Public Health Program Assignment

What interventions can be implemented to increase rates of Smoking Cessation (Specifically Regarding Discontinuing Use of Electronic Cigarettes and “Vaping”) in Youth/Young Adults (Middle School Through College-Aged) in New York City?

Scope of the Problem

Electronic cigarettes and “Vaping” involves using devices that aerosolize, or vaporize, chemical and nicotine-containing flavorings. Recently, E-cigarette use and “Vaping” has become increasingly popular, with as many as 400 different E-cigarette brands being marketed. These devices have many different appearances, including traditional cigarette-like appearance and more “high-tech” options. This form of nicotine use is very concerning because it is now the most commonly used form of tobacco among youth in the U.S.

It is hypothesized that the various “flavors” offered as well as advertising and marketing ploys are directly related to how enticing this option has been. Research published in the Environmental Health Perspective indicated that a pulmonologist, Dr. Laura Crotty Alexander, has experienced a new challenge in the face of these E-cigarette and “Vaping” users. When asked questions regarding the safety of these devices, Dr. Crotty Alexander admits that she didn’t know the answers, and the fact of the matter is that there is still not enough data regarding the long-term risks of E-cigarette and “Vaping” use. Conclusions drawn from a 2014 publication in the British Medical Journal indicated that:

a. Whether E-cigarettes are less harmful than cigarettes remains inconclusive

b. There is still a lack of data regarding whether E-cigarettes may aid in smoking cessation, and there are no FDA-approved E-cigarettes as cessation aids

c. There are still concerns regarding the environment and second-hand exposure

d. Overall, the limited data surrounding the topic cannot determine the true health impact of E-cigarette use, both for users and for the public (regarding environment and second-hand exposure)

Research also indicated that propylene glycol-based e-liquids generated similar levels of formaldehyde as those seen in tobacco smoke.

One of the other concerns of E-cigarette and “Vaping” use, perhaps most importantly and most directly related to the scope of the proposed Public Health Intervention, is that studies have indicated that preteens, teens, and students who used E-cigarettes were more likely to begin smoking cigarettes (as compared to those who did not use these devices). This statement stems from the fact that there is a large population of preteens, teens, and students that begin using nicotine in the form of E-cigarettes and “Vaping.” This is explained in many studies that indicate that participants typically have more lax attitudes regarding E-cigarette use versus traditional tobacco cigarette smoking. The factors included the perception of fewer health risks and the fact that these devices (E-cigarettes) are more socially acceptable.

Ignoring the fact, for a minute, that data cannot conclusively predict the health risks of E-cigarette use, nicotine is an addictive substance triggering the pleasure centers of the brain through a release in dopamine. In developing brains, this has potential implications regarding making future drug use more pleasurable, by priming the brains response and desire for dopamine.

There have been past successes, and some failures, regarding E-cigarette regulation. For example, Governor Cuomo passed a law in July 2017 that banned E-cigarette use in all public and private school grounds in New York State. This law was amended in November 2017 to include the banning of E-cigarette use in all places where tobacco products are prohibited in New York (i.e. bars, restaurants, etc.). Some failures include the fact that while cigarettes are taxed a total of $5.85 (total) for one-pack (20 cigarettes), there is no additional excise tax on E-cigarettes. Perhaps the biggest blunder in regulation is the fact that purchasing E-cigarettes online, even when underage, is easily accomplished. Research conducted in the state of North Carolina had 11 teens between ages 14 to 17 try and purchase E-cigarettes from 98 online retailers. In total, five orders were rejected due to failed age verification and eighteen orders failed due to website issues. Of the 98 attempted orders, 75 were successful. The study also had the teenagers answer the door when the package arrived, and none of the companies delivering asked for age-verification. Additionally, 95% of the time the packages were simply left at the door.

This overview of the issue is certainly suggestive of why changes need to be implemented now, rather than waiting for this issue to continue growing. Studies have not been successful in detecting a definitive relationship between socioeconomic status (SES) and E-cigarette use, though implementing this Public Health Intervention city-wide, can have long-reaching benefits to all including those in underserved communities.

Planning

The Public Health Intervention (description of intervention) that I am suggesting includes a multitude of legal, environmental, and behavioral changes:

Legal – It is unacceptable that cigarettes receive a hefty tax of $5.85 per pack while E-cigarettes and “Vapes” have not yet been taxed. Implementing a tax on these products (citywide, but preferably statewide), in an amount that is equivalent to that which is placed on purchasing cigarettes, is necessary. This includes the purchase of E-cigarettes and “Vaping” devices in addition to the “juices” or “oils” used to refill them. The tax imposed should create one reason for individuals to avoid purchasing these products (i.e. cost), yet the tax revenue generated will have much greater effects. ALL REVENUE GENERATED will be used for future research on the safety of E-cigarettes and Vaping and Programs for Prevention and Cessation. It is unacceptable that these products are being easily purchased by minors over the internet. Therefore, legislation that makes it illegal to sell E-cigarettes or “vapes” or any related substances (“Juices,” “Oils”) to anyone residing in New York State should be implemented.

