School-based preventive interventions targeting e-cigarette use among adolescents: a systematic review protocol

Introduction/Objectives:Since 2015, the rise in e-cigarette use among youth has concerned public health authorities. After peaking in 2019, usage rates have declined but remain high. In 2023, 10% of high school and 4.6% of middle school students reported current use. This report describes the implementation and evaluation of a school-based e-cigarette prevention program, CATCH My Breath (CMB), in 8 central Appalachian counties. These counties have some of the highest rates of tobacco use, poor health, and premature death in the United States.Methods:A total of 6217 students across 25 middle and high schools in West Virginia and Kentucky received the CMB program from 2019 to 2023. Lists of participating counties, schools, and teachers were maintained on a rolling basis over the 4 years of the project. Program reach and impact on e-cigarette knowledge and use are reported. Thirteen-item pre- and post-tests were completed electronically by students before and after each course delivery. Questions assessed knowledge about e-cigarettes, current (past 30-day) e-cigarette use, and interest in future use.Results:From 2019 to 2023, there were 9399 deliveries of the 4-session CMB course, primarily to middle school students. Approximately 84% reported being less likely to use e-cigarettes following the program. Significant improvements in e-cigarette knowledge and beliefs on 5 of 8 items were observed, including a significant increase in knowledge composite score (4.15-4.75, P < .001). From pre- to post-test, declines in current e-cigarette use (5.1% to 4.4%; P = .005) and peer influence (4.9% to 4.0%; P = .025) were also observed.Conclusions:CMB was feasible, effective, and well-received in a convenience sample of central Appalachian counties and schools. This curriculum, combined with other policy initiatives, offers hope for curbing the growing epidemic of youth e-cigarette use and nicotine dependence. The success of this project contributed to a decision by the West Virginia Bureau for Public Health and the West Virginia Department of Education to launch a joint effort to bring CMB to middle schools in all 55 counties during the next 3 school years of 2023-2026.

IntroductionDespite the rise in popularity of e-cigarette smoking or ‘vaping’, its long-term health consequences are still being investigated. In particular, it is unclear what impact e-cigarette use has on aerobic performance and exercise capacity. This information has important implications both for tobacco smokers as a harm reduction approach, and youth and young adults who are increasingly turning to e-cigarettes recreationally. Thus, this review aims to systematically evaluate the literature surrounding the effects of regular e-cigarette use on markers of cardiorespiratory fitness and physical activity.Methods and analysisThis protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. A systematic search was undertaken in October 2024, using the defined population, intervention, comparison, outcomes, study time framework to identify all relevant articles. Studies will be eligible if they include individuals who use e-cigarette products, assess regular e-cigarette use as an exposure, compare to a group of non-users and report outcomes related to measures of cardiorespiratory fitness (eg, VO2max, 6 min walk test) or physical activity (eg, sport participation, meeting weekly physical activity guidelines), regardless of study duration. Searched databases will include PubMed/Medline, Cochrane Library and Embase, with no restriction to date or language of publication. Two reviewers will carry out the title and abstract screening, full text review and data extraction. Risk of bias will be assessed using the Newcastle-Ottawa Scale for non-randomised studies and the Cochrane Risk of Bias Tool (v2) for randomised studies. Study heterogeneity will be assessed using the Q and I2 statistic tests. Efforts will be made to conduct a meta-analysis if sufficient data and homogeneity are present. Otherwise, a narrative synthesis will be conducted, focusing on common themes, subgroups and sources of variability.Ethics and disseminationEthics approval is not required for this review of previously published or presented data. The results of the review will be disseminated via conference presentations and peer-reviewed publication. Moreover, results of this review may inform public health recommendations and identify areas in the field where further research is needed.PROSPERO registration numberCRD420250589685.

