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E-cigarette use and Rhode Island High school students: What providers need to Know about the characteristics of Initiation of E-cigarettes and Related Risk behaviors MOrGan Orr, MpH(C); JaMEs C. raJOttE, Ms; traCy l. JaCksOn, phD, MpH;

tara COOpEr, MpH; ailis ClynE, MD, MpH

IntRoduCtIon skyrocketing e-cigarette use gained national attention when the u.s. surgeon General issued warnings about this youth epidemic in 2018. More recently, 2019 saw the emergence of a new clinical condition attributed to vaping nicotine- and/or tetrahydrocannabinol (THC)-containing products called E-cigarette or vaping product use Associated Lung Injury (EvALI). The long-term health effects of e-cigarette use on youth and adults are generally unknown, but some immediate harms have been documented. nicotine expo- sure during adolescence can harm the developing brain until approximately the age of 25, impacting learning, memory, and attention.1 other health risks include injuries resulting from battery explosions and accidental childhood nicotine poisonings. The prevalence of e-cigarette use in youth also increases the likelihood of exposure to secondhand smoke/ aerosol for other students. prior e-cigarette use has been associated with high school teens being more than four times likely to ever smoke combustible cigarettes,2 making youth e-cigarette users more susceptible to known negative health outcomes associated with traditional tobacco cig- arette use (e.g., cancer, heart, and lung diseases). Through longitudinal data, current e-cigarette use has been linked to 1.29 increased odds of acquiring respiratory disease,3 emphysema, chronic bronchitis, and Chronic obstructive pulmonary disease.4

since 2015, the percent of rhode Island high school stu- dents that both initiate and currently use e-cigarettes has significantly increased (Figure 1). In 2019 alone, nearly one- in-two rhode Island high school students (49%) responded

yes to “Have you ever used an electronic vapor product?” and 30% indicated one or more days when asked “during the past 30 days, on how many days did you use an elec- tronic vapor product?”5 When compared to the most recent adult e-cigarette use, these youth rates are alarming. In 2018, 22% of rhode Island adults responded yes to “Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?” and 6% indicated every day or some days when asked “do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?”6 understanding potential drivers of youth e-ciga- rette use, as well as the disparities that exist between youth who have never tried and youth that have ever tried an e-cig- arette may have clinical and intervention design value when combatting youth use. These analyses compare initiation characteristics and risk behaviors that are more prevalent among rhode Island youth who “ever tried” and “never tried” e-cigarettes.

MethodS data presented in the following analyses are from the 2017 and 2019 rhode Island High school Youth risk Behavior survey (YrBs). data are aggregate for purposes of these anal- yses to produce reportable strata sample size in addition to increasing precision and reliability of estimates. The YrBs survey is administered biennially to monitor prevalence and trends of health risk behaviors among youth (i.e., middle and high school students). The rhode Island YrBs survey is not census-based; the sample is scientifically and efficiently drawn and is proportional to students in grades 9 through 12, attending public schools. Weighted data, using a two-stage cluster sample design,7 were achieved by yielding adequate response rates (> 60%) and are representative of the rhode Island public high school population. In total, 2,221 stu- dents from 19 public high schools in 2017 (representative of 41,114 students statewide) and 1,613 students from 21 pub- lic high schools in 2019 (representative of 44,052 students) completed the YrBs. For these analyses, ever using e-ciga- rettes within one’s lifetime was measured with the question “Have you ever used an electronic vapor product?”

The overall burden of e-cigarette use was analyzed and then descriptive analyses comparing the prevalence of those who have ever used e-cigarettes by demographics was

Figure 1. rhode island High school students’ E-cigarette use

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conducted. For demographic characteristics, significance was determined by a p-value <.05 using a Chi-square Test. Bivariate analyses were calculated to examine associations between ever and never using e-cigarettes in one’s life- time and the prevalence of mental health and academic achievement characteristics as well as likelihood to engage in various risk behaviors (e.g., substance use, unsafe trans- portation-related behaviors, risky sexual practices) among e-cigarette users compared to non-users. All analyses were performed using sAs version 9.4 and differences between groups were considered statistically significant when 95% confidence intervals (CIs) did not overlap.

