-analysis were appropriate for each given study, and our results show homogenous effects on most outcomes. Fourth, our meta-analysis finds meaningful effects that are timely and will be useful to researchers and practitioners alike. As this literature continues to grow, so too will knowledge about the effects of vaping prevention messages and moderators of those effects.

Effects of Moral Frames Within Vaping Prevention Messages on Current smokers' Support for Electronic Cigarette Regulations.

Given the rise of communication campaigns to prevent and reduce the use of electronic nicotine delivery systems among minors nationwide, it is important to examine whether certain preventive messages will spill over to affect current adult smokers' support for and compliance with vaping regulations. Drawing upon the Moral Foundations Theory, the current study experimentally examined the effects of moral frames on current adult smokers' support for vape-free policies and marketing restrictions. An online sample of current smokers (N = 630) was randomly assigned to a 3 (moral frames in vaping prevention : care, purity, non-moral control) × 2 (priming of anti-smoking messages: yes or no) between-subject survey experiment. Compared with non-moral framed messages, smokers exposed to both care and purity framed messages were more likely to support vape-free policies in public places. Such effects were stronger for smokers with higher pre-treatment endorsement of the purity value, driven less by anger or disgust but more by smokers' updating of both self-oriented and secondhand harm perceptions. Moral frames, especially those appealing to care and purity moral values, are thus promising messaging strategies for vaping prevention communication campaigns in terms of increasing current smokers' support for vape-free policies. The results also help improve our understanding of the moral roots of health policy opinions and the potential of deploying moral framing to improve message design for health campaigns.

Commentary on "Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies".

Preventing vaping by adolescents and young adults is unquestionably an important goal. Ma et al.'s meta-analysis invites the conclusion that vaping prevention messages are effective. This commentary discusses two concerns about that conclusion and the affiliated meta-analysis: (1) None of the analyzed effect sizes describes the effectiveness of vaping prevention messages; the effect sizes describe the difference in effectiveness (the difference on an outcome variable) between the two conditions being compared. (2) As the two conditions being compared vary, so do the relevant conclusions--but the review combines different kinds of comparisons.

Preliminary development of the protective behavioral strategies for vaping scale.

OBJECTIVE: Exploring factors that may mitigate the harms of e-cigarette use (i.e., vaping) among college students may provide insights for prevention/intervention efforts. Study aims were to develop and conduct initial psychometric analyses on the Protective Behavioral Strategies for Vaping (PBSV) scale to measure strategies that students use before, during, after, and instead of vaping to protect themselves from vaping-related harms. METHODS: Students from one U.S. university (n = 277) completed an online survey and provided open-ended reports on things they do to avoid vaping and limit their use while vaping. Responses were used to generate an item pool of 52 strategies. Students from a second sample who vaped in the past year (n = 216) were administered these 52 items. A series of exploratory graph, unique variable, and exploratory factor analyses were used to develop and test the psychometric properties of the PBSV. RESULTS: The finalized scale contained 39 items, which featured three subscales reflecting manner of use, avoiding use by creating obstacles, and committing to quitting and using supports to quit. The PBSV composite score and each subscale negatively associated with vaping frequency and dependence. Males endorsed significantly lower scores for manner of use than females. CONCLUSIONS: This exploratory and preliminary examination of the PBSV scale's psychometric properties suggests that use of protective strategies for vaping may protect young people from more frequent use and greater dependence. More research with the PBSV scale is encouraged to determine its psychometric properties and potential practical utility as a clinical and assessment tool with young adults.

Study protocol of the Our Futures Vaping Trial: a cluster randomised controlled trial of a school-based eHealth intervention to prevent e-cigarette use among adolescents.

BACKGROUND: Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia. METHODS: A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12-14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures Vaping Program intervention group or an active control group (health education as usual). The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term. DISCUSSION: If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control. TRIAL REGISTRATION: The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662; date registered: 10/01/2023).

Using Virtual Reality in E-Cigarette and Secondhand Aerosol Prevention Messages: Implications for Emotional Campaign Design.

Vaping has dramatically increased in recent years among young adults. To increase risk perceptions and promote preventive behaviors against vaping and secondhand e-cigarette aerosol (SHA), this study designed and tested virtual reality (VR) messages based on the theory of psychological distance. We randomly assigned 137 participants to see one of three messages: a VR message presenting SHAs impact on the self (VR-Self), a VR message showing SHAs impact on others (VR-Other), and a print advertisement. Risk perceptions and preventive intentions/behaviors were assessed at three different times: before, immediately after, and 1 week after the experimental treatment. All three messages increased desired intentions and risk perceptions immediately, reduced vaping interest both immediately and 1 week after message exposure, and increased behavior to persuade others to quit vaping after a week. Compared with the print advertisement, VR-Other generated less vaping interest immediately following message exposure (ß = 1.40, p = 0.05). After 1 week, VR-Self (ß = 1.62, p = 0.05) and VR-Other (ß = 2.37, p = 0.01) generated less vaping interest than the print advertisement. VR-Other also generated a higher level of perceived harm of SHA (ß = 1.27, p = 0.01) than the print advertisement. VRs advantage over print in reducing vaping interest was increased after 1 week. Although VR-Other generated less emotions, such as fear, than VR-Self (z = 2.48, p = 0.02) and print (z = -2.82, p = 0.02), its persuasiveness was not hindered. Disgust increased the intentions to persuade others to quit vaping immediately after the experimental treatment (ß = 0.85, p = 0.02), and anger aroused by recalling the messages decreased vaping interest 1 week later (ß = -2.07, p = 0.02).

Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies.

Vaping prevention messages are widely used to communicate the health harms and addiction risks of vaping and discourage vaping among adolescents and young adults. We conducted a meta-analysis of experimental studies to examine the effects of these messages and to understand their theoretical mechanisms. Systematic, comprehensive searches generated 4,451 references, among which 12 studies (cumulative N = 6,622) met inclusion criteria for the meta-analysis. Across these studies, a total of 35 different vaping-related outcomes were measured, and 14 outcomes assessed in two or more independent samples were meta-analyzed. Results showed that compared to control, exposure to vaping prevention messages led to higher vaping risk perceptions, including harm perceptions (d = 0.30, p < .001), perceived likelihood of harm (d = 0.23, p < .001), perceived relative harm (d = 0.14, p = .036), addiction perceptions (d = 0.39, p < .001), perceived likelihood of addiction (d = 0.22, p < .001), and perceived relative addiction (d = 0.33, p = .015). Also, compared to control, exposure to vaping prevention messages led to more vaping knowledge (d = 0.37, p < .001), lower intentions to vape (d = -0.09, p = .022), and higher perceived message effectiveness (message perceptions; d = 0.57, p < .001; effects perceptions; d = 0.55, p < .001). Findings suggest vaping prevention messages have an impact, yet may operate through different theoretical mechanisms than cigarette pack warnings.