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Adolescent Use of and Susceptibility to Heated Tobacco Products Shuwen Li, MPP,A Katherine Braden, MPH,A Yue-Lin Zhuang, Phd,A Shu-Hong Zhu, Phd,A,B

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Adolescent Use of and Susceptibility to Heated Tobacco Products Shuwen Li, MPP,A Katherine Braden, MPH,A Yue-Lin Zhuang, Phd,A Shu-Hong Zhu, Phd,A,B Adolescent Use of and Susceptibility to Heated Tobacco Products Shuwen Li, MPP,a Katherine Braden, MPH,a Yue-Lin Zhuang, PhD,a Shu-Hong Zhu, PhD,a,b BACKGROUND AND OBJECTIVES: A leading brand of heated tobacco products (HTPs), IQOS, was abstract authorized to be sold in the United States in 2019. Researchers have examined the awareness and use of HTPs among US adults. In this study, we examined high school students’ awareness, use, and susceptibility pertaining to HTPs. METHODS: A large, cross-sectional population survey of randomly sampled 10th- and 12th- graders in California (N 5 150 516) was conducted online during school hours from September 2019 to March 2020. RESULTS: Overall, 8.9% (95% confidence interval [CI], 8.7%–9.1%) of California high school students had heard of HTPs. Approximately 0.67% (95% CI, 0.61%–0.73%) had ever tried HTPs, and 0.20% (95% CI, 0.17%–0.23%) were current users (ie, 30% of ever users continued to use HTPs at the time of survey). Among those who never tried HTPs, 18.3% (95% CI, 17.9%–18.8%) were susceptible to future use. The susceptibility to HTP use was greater among users of cigarettes or e-cigarettes than among nonusers. CONCLUSIONS: The awareness of HTPs among adolescents was remarkable given the low availability of products at the time of survey. Only a small percentage of adolescents experimented with HTPs. However, almost a third of those who had experimented with HTPs continued to use them. This high ratio and the fact that almost 1 out of 5 never users were susceptible to future HTP use should put the public health community on high alert as more HTP products are coming into the market, with promotion of these products likely to increase. aMoores Cancer Center and bHerbert Wertheim School of Public Healh, University of California San Diego, La Jolla, WHAT’S KNOWN ON THIS SUBJECT: The awareness and California use of heated tobacco products (HTPs) among US adults Dr Zhu conceptualized and designed the study and finalized the draft of the manuscript; Ms Li have been studied both before and after a leading brand, conducted the analysis, wrote the first draft, and critically reviewed and revised the IQOS, received premarket tobacco product application manuscript; Ms Braden coordinated and supervised the data collection and critically reviewed authorization in 2019. Little is known about its impact on and revised the manuscript; Dr Zhuang conducted the analysis and critically reviewed and adolescents. revised the manuscript; and all authors approved the final manuscript as submitted and agree WHAT THIS STUDY ADDS: Approximately 9% of California to be accountable for all aspects of the work. high school students had heard of HTPs. Among those who Deidentified individual participant data will not be made available. had tried HTPs, 30% continued to use HTPs at the time of DOI: https://doi.org/10.1542/peds.2020-049597 survey. Among those who had not tried HTPs, 18% were susceptible to future use. Accepted for publication May 10, 2021 Address correspondence to Shu-Hong Zhu, PhD, University of California, San Diego and Moores Cancer Center, MC-0905, 9500 Gilman Dr, La Jolla, CA 92093-0905. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. To cite: Li S, Braden K, Zhuang Y-L, et al. Adolescent Use of Pediatrics FUNDING: Supported by a contract from the California Department of Public Health (CDPH-16- and Susceptibility to Heated Tobacco Products. 10109). The funding agency had no role in the design and conduct of this study. 2021;148(2):e2020049597 Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 148, number 2, August 2021:e2020049597 ARTICLE Cigarette smoking among US States, although they have no PMTA middle schools (eighth-graders) adolescents has declined authorization from the FDA. were sampled separately. This study significantly in the last decade.1 included high schools only. The However, the decrease in smoking Researchers have found that 5% to sampling design for high schools has been accompanied by a 12% of American adults were aware first divided the state into 35 dramatic increase in e-cigarette of HTPs and that some adults have regions. Eligible schools in each 10–12 use.2 The use of e-cigarettes among tried them. The level of region were then randomly sampled. US high school students increased awareness of HTPs among Public and nonsectarian schools from 1% in 2011 to 27.5% in adolescents appeared to be similar were eligible. Special education, ’ 2019.3,4 