ReSultS

overall, a combined rate of 44.8% of rhode Island high school students reported having ever used e-cigarettes, using the aggregate data for 2017 and 2019. statistical significance between all demographic characteristics (Table 1) was found with the exception being sex. non-Hispanic Black high school students significantly try e-cigarettes less than White students and students of other ethnic and racial minorities. E-cigarette initiation increases with age/grade level and is highest in the 11th and 12th grades. students who iden- tify as gay, lesbian, and bisexual and students who identify

demographics Ever used E-cigarettes

percent 95% cI

sex

Male 43.6 40.3–47.0

Female 45.7 41.9–49.5

Race/Ethnicity*

non–Hispanic white 47.4 44.7–50.1

non–Hispanic Black 37.9 28.6–47.3

Hispanic 41.1 36.8–45.3

non–Hispanic Other 46.3 40.8–51.8

grade*

9th 37.1 33.1–41.2

10th 39.9 34.8–45.1

11th 50.7 44.0–57.4

12th 53.0 40.5–53.6

sexual Orientation*

Gay/lesbian/Bisexual 54.2 45.9–62.5

Heterosexual 44.6 42.0–47.1

learning disability*

yes 56.0 48.2–63.9

no 42.6 40.3–44.9

never used E-cigarette

Ever used E-cigarette

% 95% cI % 95% cI

mental/behavioral Health status*

Mental health not good ≥ 1/30 days

59.0 53.2–64.9 68.5 66.1–70.9

Bullied electronically or at school

16.3 13.0–19.6 26.5 22.5–30.5

seriously considered attempting suicide

10.1 8.7–12.6 18.9 15.8–22.1

Felt sad or hopeless ≥14 days in past year

22.3 19.6–25.1 40.8 36.2–45.5

perception of Own grades*

Mostly as and/or Bs 79.7 74.3–85.1 69.7 65.6–73.7

Mostly Cs, Ds, or Fs 20.3 14.9–25.7 30.3 26.3–34.4

Table 2. Distribution of E-cigarette use among ri High school students,

by Mental Health and academic achievement Characteristics, 2017–2019

*Bolded percentages and 95% Cis are statistically significant when compared to never e-cigarette users.

*significant difference p<.05 in chi square test

Table 3. prevalence of Other youth risk Behaviors among rhode island

High school students who Have Ever used E-cigarette, 2017–2019

Table 1. prevalence of lifetime E-cigarette use among ri High school

students by selected Demographics, 2017–2019

never used E-cigarette

Ever used E-cigarette

% 95% cI % 95% cI

substance use*

Ever used marijuana 12.5 9.4–15.6 67.7 63.0–72.3

Currently used marijuanaϒ 5.9 4.2–7.7 44.4 40.3–48.6

Ever misused prescription pain meds^

4.3 2.9–5.7 15.4 12.0–18.8

Ever used drugs (cocaine, heroin, 3 ,4-methylene- dioxymethamphetamine)

1.2 0.5–2.0 8.5 6.8–10.3

Ever smoked cigarettes 5.4 4.1–6.8 33.8 30.0–37.6

Currently drank alcoholϒ 7.8 5.7–9.9 41.2 34.8–47.6

motor vehicle safety*

rode in a car where the driver had been drinkingϒ

8.8 7.0–10.5 19.1 16.0–22.2

texted/checked email while drivingϒ

18.0 12.9–23.1 49.4 42.2–56.7

never or rarely wore a seatbelt

4.0 2.4–5.6 7.9 5.8–10.0

sexual practice

Didn’t use a condom during last sexual encounter

37.4 31.0–43.8 46.4 39.6–53.2

ϒ at least once in the 30 days prior to survey administration.

^ taken prescribed pain medications differently than how a doctor told them to use it.

*Bolded percentages and 95% Cis are statistically significant when compared to never e-cigarette users.

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having a learning disability are also more likely to ever use e- cigarettes than their respective peers who identify differently.

poor mental health status is more prevalent in those who try e-cigarettes compared to those who do not (Table 2). self-reporting of poor mental health, being bullied, consid- ering suicide, and feeling sad/hopeless are all more preva- lent in those who try e-cigarettes. nearly 70% of those who have ever used e-cigarettes had at least one day in the last 30 where their mental health was not good, and 19% have seri- ously considered committing suicide in the past year. Those who ever use e-cigarettes were significantly more likely to report a perception of getting C/d/F grades in terms of academic achievement.

prevalence of all risk behaviors (Table 3), except not using a condom in the last sexual encounter, are significantly higher in students that ever use e-cigarettes. There are nota- bly larger differences present in substance use and motor vehicle safety risk behaviors. nearly 68% of ever e-cigarette users have ever tried marijuana, compared to only 13% of never e-cigarette users.