Background Cigarette smoking can negatively affect treatment response in inflammatory bowel disease (IBD) patients, especially among those with Crohn’s disease (CD). E-cigarette has been considered a safer alternative to delivering nicotine for IBD patients who smoke. However, given the recent large number of reported e-cigarette-related lung injury cases, CDC released an interim guidance update on those lung injuries. They also coined a term EVALI (e-cigarette, or vaping, product use associated lung injury) emphasizing the possible harms in e-cigarette smoking. To the best our knowledge, we currently do not know the recent smoking habits in American IBD patients, especially when it reveals that e-cigarette use might cause serious lung injuries. Methods We used National Health Interview Survey (NHIS) for 2015–2016, which is a nationally representative survey for noninstitutionalized adults in the US. Weighted counts and percentages were estimated using survey design for the population-level results. We identified those who reportedly were told by a doctor or healthcare professional that they have IBD. We first estimated the prevalence of current e-cigarette or cigarette use among IBD patients. We then estimated the frequency of use (every day or some days) among the current users. We also categorized IBD patients into 4 groups by smoking type: those using e-cigarette only, cigarette only, using both, and neither. To see the characteristics of e-cigarette users, we stratified e-cigarette users by current/former/never cigarette use status. Results We identified 951 participants (population estimate: 3.1 million) with IBD. Among those people, 5.0% (95% CI: 3.1–6.9) was current e-cigarette users while 17.9% (95% CI: 14.8–21.0) was current cigarette smokers. Prevalence of every-day use and some-day use of e-cigarette was similar (2.4% vs 2.6%), while there was much higher prevalence of every-day use than some-day use in cigarette (15.3% vs 2.6%). Those who were using both e-cigarette and cigarette was 3.2% (Table). Majority of e-cigarette users were also currently using cigarette (63.6%, 95% CI: 48.9–78.3), while 32.7% (95% CI: 18.4–47.0) of them were former cigarette smokers. Only 3.7% (0.0–8.9) of them never used cigarettes. Conclusion While numerous studies show e-cigarette use is generally increasing rapidly in the US, we found that 5% of IBD patients are currently using e-cigarette. Almost two-thirds of them were also currently smoking cigarette and one-third of them were former smokers. It is possible that most of the e-cigarette users are still in the process of transitioning from cigarette smoking and thus using both types. We lack information on effects of using e-cigarette or both e-cigarette and cigarette in IBD treatment outcomes, as well as how e-cigarette use will complicate other health risks in IBD patients (e.g. lung injuries). We need further research on these effects to properly guide IBD patients who are in need of smoking cessation.

The banning of sales of nicotine e-liquid in e-cigarette shops has been implemented in several states in Malaysia. The distribution of nicotine e-liquid can only be allowed by licensed pharmacies or registered medical practitioners. This study aimed to evaluate e-cigarette users' responses to the control policy in a cross-sectional survey of 851 e-cigarette users by utilizing a self-report questionnaire that assessed (1) attitudes on regulation policy of e-cigarette banning; (2) e-cigarette use behaviors; and (3) sources of e-liquid after the regulation policy has been implemented. Participants from the state of Selangor where the banning policy was implemented were surveyed. The majority (95.8%) opposed the banning and believed e-cigarettes should be sold to anyone aged 18 years or above as with tobacco cigarettes, only a minority believed that nicotine e-liquid should only be available for sale over the counter in pharmacy stores (14.6%) and in clinics with a doctor's prescription (11.8%). The majority (44.2%) reported that they would continue their e-cigarette use as before the banning policy, while 20% plan to completely stop e-cigarette usage without replacing it with any alternatives. The vast majority (87.9%) was still able to obtained nicotine e-liquid from e-cigarette shops in spite of the ban and the second most common source was from online purchase (63.1%). The sales of nicotine e-liquid from black-market were evidenced as many reported obtaining zero nicotine e-liquid from the black market (54.4%). Self- or home-made (30.8%) nicotine e-liquid was also reported. Majority of respondents that self-made e-liquid were from the average monthly income group (below MYR3000). Obtaining nicotine from the pharmacy was least preferred (21.4%). Provision of professional advice to nicotine e-liquid users along with the ban may lessen the likelihood of users switching to tobacco cigarettes or other nicotine alternatives. Banning of sales of nicotine e-liquid in e-cigarette shops resulted in a boom in the black market supplying nicotine e-liquid and, self- or home-made nicotine e-liquid. Enforcing regulations and monitoring black market sales is warranted. Efforts to educate e-cigarette users of the danger of sourcing nicotine e-liquid from the black market and self- or home-made nicotine e-liquid are essential.

BackgroundE-cigarettes are currently being debated regarding their possible role in smoking cessation and as they are becoming increasingly popular, the research to date requires investigation.ObjectivesTo investigate whether the use of e-cigarettes is associated with smoking cessation or reduction, and whether there is any difference in efficacy of e-cigarettes with and without nicotine on smoking cessation.Data SourcesA systematic review of articles with no limit on publication date was conducted by searching PubMed, Web of Knowledge and Scopus databases.MethodsPublished studies, those reported smoking abstinence or reduction in cigarette consumption after the use of e-cigarettes, were included. Studies were systematically reviewed, and meta-analyses were conducted using Mantel-Haenszel fixed-effect and random-effects models. Degree of heterogeneity among studies and quality of the selected studies were evaluated.ResultsSix studies were included involving 7,551 participants. Meta-analyses included 1,242 participants who had complete data on smoking cessation. Nicotine filled e-cigarettes were more effective for cessation than those without nicotine (pooled Risk Ratio 2.29, 95%CI 1.05-4.97). Amongst 1,242 smokers, 224 (18%) reported smoking cessation after using nicotine-enriched e-cigarettes for a minimum period of six months. Use of such e-cigarettes was positively associated with smoking cessation with a pooled Effect Size of 0.20 (95%CI 0.11-0.28). Use of e-cigarettes was also associated with a reduction in the number of cigarettes used.LimitationsIncluded studies were heterogeneous, due to different study designs and gender variation. Whilst we were able to comment on the efficacy of nicotine vs. non-nicotine e-cigarettes for smoking cessation, we were unable to comment on the efficacy of e-cigarettes vs. other interventions for cessation, given the lack of comparator groups in the studies included in this meta-analysis.ConclusionsUse of e-cigarettes is associated with smoking cessation and reduction. More randomised controlled trials are needed to assess effectiveness against other cessation methods.

