Wednesday, March 20, 2019

By Laura Hedli

Modern e-cigarettes have been around for just about as long as today’s teenagers have been alive, and oh how the two have grown up together. Patented in 2003 by Chinese inventor Hon Lik as a non-combustible tobacco product to help adults quit smoking, e-cigarettes are now exposing underage users with no prior history of smoking to nicotine. According to survey findings by the U.S. Food and Drug Administration (FDA) and the U.S. Centers for Disease Control and Prevention, 3.6 million middle and high school students identified as current e-cigarette users in 2018. For high school students in particular, there was a 78% rise in e-cigarette use between 2017 and 2018.

In response to the findings, U.S. Attorney General Jerome Adams issued an advisory last December, calling e-cigarette use an “epidemic among youth.” Meanwhile, JUUL—a pod-based e-cigarette brand popular with teens that has corned about 75 percent of the e-cigarette market —announced a partnership with Altria, the maker of Marlboro cigarettes. Altria now owns about 35 percent of JUUL’s shares. As The Verge reports, veteran tobacco companies like Altria and Reynolds American increasingly control the e-cigarette market, which is expected to be worth $34 billion by 2021—the year today’s e-cigarette turns 18.  

Addictive Behaviors journal just released a special April issue on e-cigarettes and non-combustible tobacco products (e-pub available); Stanford Maternal and Child Health Research Institute (MCHRI) postdoctoral awardee Karma McKelvey, PhD, MPH, and her mentor, Professor of Pediatrics Bonnie-Halpern Felsher, PhD, are co-editors of the issue. Their timing couldn’t be better.

While new research is reported daily on the effects of e-cigarettes on the brain and body, there remain significant gaps in our understanding. Vaping—a term used to refer to any electronic “vaporizer”—exposes users to potentially harmful aerosols inhaled through the lungs and exhaled into the environment. While vaping has been shown to spare users from inhaling many of the carcinogenic products associated with smoking, the practice has not been demonstrated to be safe.

Originally designed to look like conventional cigarettes, e-cigarettes now come in a variety of different shapes and sizes. Most notably, the JUUL design resembles a USB drive and its pods carry about as much nicotine as a pack of cigarettes. Another hallmark of e-cigarettes are the cornucopia of e-liquid or pod flavors, like Vaper Treats’ Cupcake Man or JUUL’s Mango, and these flavoring additives are not usually regulated. Advertisements and promotional content created by social media influencers have appealed to youth and make vaping look cool, sexy, and fun.

For Drs. McKelvey and Halpern-Felsher, it’s no wonder kids are becoming addicted.

In the Introduction to the Addictive Behaviors special issue, they write: “A lack of regulation and cohesive public health messaging surrounding these newer tobacco products, combined with rampant online sales and marketing, produced a perfect storm that has enabled widespread and rapid adoption, and continued use of novel non-combustible tobacco products.”

The issue contains more than 30 papers on the topic. Dr. McKelvey’s editorial efforts were supported in part by her 2018 MCHRI postdoctoral award for two years. Now in her second year, she’s received $83,448 in funding to date.

Taking the lead to explore a troubling trend among youth

Dr. McKelvey is a senior postdoctoral scholar who knew she wanted to work with Dr. Halpern-Felsher, a renowned expert on adolescent tobacco use, risk perceptions, and health-related decision-making. In fact, when Dr. McKelvey started as a postdoctoral fellow at the University of California, San Francisco (UCSF) in 2015, she was disappointed to find out that Dr. Halpern-Felsher had moved from UCSF to Stanford in 2014. Even while Dr. McKelvey was at UCSF, she found a way to author a paper with Dr. Halpern-Felsher on adolescent cigarette smoking perceptions and behavior.

“I just kept working with her,” says Dr. McKelvey. “As my fellowship was starting to end, I was like: You probably need a postdoc. You really need a postdoc. Turns out she needed a postdoc.”

“I did not need my arm twisted on that one,” says Dr. Halpern-Felsher.