dISCuSSIon

The current analyses suggest significant differences exist among students who have ever used e-cigarettes based on demographics, mental health and academic achievement characteristics, and engagement in other risk behaviors. Those who have ever tried e-cigarettes were more likely to report engaging in other risk behaviors, such as substance use and unsafe transportation-related behavior. Additional analyses were conducted to compare risk factors and behav- iors among current (past 30 day) e-cigarette use with those who have ever tried e-cigarettes. However, there were no dif- ferences between these two groups with the exception of a newfound lack of statistical significance between the sexual orientation and perception of own grades variables. As such, the current-use group was excluded from this paper. use of marijuana, ever in one’s lifetime or currently, was much more prevalent within those who ever used e-cigarettes. While e-cigarette and marijuana use associations are an area of further study, 8.9% of all high and middle school students had ever used marijuana in an e-cigarette in 2016, according to the national Youth Tobacco survey. The data presented that compare marijuana use between both e-cigarette groups offer support for the idea that e-cigarettes may be a vehicle for and a risk behavior of youth using marijuana.8

regarding youth initiation nationally, flavors are cited to appeal to youth with approximately 31% of both middle and high school students reporting that flavor availability was a reason they used e-cigarettes.9 In 2017–2018, nearly 68% of high school students nationwide reporting current use of e-cigarettes said they used flavors.10 research also sup- ports that fruit/candy flavors perpetuate the misperception that such products are less harmful than tobacco-flavored

e-cigarettes.11 In light of recent data, the state of rhode Island promulgated emergency regulations in october that prohibit flavored e-cigarette products – including menthol – to curb youth use. In november 2019, Massachusetts passed legislation that prohibited the sale of flavored tobacco prod- ucts. Federal T-21 legislation raising the minimum legal age for tobacco and nicotine sales to 21 years of age and older was signed into law on december 20, 2019. on January 2, 2020, the FdA finalized an enforcement policy on “unau- thorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint.” rhode Island, through the Governor’s vaping Advisory Committee, is developing policy recommendations for consideration locally. A sum- mary of policy options developed by the Association of state and Territorial Health officials can be found at https:// www.astho.org/programs/prvention/Tobacco/E-Cigarettes/ E-Cigarette-policy-options-for-states. on January 16, 2020, a budget article was released in rhode Island by Governor raimondo that included policies associated with curbing youth e-cigarette use.

As of January 16, 2020, rhode Island has reported six cases of EvALI to the CdC, inclusive of two cases age 18 years and under. This investigation remains concerning as youth disproportionately use e-cigarettes compared to the 6% of adults who reported current use in 2018. nationally, as of January 7, 2020, 76% of hospitalized EvALI patients were under 35 years old, with an age range starting at 13 years old. Further, 57% of hospitalized EvALI patients reported using nicotine-containing products with 13% citing exclusive use of nicotine. While vitamin E acetate in THC cartridges has been strongly linked to the EvALI outbreak, CdC has noted there may be other chemicals of concern related to EvALI and recommends that individuals consider refraining from all e-cigarette or vaping product use.12

understanding the risk factors and risk behaviors of youth e-cigarette use in rhode Island carries important clinical and public health significance. These data can inform clin- ical screening guidance and practices to detect and address e-cigarette use, poor mental health, and potentially injuri- ous health behaviors early. The need for increased screen- ing, Brief Intervention, and referral to Treatment (sBIrT) for youth across community and clinical settings is also high- lighted. resources for providers to help youth quit as they begin to experience withdrawal from prohibition on flavored e-cigarettes are available. The rhode Island nicotine Help- line (1-800-QuIT-noW) provides a simple, no-cost point- of-access to telephonic cessation services in spanish and English for tobacco/nicotine users 13 years of age and older. This service provides screening, assessments of readiness to quit, counseling/advice, nicotine replacement therapy (nrT) for those 18 years of age and older, support materials, and local community-based cessation services information. The Truth Campaign’s “This is Quitting” free mobile program helps young people quit vaping. By texting dITCHJuuL to

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88709, individuals will receive messages from other young people who have attempted to or quit e-cigarettes along with evidence-based tips and strategies to help. Both are valuable assets for clinicians. While no nrT guidelines currently exist in the u.s. for youth vaping cessation, the American Academy of pediatrics is developing materials and recommends using existing tobacco guidelines and clinical judgment on a patient-by-patient basis.

study limitations These analyses have several limitations. All data from the YrBs are self-reported by students and subject to recall bias. underrepresentation of data due to stigma with engaging in illegal activity is possible. YrBs data on marijuana use is inclusive of all types of products (e.g., edible, combustible, e-liquid, and others) and is not vaping-specific. use of prev- alence estimates in these analyses do not represent causal- ity and further analysis is needed to estimate measures of association between the data presented.

