Vaping Among Indiana’s Youth

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Center for Health Policy, Department of Health Policy & Management,

Fairbanks School of Public Health.

Background & PrevalenceSECTION 1

Vaping among young

people has reached

epidemic proportions• The CDC reports that between 2017-

2018

• Vaping increased by 78% among

high school students.

• Vaping increased by 48% among

middle school students.

Vaping refers to the act of using

electronic nicotine delivery systems

(ENDS) aka e-cigarettes.

• E-cigarettes come in a variety of shapes and sizes.

• All e-cigarettes typically have the following parts:

• A battery, a heating coil, a chamber to hold

liquid (e-liquid), and a mouth piece.

• When activated, the battery heats the e-liquid,

creating an aerosol that a user inhales.

• Can vaporize e-liquid with and without nicotine

as well as other substances like THC

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Vaping rose by 71% among high school and middle

school students between 2017-2018 representing 3.6

million students

National Youth Tobacco Survey

2011 2012 2013 2014 2015 2016 2017 2018 2019

E-cigarettes 6.0% 2.0% 2.9% 9.2% 11.1% 8.1% 7.9% 13.5% 20.0%

Cigarettes 10.5% 9.3% 8.0% 6.2% 6.1% 5.3% 5.2% 5.2% 4.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

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Vaping across all grade levels between 2017-2018

was the largest increase in any adolescent substance

use outcome in 43 year history of the MtF

Monitoring the Future Survey

2015 2016 2017 2018 2019

8th 8.0% 6.2% 6.6% 10.4% 12.2%

10th 14.2% 11.0% 13.1% 21.7% 25.0%

12th 16.3% 12.5% 16.6% 26.7% 30.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

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Vaping of nicotine has been driving the

increase in vaping across all grade levels.

Monitoring the Future Survey

2017 2018 2019

8th 3.5% 6.1% 9.6%

10th 8.2% 16.1% 19.9%

12th 11.0% 20.9% 25.5%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

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Vaping of THC across all grades increased

significantly between 2018-2019

Monitoring the Future Survey

2017 2018 2019

8th 1.6% 2.6% 3.9%

10th 4.3% 7.0% 12.6%

12th 4.9% 7.5% 14.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

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Vaping nearly doubled among Indiana middle

and high school students between 2016-2018

representing an increase of 35,000 students

Indiana Youth Tobacco Survey

2012 2014 2016 2018

Middle School 1.2% 4.9% 2.8% 5.5%

High School 3.8% 15.1% 10.5% 18.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

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Vaping increased substantially across all grade

levels from 2017-2018

Indiana Youth Survey

2015 2016 2017 2018

8th Grade 10.4% 9.4% 8.6% 11.9%

10th Grade 18.2% 15.4% 14.0% 20.4%

12th Grade 24.8% 21.6% 19.7% 28.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Why do youth vape?SECTION 2

Youth vape for several

reasons:

• Curiosity – 55.3% of middle and high school students who ever tried an e-cigarette did so out of curiosity.

• Flavors - 69.6% of middle and high school students who used a tobacco product used a flavored product, the most commonly used product was e-cigarettes.

• Family & Peer Influence – 30% of youth who ever used e-cigarettes did so because a friend or family did so.

Advertising

• Spending on advertising of e-cigarettes grew from 6.4 million in 2011 to 115 million in 2014.

• Increase in spending correlated to significant increase in e-cigarette use.

• In 2016, 4 in 5 youth (20.5 million) had been exposed to an e-cigarette ad.

• Young people regularly exposed to e-cigarette advertising have a higher likelihood of ever having tried e-cigarettes or of being a current user.

JUUL• Driving increase in vaping among young people.

• New type of e-cigarette known as a “stealth vaporizer”.

• Sleek, techy, and offers high levels of nicotine.

• Advertised aggressively through social media.

• Between 2016-2017 sales increased by 600%.

• By end of 2018, JUUL had captured 76% of retail e-cigarette market.

• In 2018, 6.0% of middle and 24.2% of high school students had used a JUUL in the past 30 days.

