Youth and Tobacco in Texas

Dr. Karn is the Project Director for the Tobacco Research & Evaluation Team with the University of Texas at Austin, Kinesiology and Health Education Department. Dr. Loukas is a Professor and Program Director of Health Behavior and Health Education in the Department of Kinesiology & Health Education at the University of Texas at Austin.

Recently, they’ve been focusing on trying to help fill the gap in research on e-cigarettes, which have become more popular among young people than combustible cigarettes.

“The lack of long-term studies is the biggest gap,” says Dr. Loukas, who is currently leading a five-year study examining tobacco use and marketing trends at four-year universities and two-year vocational programs. “If you have cross-sectional studies and studies situated at one point in time, they are good at providing you some information about use and products at a given time. But we are talking about an evolving product. We are talking about a product that in 2017 is already a fourth generation product even though it only hit the market in 2008. This product is changing so fast.”

The Texas Health Journal spoke to Dr. Karn and Dr. Loukas at their offices in the Kinesiology and Health Education Department at The University of Texas at Austin.

Paromita Pain: Why have you focused so much of your work on college students?

Karn: Habitual tobacco users tend to start using before college, but the behavior solidifies when they’re young adults. It’s when they are in college that they are actually going to become addicted and become lifelong tobacco users. So the Peers Against Tobacco project, for instance, is intended to prevent students from becoming addicted to tobacco in the first place.

Tell me more about this initiative.

Karn: It’s a multi-pronged approach. We have developed outreach/awareness campaigns, a curriculum, campus environment scans, and policy resources as well as a complete database for all Texas colleges (public and private) to locate their current tobacco policy. The idea is to shift the paradigm. It’s about changing the perception of tobacco use on and around campus, about making it unacceptable. It is peer driven. So peers educate others peers on campus. It’s also focused on alternative products, so not only cigarettes but also e-cigarettes, SNUS, hookah and smokeless tobacco.

More Texans die each year from smoking than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined. Cigarettes packets contain warnings, but they don’t always seem to make a difference. Why do you think people are so resistant to giving up tobacco?

Dr. Alexandra Loukas: There has been a lot of money and effort put into the prevention of tobacco use, including policies like requiring warning labels. But the labels are small, when they’re present at all. Currently, there are warnings only on combustible cigarettes and smokeless tobacco, and they’re small.

A larger problem is that however much we’ve put into prevention, the tobacco industry has put far more into marketing their products. In Texas, in fact, the tobacco companies spend more money per capita than in any other state. At the same time, we rank 38th in the country for state-level spending on tobacco prevention programs. So there is a big disparity between how much money is being spent on advertising and promotion of these products, and how much we have at the state level to prevent the use of these products. Marketing has been shown to be particularly effective with children and young adults. So that’s one of the reasons why we have a hard time getting ahead in prevention efforts. Also, nicotine is very addictive.

The landscape has changed so much just in the last few years, with the introduction of all these new electronic products. What does that change about what you’re doing?

Loukas: E-cigarettes have caused more of a split within the public health community than any other tobacco product I can think of. Some people in the field believe that no nicotine-containing product should ever be promoted to any group for any reason. There are others, however, who believe that if people are already addicted to cigarettes, and they won’t quit smoking, and they don’t want to quit smoking, then we could reduce the risks associated with smoking by having them switch to potentially less harmful e-cigarettes. The problem is making sure that this “harm reduction” approach doesn’t inadvertently attract new users. How do you promote a message that this is a lower risk product and not make youth in particular more likely to try it?

Karn: Right now we know too little about e-cigarettes to recommend them as harm reduction tools. It is unclear what level of nicotine is in these devices, since they are not regulated as a cessation tool. If you don’t regulate the level of nicotine in them, you can’t help someone quit with the standard step-down approach. With everything we have seen so far, it probably is a risk reduction for people who use combustible tobacco products already. But the idea for college students is not to use nicotine at all, because it is an addiction and nicotine is a harmful and addictive drug. Staying away from all tobacco products at a young age is critical since the brain is still developing. Preventing young adults from starting any tobacco product and becoming addicted will save us money and will improve their overall quality of life. 