Diagnosing EVALI in the Time of COVID-19

To the Editor

AN UNUSUAL CASE OF CARDIOVASCULAR COLLAPSE AFTER EVALI

Assessing nicotine dependence in adolescent E-cigarette users: The 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Nicotine Dependence Item Bank for electronic cigarettes

Background: Tobacco use remains a major public health concern among adolescents, particularly as electronic cigarette (e-cigarette) use has increased in recent years. While academic performance has been linked to health-risk behaviors, less is known about its specific relationship to tobacco use among predominantly Black youth in urban settings. Understanding this association is essential for informing targeted prevention strategies. Objective: To examine the association between academic performance (self-reported grades from A to F) and use of tobacco products—including conventional cigarettes, e-cigarettes, and other forms—among predominantly Black high school students in Baltimore, a city marked by socioeconomic and health disparities. Methods: A cross-sectional analysis was conducted using survey data from 604 public high school students in Baltimore. The main predictor was self-reported average school grades. Outcomes included ever use of (1) combustible tobacco products, (2) e-cigarettes, and (3) any tobacco product. Logistic regression models estimated associations between academic performance and each tobacco outcome, adjusting for age, sex, race, parental education and employment, and household structure. Results: Among participants (mean age = 16.1 years), 20.2% reported using e-cigarettes, 7.1% used cigarettes, and 25.2% had used any tobacco product. Academic performance was inversely associated with all forms of tobacco use. Students with A, B, or C grades had significantly lower odds of e-cigarette use compared to those with D or F grades. Students with A grades had lower odds of cigarette use and any tobacco use. Conclusions: Lower academic achievement was consistently associated with higher odds of tobacco use among predominantly Black adolescents. Academic performance may help identify youth at higher risk of tobacco use and guide school-based prevention and intervention strategies in similar urban settings.

Objective New legislation to curb the rapid increase in e-cigarette use among youth is underway. We estimated the future healthcare costs for chronic diseases from e-cigarette use among never smokers who transition to tobacco smoking. Methods Using population-attributable fractions, we estimated the health expenditure attributable to e-cigarettes based on the prevalence of e-cigarette use, uptake of tobacco smoking, and risk of smoking on developing chronic disease. Data for men and women were derived from published reports on e-cigarette use prevalence, risk of smoking-related disease and addiction, and health expenditure for 25 diseases. Sensitivity analyses were undertaken to address data input variation. Results Future healthcare costs attributed to new e-cigarette-initiated smokers were conservatively estimated to be (in Australian dollars) $179.6 million annually. Collectively, the estimated costs were highest for respiratory diseases ($102.2 million; 57% of total costs), malignant cancers ($49.6 million; 28%), and cardiovascular disease ($27.7 million; 15%). The uptake rate of e-cigarettes was more important in driving healthcare costs than the proportion moving from e-cigarettes to cigarette smoking. Conclusion High avoidable health system costs are predicted for the treatment of chronic conditions created by e-cigarette-initiated smoking. These costs exclude the immediate and direct healthcare harms of e-cigarette-related poisoning, lung injury, and respiratory problems, and costs associated with the unknown health harms of e-cigarette use alone. The proposed regulations to curb recreational e-cigarette use in Australia are set to prevent expensive health care arising sometime in the future from new cigarette smokers.