At Dr. Halpern-Felsher’s suggestion, Dr. McKelvey began to apply for her MCHRI award even before she arrived at Stanford. Postdoctoral scholars apply as principal investigators for MCHRI grants, which Dr. McKelvey feels is significant. “It's still a mentored position but it gives me a real feeling for being an independent researcher,” she says, adding the experiences she’s had while on her MCHRI award have directly applied to the career development (K) award application she recently prepared to submit to the National Institutes of Health. “I believe that it enabled our department chair to feel pretty secure in supporting my K application because I have this history of funding. It’s been really affirming.”

While she’s still technically a trainee, Dr. McKelvey credits MCHRI with giving her “freedom and autonomy” to make her own contributions in the field and take on leadership roles.

As a postdoctoral scholar, Dr. McKelvey has had the opportunity to publish several articles as lead author. (Dr. Halpern-Felsher is often the senior author.) She’s collected stories on e-cigarette use from educators, parents and teens, and she recounts one where a 17-year-old girl said she had been vaping since age 14 because a friend had introduced her to cotton candy flavored e-liquid. The girl hadn’t been interested in vaping, but her friend said it smelled like cotton candy, so she tried it. Stories like these have fueled a forthcoming article (part of the Addictive Behaviors special issue) in which the researchers report how teens feel ads for flavored e-cigarettes target them and not older adults.

Last October, the media widely reported on findings of a study the duo published in JAMA Open Network. The results of a survey of 445 California adolescents and young adults showed that they prefer using e-cigarettes versus conventional cigarettes. Participants perceived that JUUL e-cigarettes, specifically, were less harmful or addictive than the other products mentioned in the survey. While only 15.6 percent of those surveyed had used JUUL, JUUL users were more likely to have vaped within the last 30 days compared to other e-cigarette users and were much more likely to have co-used JUUL and other e-cigarettes or conventional cigarettes.

Ever since the article was published in JAMA Network Open, Dr. Halpern-Felsher has been fielding journalists’ requests for interviews as new findings on JUUL and other e-cigarettes are released. “CNN and I are now best pals,” she says.

Combating the e-cigarette epidemic by focusing on prevention

Not waiting until more evidence accumulates before they act, Drs. Halpern-Felsher and McKelvey are focused on equipping youth with knowledge about tobacco that could lead to immediate behavior change. Enter the Tobacco Prevention Toolkit.

Launched in October 2016, the Tobacco Prevention Toolkit is an educational resource that’s online and free. Its target audience is middle school and high school students, and educators and students are permitted to adapt all lessons and activities to fit individual needs.   

“The best thing about working with Bonnie is that she puts her stuff on the line,” says Dr. McKelvey.

Dr. Halpern-Felsher estimates the toolkit reached over 200,000 students in 2018, with the majority living in California. Wider dissemination is the goal, as educators are hungry for something new. The Toolkit is being translated into Spanish, and plans are underway for Chinese and French translations as well.

As the toolkit is reaching more and more students, the duo want to know – just how effective is it?

Dr. McKelvey aims to find out. Thanks to her MCHRI postdoctoral award, she’s conducting a pre-post assessment of the Toolkit curriculum, using qualitative research methods to measure the toolkit’s implementation, usability, and accessibility. She has analyzed transcripts of interviews with students, teachers, and administrators, and plans to publish her results soon. Preliminary findings show educators find the Toolkit novel and worthwhile, and surveys with students indicate the Toolkit has changed students’ knowledge about, attitudes toward, and use of all tobacco products.

In parallel with Dr. McKelvey’s research, Dr. Halpern-Felsher and her team are conducting a broader randomized controlled trial to test the Toolkit’s effectiveness.

“For it to be acceptable as a program that educators in California can use their to-be monies for it has to be evidence based, which means it has to be formally evaluated,” says Dr. McKelvey.

How do you make drug prevention education effective and teen friendly?

There was Nancy Reagan’s “Just Say No” campaign and then D.A.R.E. (Drug Abuse Resistance Education).

“Here’s your brain on drugs” Dr. Halpern-Felsher says, remembering the famous commercial from her youth. “Cracking the egg. The sizzling. My reaction was: That looks good, can I have one?” she jokes.

So, what distinguishes the Tobacco Prevention Toolkit from predecessors that are easy to mock and are not particularly effective according to some researchers?

In addition to being theory- and evidence-based and updated daily with the latest information, Dr. Halpern-Felsher and her co-founders consulted with educators, students, and parents to determine what was missing from school-based tobacco prevention programs. (For a full description on the gaps they identified, visit the Tobacco Prevention Toolkit About Us page). “Having the stakeholders involved is extremely important,” says Dr. Halpern-Felsher.