ConCluSIon

In 2019 alone, nearly one-in-two rhode Island high school students (49%) have ever used e-cigarettes. poor mental/ behavioral health status, hopelessness, and suicide con- templation are more prevalent in students who ever use e-cigarettes. A major difference between students who ever and never use e-cigarettes is that 68% of students who ever used e-cigarettes reported marijuana use. substance use and motor vehicle safety risk behaviors also have a higher prevalence among those who try e-cigarettes. understand- ing the risk factors and risk behaviors of youth e-cigarette use carries important clinical and public health significance to improve upon existing resources for cessation, including the rhode Island nicotine Helpline and This is Quitting mobile application.

References 1. surgeon General’s Advisory on E-cigarette use Among Youth.

Available at: https://e-cigarettes.surgeongeneral.gov/documents/ surgeon-generals-advisory-on-e-cigarette-use-among-youth- 2018.pdf

2. Berry KM, Fetterman JL, Benjamin EJ, et al. Association of Elec- tronic Cigarette use With subsequent Initiation of Tobacco Cigarettes in us Youths. JAMA netw open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794

3. Bhatta dn, Glantz sA. Association of E-Cigarette use With re- spiratory disease Among Adults: A Longitudal Analysis. Am J prev Med. 2019;doi:10.1016/j.amepre.2019.07.028.

4. M perez et al. E-Cigarette use Is Associated with Emphysema, Chronic Bronchitis and Copd.

5. 2019 rhode Island department of Health, Center for Health data and Analysis. rhode Island Youth risk Behavior survey (YrBs).

6. 2018 rhode Island department of Health, Center for Health data and Analysis. rhode Island Behavioral risk Factor surveil- lance survey (BrFss).

7. Brener nd, et al. Methodology of the Youth risk Behavior sur- veillance system-2013. Morbidity and Mortality Weekly report 2013; 62:1 1-25.

8. dai H. self-reported Marijuana use in Electronic Cigarettes Among us Youth, 2017 to 2018. JAMA. published online de- cember 17, 2019. doi:https://doi.org/10.1001/jama.2019.19571

9. The 3 main reasons youth use e-cigarettes. (n.d.). retrieved from https://truthinitiative.org/research-resources/emerging-tobac- co-products/3-main-reasons-youth-use-e-cigarettes.

10. Cullen KA, Ambrose BK, Gentzke As, Apelberg BJ, Jamal A, King BA. notes from the Field: use of Electronic Cigarettes and Any Tobacco product Among Middle and High school students- united states, 2011–2018. MMWr Morb Mortal Wkly rep 2018; 67:1276–1277. doI: http://dx.doi.org/10.15585/mmwr.mm6745a5.

11. Meernik C, Baker HM, Kowitt sd, et al. Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated system- atic review. BMJ open 2019;9:e031598. doi: 10.1136/bmjopen- 2019-031598

12. outbreak of Lung Injury Associated with the use of E-Ciga- rette, or vaping, products. (2020, January 14). retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/ severe-lung-disease.html

authors Morgan orr, MpH(c), serves as an Evaluator in the Tobacco

Control program, rhode Island department of Health. James rajotte, Ms, serves as Chief of the Center for Health

promotion, rhode Island department of Health. Tracy Jackson, phd, MpH, serves as a senior public Health

Epidemiologist in the Center for Health data and Analysis, rhode Island department of Health.

Tara Cooper, MpH, serves as the Health surveys Team Manager in the Center for Health data and Analysis, rhode Island department of Health.

Ailis Clyne, Md, MpH, serves as Medical director for the division of Community Health and Equity, rhode Island department of Health.

acknowledgment special thanks to the entire Tobacco Control program (TCp) team

and valentina Adamova, TCp Manager.

correspondence James C. rajotte, Ms Chief, Center for Health promotion rhode Island department of Health [email protected]

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