The product design for e- to that of adults before IQOS PMTA juvenile court, district and/or 23,24 cigarettes has gone through several authorization. No study, county community, continuation, or other alternative schools were not generations but always with a however, has examined the sampled. Within each high school, plethora of flavors.5 E-cigarettes are awareness or usage of HTPs among adolescents after IQOS received its only 10th- and 12th-graders were now the most prevalent tobacco PMTA authorization. sampled. product used by adolescents,6 although their popularity seems to The current study investigated the The 2019–2020 CSTS approached a have declined in 2020.7,8 awareness and usage of HTPs random sample of 608 schools, and among adolescents after IQOS’ 482 agreed to participate (79.3%). A new line of tobacco products, PMTA authorization. For students Among these, 358 schools however, is ready to compete for who had tried HTPs, the study completed the survey (74.3%) adolescents’ attention: heated assessed the proportion who between September 2019 and March tobacco products (HTPs).7,9 HTPs, continued to use these products. For 2020. A total of 162 675 students in which generate nicotine-containing those who had not tried them, it 8th, 10th, and 12th grades aerosols by heating tobacco instead examined their susceptibility to participated, with an overall student of burning it, have already gained using HTPs in the future. response rate of 68.3%. The current some recognition among US Susceptibility to trying particular analyses included data from 311 adults.10–12 With novel and slick tobacco products has been shown to high schools (47 middle schools exterior designs, many HTPs are 25 were excluded). A total of 150 516 13,14 be a useful monitoring strategy. also flavored. Currently, only 1 Because HTPs have not yet become 10th- and 12th-graders answered brand of HTPs, IQOS, has obtained widely available in the United States, the HTP-related questions in the survey (Table 1). The CSTS was premarket tobacco product the susceptibility measure could administered online during class application (PMTA) authorization serve as a warning sign. Toward time. Participation was voluntary. from the US Food and Drug these objectives, we analyzed the 15 The study was approved by the Administration (FDA). With its data from the most recent California University of California San Diego PMTA authorization, IQOS can be Student Tobacco Survey (CSTS) Human Research Protections legally sold in the United States. The (2019–2020), a survey with Program, Institutional Review Board distribution of IQOS so far is still >150 000 high school student 170787. limited, mainly in 2 municipalities: participants. Atlanta, Georgia, and Richmond, Measures Virginia.16,17 However, there are METHODS To add clarity, pictures and online outlets and resellers that sell descriptions of all tobacco products IQOS to US residents. HTPs have Design and Participants were presented before any question been successful in several markets This study used data from the was asked. Students who answered outside of the United States.18–20 – 2019 2020 cycle of the CSTS, an yes to having ever smoked Three tobacco companies dominate ongoing school-based survey that cigarettes were considered ever these markets: Philip Morris provides statewide estimates of smokers. Students who answered International (PMI), Japan Tobacco tobacco use among middle and high yes to vaping nicotine or just International (JTI), and British school students in California. The flavoring were considered ever e- 20,21 American Tobacco (BAT). In CSTS used a two-stage cluster cigarette users. addition to IQOS, BAT’s Glo and JTI’s sampling design, in which school Ploom Tech (known as Logic was the primary sampling unit and For HTPs, the questionnaire used Vapeleaf in the United States.)22 classroom was the secondary the term “heat-not-burn,” which is have been found in the United sampling unit. The high schools and another common name for these Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 LI et al TABLE 1 Prevalence of Having Heard of HTPs Among High School Students, 2019–2020 CSTS Total Never Used Cigarettes or E-cigarettes Ever Used E-cigarettes Only Ever Used Cigarettes N 5 150 516 n 5 110 880 n 5 29 857 n 5 9369 % (95% CI) % (95% CI) % (95% CI) % (95% CI) Overall 8.9 (8.7–9.1) 8.4 (8.2–8.6) 8.3 (7.9–8.8) 16.6 (15.5–17.7) Sex Male 9.2 (8.8–9.5) 8.5 (8.1–8.8) 9.2 (8.6–9.8) 16.8 (15.3–18.4) Female 8.3 (8.0–8.6) 8.3 (8.0–8.7) 7.2 (6.6–7.7) 12.3 (10.9–13.7) Other 13.5 (12.2–14.9) 9.7 (8.1–11.2) 15.4 (12.8–18.0) 28.7 (24.4–33.1) Undisclosed 10.3 (9.1–11.4) 7.5 (6.3–8.6) 10.2 (8.0–12.5) 29.6 (23.3–35.9) Race and/or ethnicity NH-white 9.6 (9.2–10.0) 9.3 (8.8–9.7) 7.8 (7.1–8.5) 17.1 (15.0–19.2) NH-Black 7.9 (6.9–9.0) 7.2 (6.1–8.3)
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