Loukas: We did one study on college students in which we found that those who used only e-cigarettes were more likely to subsequently initiate or try a combustible cigarette than those who didn’t use nicotine at all. We don’t know if that means they are going to become addicted to cigarettes, but we do know that they were more likely to try cigarettes than those who were e-cigarette and tobacco naïve. One plausible scenario is that e-cigarettes are serving as the more socially acceptable starter products. Then a user moves to cigarettes because they need a bigger hit. But this research is in its infancy. Whether or not e-cigarette users will become regular users of cigarettes is unknown at this point.

One of the striking things about the new products is the variety of flavors they come in. That’s not something we’ve seen with traditional cigarettes. How does that affect usage patterns?

Dr. Loukas: Due to the Family Smoking Prevention and Tobacco Control Act, menthol is the only flavor of cigarettes allowed to be sold in the United States. But alternative tobacco products don’t have these mandates. They’re allowed to sell products in every single flavor. E-cigarettes have over 7,000 unique flavors, including gummy bear flavors, that are potentially very appealing to young people. We know from research that novice tobacco users, people who are new and who are intermittent users, are much more likely to use flavored products than unflavored ones.

We have also found that in certain types of flavored products, females are more likely to be using those products. That means if you have a flavored cigar, females are more likely to use that rather than unflavored ones in comparison to men. Menthol is the same way. Young kids are also more likely to smoke menthol cigarettes then the regular cigarettes.

The 2016 Surgeon General’s Report on e-cigarettes and youth cites nearly 200 studies on the subject. With regard to young people and smoking, what are the areas that need more research? What gaps in our understanding of young people and tobacco use do we still need to address?

Karn: We need to find out more about the harm and dangers related to e-cigarettes.

Loukas: The lack of long-term studies is the biggest gap. If you have cross-sectional studies and studies situated at one point in time, they are good at providing you some information about use and products at that given time. But we are talking about an evolving product. We are talking about a product that in 2017 is already a fourth generation product even though it only hit the market in 2008. This product is changing so fast.

These products were not regulated by the FDA until August 2016. As a result, there is a lot of variability in the devices and the nicotine liquids that are on the market. What we need are long-term studies, particularly for behaviors related to addiction. To know how addiction happens, you have to follow someone and determine how he or she becomes addicted. And if they are using e-cigarettes and cigarettes, the process could be very different than if they’re using just cigarettes or e-cigarettes alone. Then if they are using hookah every once in a while, and then cigars sometimes, and cigarettes at other times, the process becomes all the more complicated.

E-cigarette use behavior on its own is not like any other kind of tobacco use behavior. Most people smoke an entire cigarette in one sitting. They may save a part of the cigarette and use it later, especially because cigarettes are expensive. But with an e-cigarette you can literally walk down the street and take a really long puff, then put it back and 12 minutes later take another puff.  You don’t sit there until you finish anything. So it is really hard for us to assess such behavior. It’s also difficult because you can purchase different e-cigarette liquids that have different nicotine contents.

To understand why young adults start using tobacco products or continue using the products or become addicted, you need to assess the entire trajectory across young adulthood, when some initiation begins, all the way to adulthood when regular use sets in.

And you’re doing that, right?

Loukas: That’s what we do at the Tobacco Center of Regulatory Science (TCORS) on Youth and Young Adults. We collect the scientific evidence that can be used to help the FDA make decisions about tobacco regulations that are ultimately aimed at improving public health and reducing death and disease caused by tobacco use. These are aimed at protecting the health of children and adolescents, at the people who absolutely should not be using those products because it’s most damaging to their health over the long term. 

We’re working on a study where we followed about 5,000 college students for three years. We surveyed them every six months regarding their tobacco use behaviors and exposure to tobacco marketing. These young adults were recruited from 24 colleges surrounding the four largest cities in Texas. We also did objective assessments of marketing at the points of sale around schools like convenience stores and gas stations. We just finished our very last wave of data collection and we’re now reapplying for funding to continue to track their behaviors into adulthood.