Behavioral – Those in Middle School (Mandatory) through College (Optional) should attend assemblies where E-cigarettes and “Vaping” are discussed. These assemblies will be directly funded by the tax imposed on the purchase of these and related products. The goal of these assemblies would be a form of primary prevention, in which the inconclusive nature, and some of the risks (like nicotine use) of E-cigarettes and “Vaping” is discussed. Misunderstandings about E-cigarettes and “Vaping,” like the thought that they are “safer alternatives” to cigarettes, will be debunked. The students would be encouraged to ask questions in an effort to allow them to engage in the discussion and learn. Schools should also offer their students information on smoking cessation, including where they can go for help in quitting using nicotine products. Assuming that there are nurses or other health staff at the school, it is possible that these staff can organize “Quit Groups,” or better publicize the fact that these services are accessible to students. Clinicians statewide (and hopefully nationwide) should be asking all patients, but especially the demographic mentioned in this intervention, explicitly about E-cigarette use and “Vaping.” The role of the clinician in promoting primary prevention, or in helping their patients quit using nicotine products, is significant.

Environment – Campaigns, particularly in local public schools, private schools and colleges (citywide), can have far-reaching effects. These campaigns can include e-mail blasts, flyers around school, free stickers, and other gear (funded by tax imposed) that expresses what would be discussed in the aforementioned assemblies.

There are several Key Stakeholders that would need to be considered in creating this Public Health Intervention:

New York City Government Officials – Getting their buy-in would not be too difficult. Highlighting the statistics regarding use of E-cigarettes and “Vaping” devices among Youth/Young Adults, and showing how this Public Health Intervention can have a positive impact on the community would aid in getting their support.
New York State Government Officials – Getting their buy-in may be more difficult because the interests of E-Cigarette and “Vaping” Companies (financial) versus those of the general public would be at odds. Citing important statistics of use of these products and the unknown nature of their health impact would be helpful. Additionally, noting the fact that these products are getting into the hands of minors may make this issue more concerning. The fact that taxes are not being implemented on all of the population, and rather on individuals choosing to engage in this habit (which is exactly the case for cigarette purchases) should also encourage their support. In other words, implementing these changes (legislation) will not be viewed as too drastic by the general public.
E-Cigarette and “Vaping” Companies – Getting their buy-in would be the most difficult, and probably would not occur at all. Statistics would probably not do much in convincing these companies that an intervention needs to be set forth. The best option would be that government officials (state) can implement legislature that these companies would be mandated to abide to.
Community – Getting the community buy-in would not be difficult through citing statistics and essentially getting this issue exposure. Letters may be sent home to the parents of school-aged children notifying them of the implementation of this intervention and its importance.
Clinicians – Getting the clinicians to buy-in would not be difficult. If they are practicing evidence-based medicine (which they should be), they are aware of where the scientific community currently stands on the health impacts of these products. They should be willing to discuss the use of these products with their patients and encourage tobacco and nicotine abstinence or work with them to aid in tobacco cessation.

Pre- and Post-Intervention surveys will be required to study whether the intervention is successful. These surveys would include questions asking whether the patient taking the survey has ever used E-cigarettes or “Vapes,” whether they use them regularly, how often, their perceptions of whether or not they are harmful (compared to cigarette smoking), among many others. These surveys could be given out to the demographic at school. Additionally, there may be individuals within this age that do not attend school. In this event, then clinicians can give the survey to their patients.

The program is essentially “self-funding,” so it should be feasible long-term assuming that the population of E-cigarette and “Vaping” users does not diminish to such a point where there are very few left (or no more). It can serve as a guide for programs in other communities (then hopefully states) as well.

Development & Dissemination of the Intervention

Goal – To increase rates of smoking cessation and decrease rates of new smokers, especially first-time smokers, specifically regarding Electronic Cigarettes and “Vaping” in Youth/Young Adults (Middle School Through College-Aged) in New York City

Inputs – As previously mentioned, funding will come in the form of the taxes imposed upon the sale of these and related products. It is possible that a non-for-profit local organization can be created (i.e. manpower would be necessary) that could host the assemblies and perform the community outreach described above. In the event that a non-for-profit is created, renting a physical space like an office may be necessary.

Evaluation & Maintenance

Evaluation – The Pre- and Post-Intervention surveys (mentioned in the Planning section) would be useful in determining if the plan is working. Comparing the number of current E-cigarette users and “Vape” users within the demographic Pre- and Post-Intervention (measured by survey) would also be useful. Additionally, comparisons on perceptions of E-cigarettes and “Vaping” Pre- and Post-Interventions would be useful data to have. Data that evaluated how Youth/Young Adults were getting their E-cigarettes Pre- and Post-Intervention would help the program visualize the effect of legislature banning online sale of these products and determine other ways that Youth/Young Adults are getting them. The evaluation could take place quarterly (i.e. every 3 months) to evaluate if changes should be made. Additionally, Pre- and Post-Intervention surveys can occur by evaluating clinicians and how often they ask explicitly about E-cigarettes and “Vaping” and if they counsel their patients on this issue. In the event that the intervention is unsuccessful, it may be useful to survey individuals within the demographic that were former E-cigarette users and “Vape” users. They may have some more insight in what measures should be taken to help other users quit by sharing their experience as to what motivated them. Maintenance of the program, financially, is set up such that it is self-sustaining. Funding should theoretically be continuous.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859972/

https://jamanetwork.com/journals/jama/article-abstract/1886077?redirect=true

http://tobaccocontrol.bmj.com/content/26/4/386

https://academic.oup.com/ntr/article-abstract/18/5/647/2511294

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4154203/

https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes

https://betobaccofree.hhs.gov/about-tobacco/Electronic-Cigarettes/index.html

http://www.pbs.org/wgbh/nova/next/body/vaping/

https://www.health.ny.gov/press/releases/2017/2017-11-22_e_cigarettes_banned.htm

https://www.tax.ny.gov/bus/cig/cigidx.htm

http://www.publichealthlawcenter.org/resources/us-e-cigarette-regulations-50-state-review/ny