BackgroundElectronic cigarettes (e-cigarettes) are relatively new tobacco products that are attracting public attention due to their unique features, especially their many flavor options and their potential as an alternative to cigarettes. However, uncertainties remain regarding the determinants and consequences of e-cigarette use because current research on e-cigarettes is made more difficult due to the lack of psychometrically sound instruments that measure e-cigarette related constructs. This systematic review therefore seeks to identify the instruments in the field that are designed to assess various aspects of e-cigarette use or its related constructs and analyze the evidence presented regarding the psychometric properties of the identified instruments.MethodsThis systematic review utilized six search engines: PubMed, Medline, CINAHL, PsycINFO, Web of Science, and EMBASE, to identify articles published in the peer-reviewed journals from inception to February 2022 that contained development or validation processes for these instruments.ResultsEighteen articles describing the development or validation of 22 unique instruments were identified. Beliefs, perceptions, motives, e-cigarette use, and dependence, were the most commonly assessed e-cigarette related constructs. The included studies reported either construct or criterion validity, with 14 studies reporting both. Most studies did not report the content validity; for reliability, most reported internal consistencies using Cronbach’s alpha, with 15 instruments reporting Cronbach’s alpha > 0.70 for the scale or its subscales.ConclusionsTwenty-two instruments with a reported development or validation process to measure e-cigarette related constructs are currently available for practitioners and researchers.This review provides a guide for practitioners and researchers seeking to identify the most appropriate existing instruments on e-cigarette use based on the constructs examined, target population, psychometric properties, and instrument length. The gaps identified in the existing e-cigarette related instruments indicate that future studies should seek to extend the validity of the instruments for diverse populations, including adolescents. Instruments that explore additional aspects of e-cigarette use and e-cigarette related constructs to help build a strong theoretical background and expand our current understanding of e-cigarette use and its related constructs, should also be developed.

Background E-cigarette use was associated with health effects, including lung injury. This cross-sectional study aimed to assess the university students' health belief in e-cigarette use associated with lung injury based on the Health Belief Model (HBM). Methods We collected data using an online self-administered questionnaire from December 2020 to February 2021 from university students at two universities in northern Thailand who were currently using e-cigarettes. The HBM was measured using questions with a 4-Likert-scale answer (1=strongly disbelieve,2=disbelieve,3=believe,4=strongly believe), then the answers were categorized into 2 groups (belief and disbelief). Results Of 306 students (61% men, the mean age of 21.8 ± 3.0 years), 53% used both e-cigarettes and conventional cigarettes, and 47% used only e-cigarettes. It showed that 74% of students believed that if they used e-cigarettes, they were at risk of lung injury (HBM: perceived susceptibility), and 68% believed that they had a chance to die from lung injury caused by using e-cigarettes (HBM: perceived severity), and 76% believed that quitting e-cigarettes could reduce the chance of death from lung injury (HBM: perceived benefits). Most students (62%) believed that the strongest barrier for quitting e-cigarettes was that it required a high effort and strong intention (HBM: perceived barriers of quitting e-cigarette), and 76% of students perceived their self-efficacy and believed that when they intended to quit e-cigarettes, they would be successful (HBM: perceived self-efficacy). Most participants believed that family members (78%), lovers (75%), and university restrictions (53%) exerted a positive influence in quitting e-cigarettes (HBM: cues to action). Conclusions The HBM helps us to understand using e-cigarettes associated with lung injury among university students. The university should initiate health promotion activities concerning reducing e-cigarettes use among adolescents and young adults. Key messages Using e-cigarettes is dangerous for health including lung injury, and university students should stop using e-cigarettes. The university should initiate or enhance prevention and health promotion activities concerning reducing e-cigarettes use among adolescent and young adults.

Chronic Obstructive Pulmonary Disease (COPD) is a global health concern, primarily linked to cigarette smoking. The potential role of electronic cigarettes (e-cigarettes) in COPD development remains unclear. Despite growing popularity as a smoking alternative, evidence suggests e-cigarettes may have harmful respiratory effects. This systematic review and meta-analysis assess the relationship between e-cigarette use and odds of having COPD. A comprehensive search of Web of Science, Embase, and PubMed was conducted to identify observational studies that assessed the association between e-cigarette use and the risk of COPD, providing risk estimates (hazard ratios, risk ratios, or odds ratios) for current, former, and ever e-cigarette users. Random-effects meta-analysis was performed using R software (V 4.4), and heterogeneity was assessed with the I2 statistic. Sensitivity analyses were conducted to test the robustness of the findings. Publication bias was evaluated using Egger’s test and funnel plots. Seventeen studies (1087 records screened) were included. E-cigarette use was associated with significantly higher odds of COPD compared to non-use. The pooled odds ratios were 1.48 (95% CI: 1.36–1.61) for current users, 1.84 (95% CI: 1.51–2.23) for former users, and 1.79 (95% CI: 1.42–2.25) for ever users. Sensitivity analysis confirmed the robustness of the findings. E-cigarette use is associated with higher odds of having COPD. Public health efforts should consider raising awareness of the potential respiratory risks associated with e-cigarette use.

A LUNG ABSCESS IN AN E-CIGARETTE USER