Aditi Venkatesh, 17, is on the Student Advisory Board for the Toolkit. Venkatesh attended a private high school, where she says little was provided in the way of prevention education. She did, however, receive school-based education about drugs and tobacco while attending public middle school.

“I have a lot of friends in the public school system. From my experiences and their experiences, it's been a lot of scare tactics like: Don't do drugs. This is what will happen,” says Venkatesh. She explains that the Tobacco Prevention Toolkit doesn’t over exaggerate, but rather explains the science behind tobacco use to help kids understand what goes on in their bodies and make their own decisions. “I think it’s really important and what makes the toolkit so different.”

She should know. Venkatesh has worked with Breathe California of the Bay Area in their Youth for Lungs group, and has conducted youth trainings in California and also nationwide with the Campaign for Tobacco-Free Kids. She has lobbied in D.C., providing California and Nevada senators with information on why the FDA should regulate e-cigarettes.

Venkatesh’s experiences make her uniquely suited to help shape the Toolkit’s interactive curriculum. She explains a brand new activity called Cancerettes, which sounds sort of like a mash between roulette and the popular Hasbro Game of Life board game. In it, participants are given a pack of “cigarettes”—or pieces of paper rolled to look like cigarettes. Each paper contains a scenario. For example: You decide to go to the local park, and your friends tell you to hit a JUUL, and you take it. Move two steps back.

In addition to the many activities that require student participation and distinguish the Toolkit from didactic teaching programs, Venkatesh praises the Toolkit’s breadth of information. She was surprised to learn, for example, about the aggressive advertising tactics tobacco companies use and didn’t realize how flavors have been marketed to kids to hook a new generation on nicotine. The Toolkit provides information on both counts.

The future of e-cigarettes and their impact on our health

Venkatesh plans to study engineering when she starts college later this year, and her work regarding e-cigarettes has made her appreciate the value of social responsibility.

“There are a lot of technologies coming up that we need to look at and see how they are impacting society,” says Venkatesh. “This experience has really taught me that you can’t just create products without understanding how they’re going to affect people.”

While there is an ongoing debate on whether e-cigarettes are an effective smoking cessation tool for adults, there is no denying their popularity with kids. More than one in four high school students now regularly uses (in the past 30 days) some sort of tobacco product. Whereas it took decades to pass legislation designating smoke-free, tobacco-free places, JUULs are now being plugged into laptops at schools.

Clearly worried by what they have been witnessing, researchers like Drs. McKelvey and Halpern-Felsher are working at breakneck speed to understand, reduce, and ultimately prevent tobacco use among adolescents and young adults. Sometimes they have even relied on citing information from the popular press because the science just hasn’t caught up yet.

Because the FDA initially took a harm reduction approach, thinking e-cigarettes were favorable to conventional cigarettes, Dr. Halpern-Felsher says the organization has been slow to act. More recently, however, FDA Commissioner Scott Gottlieb has taken a more aggressive stance in regulating the tobacco and e-cigarette industries. The organization is revisiting their compliance policies, investigating a ban of flavored e-liquids and pods as well as ban on menthol in cigarettes, and putting pressure on JUUL. The e-cigarette company announced in November that in an effort to curb underage vaping, it would halt sales of flavored pods at over 90,000 retail stores and delete its Facebook and Instagram accounts in the U.S. Yet, JUUL also submitted comments to the FDA pushing to have flavor bans blocked.

Stricter regulations may or may not be issued. On March 5, Gottlieb unexpectedly announced he would resign from his post at the FDA at the end of the month.

What’s more, no one knows the long-term effects of e-cigarettes on our health. It’s all too new.

To this end, Dr. McKelvey hopes she is the first in a line of postdoctoral scholars supported by MCHRI to study tobacco use. “Tobacco—I don't think it's ever going to go away. The importance to maternal and child health of continued work on tobacco-related perceptions and prevention cannot be overstated.”

Laura Hedli is a writer for the Division of Neonatal and Developmental Medicine in the Department of Pediatrics and contributes stories to the Stanford Maternal and Child Health Research Institute.