Concerns about Vaping

Vaping is a gateway to

combustible cigarette

use.• Youth who reported ever using e-

cigarettes were more likely to have

experimented with cigarettes and more

likely to be current smokers.

• Longitudinal studies indicate that youth

who smoked e-cigarettes at baseline

were 4 times more likely to be smoking

cigarettes at follow up.

Vaping exposes

adolescent brains to

nicotine• The adolescent brain is more sensitive to

nicotine.

• Nicotine impairs development of areas of the brain that control mood, attention, learning, and impulse control.

• Youth who use nicotine-containing products are more likely to develop dependence on nicotine.

• Young people can develop an addiction to nicotine with relatively little exposure, as little as 40 puffs on a JUUL on a daily or near daily basis.

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The contents of e-cigarette liquid exposes

young people to other risks:

1. The components of e-liquid have not been deemed safe for inhalation.

2. When heated, many of the components of e-liquid can form carcinogens.

3. Inhalation of fine particles in e-cigarette aerosol can promote lung disease

like chronic bronchitis and asthma in young people who are regular users.

4. E-cigarette aerosol also contains various heavy metals, all of which can

be toxic when inhaled.

Key Informant Interviews

Background

• Interviews were completed with 9 key

informants.

• Informants were involved with state- or

county-level tobacco control and

prevention efforts.

• The purpose of the interviews was to

better understand how vaping was

affecting Hoosier youth.

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How much of a problem do you think vaping/e-

cigarette use is among Indiana’s youth?1. All informants expressed that vaping was a significant problem within Indiana:

– “I totally agree with the Surgeon General, Dr. Jerome Adams, that it’s an epidemic”.

2. Informants believed JUUL was responsible for the current level of vaping and that it was popular because it doesn’t smell, is sleek, can be used discreetly, and does not carry the stigma of cigarettes but most importantly:

– “I definitely think it is the flavors”

3. In terms of access informants believed that “the majority of youth report getting products from social sources”.

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What groups of young people are particularly

vulnerable to vaping or are vaping at higher

rates?1. While some informants believed that young people in middle school were

most vulnerable, the overall consensus was reflected by one informant

as:

– “I say in every presentation that I give JUUL did not care who it targeted. It did

not target to the African-American or the LGBT community alone. It targeted

to us. I feel it targeted to the poor, to the rich, to the low education, to the high

education, it did not discriminate.

What is vaping problematic and

why should we be concerned about

it?• Similar to what the national literature says, informants

cited concerns that “we are concerned about nicotine on the developing brain…the area that affects learning, mood, impulse control, concentration…” and that it “results in symptoms of dependence”.

• Informants expressed that little is known about the components of e-cigarette liquid and that it “may take years before we understand the health consequences”.

• One informant stated it as:

• “…this generation is the new guinea pig for the tobacco industry and by the time they really get the data and the science behind it…the current generation is already going to be hooked and addicted”.

What would the ideal

prevention/intervention model look

like?

• Informants agreed that following CDC recommendations

and better funding of TPC would be ideal:

• “I think it starts with a well-funded and well-run state

prevention program following CDC best practices. I

think it would also include reaching kids where they

are. A program needs to have community resources,

they need to be staffed. Each community would need

to have resources to help people quit. It’s going to

mean investing in [web-based and social-media-based]

communications. I think policy makers are

uncomfortable investing state dollars that way. We’re

going to have to get over that hesitation if we really

want to reach kids…”

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Policy Recommendations1. Ban all non-tobacco flavors in not just e-cigarette products but all tobacco products.

2. Cap the level of nicotine available in e-cigarettes to levels that would reduce the risk of addiction.

3. Tax e-cigarettes and price them at levels comparable to cigarettes.

4. Adopt more comprehensive smoke free laws.

5. Implement public education/media campaigns.

6. Increase restrictions on tobacco licenses and improve enforcement efforts for retailers.

7. Develop effective school-based strategies that de-emphasize suspensions or expulsions while

emphasizing counseling, education, and in-school services for quitting.