Title: What is the impact of vaping on smoking, nicotine intake and toxin exposure among youth in England compared with youth in North America?
Funder: Department of Health and Social Care

Abstract: Aims: To understand how policies on the content of e-cigarettes in England affect possible risks to health of 16-19 year olds (‘youth’) compared with those in Canada and the United States (US). _x000D_ Background: There is very little research on youth in England and their vaping and smoking behaviours, yet this is an important age group when regular smoking (tobacco cigarettes) sets in. It is likely that vaping (using e-cigarettes) becomes established then too. We also don’t know what youth are inhaling when they vape and hence what risks they might be taking. Nicotine is what causes addiction and some of the newer e-cigarettes, which contain a different form of nicotine (‘nicotine salts’), might be more addictive than other e-cigarettes. Finally, there has been an outbreak of lung diseases in the US which is probably due to vaping illegal substances (so not nicotine e-cigarettes) but we do need to monitor the situation._x000D_ We have a unique opportunity to build on a study that we are currently involved in, which is funded by Canada and the US. Every year since 2017, we have surveyed 12 thousand youth in Canada, US and England on their vaping and smoking behaviours. In 2019, we also 1) followed up some completing our main survey four weeks later with another short survey and 2) asked those who said that they had vaped and/or smoked in the past week, and some who had not used either product, to provide a urine sample. The urine is tested for how much nicotine and dangerous substances it contains, to help us understand how much vaping might be harming their health compared with smoking or not using either product. _x000D_ So far, our surveys have shown that in the US and Canada vaping has increased rapidly, whereas in England regular vaping has remained relatively stable. Youth smoking has also increased in Canada. We need to understand why there are these differences across the countries. One possibility is because e-cigarette policies in England are different from those in US/Canada. For example, England limits the nicotine content of e-cigarettes, whereas US and Canada allows nearly three times as much. Nicotine salt e-cigarettes are more commonly used by youth in US and Canada, but their use is also increasing in England. _x000D_ Design and methods used: We are asking for monies to build on this study for the next 3 years. We want to increase the number of youth in England who we ask to provide urine samples (by 160 over both years) and also get 80 youth who use nicotine salt e-cigarettes (40 in England and 40 in Canada/US) to provide urine samples. We will continue to test the urine for nicotine and dangerous substances. However, we will also now be able to compare all our findings and possible risks of vaping to health, between England and US/Canada. This will help us to investigate whether our e-cigarettes policies in England are keeping our youth safe. We will also ask youth about their respiratory problems (such as coughing and wheeze) and compare these between countries, and vapers, smokers and non-users. _x000D_ Patient and public involvement: We have met with youth who vape and smoke or who do not use either product to help us with survey questions and the way we collect urine. We will hold more discussions with different groups of youth over the 3 years to get more input and help understand our findings._x000D_ Dissemination: We will publish our findings in academic papers, the media and through presentations to policy makers, youth and at conferences

Lay abstract: Research Question: Are there differences in youth vaping and smoking patterns, nicotine and toxicant exposure or respiratory symptoms among youth vapers, smokers, and non-users in three countries with different e-cigarette regulations?_x000D_ Background: Youth vaping rates have remained fairly stable in England, but have increased substantially in Canada and the US. It is unknown whether a similar increase in youth vaping may occur in England in future. England’s regulations on e-cigarettes, such as a 20mg/ml limit on nicotine content, may be helping keep rates low. Additionally, the high vaping rates in the US and Canada may be due to the introduction of nicotine salts, and the dominance of the JUUL brand, with the North American version containing up to 50mg/ml of nicotine. Concerns about youth nicotine exposure from vaping and other health effects have increased given the ability of nicotine salts to deliver greater concentrations of nicotine and recent cases of vaping associated lung injury in the US._x000D_ Aims and Objectives: We aim to compare vaping and smoking patterns and nicotine and toxicant exposure among youth (16-19-year olds) who vape with youth who smoke, vape and smoke (dual users), and non-users, and to compare youth in England, the US and Canada. Our key objectives are to: 1) compare patterns of vaping and smoking among youth in England Canada and the US, 2) using urine samples, test for differences in exposure to potential toxicants and nicotine between youth vapers, smokers, dual users and non-users, and in England compared with the other countries; 3) using urine samples, test for differences in exposure to potential toxicants and nicotine between youth vapers of nicotine salt models in England and North America; 4) compare respiratory symptom reporting among youth by use status and across the three countries; 5) conduct patient and public involvement to inform research and dissemination._x000D_ Methods: 1) Patterns of vaping and smoking will be measured using the International Tobacco Control Project, a six-monthly survey of 16-19 youth in Canada, England, and the US (N=approx 12,000) at each wave and a four-week follow-up survey every other wave oversampling current vapers. 2) and 3) In a yearly sub-sample of respondents from the main annual survey, after consenting, participants will be posted a urine collection kit; samples will be tested for biomarkers including nicotine metabolites, NNAL, Volatile Organic Compounds, and metabolites, Polycyclic Aromatic Hydrocarbons, and creatinine. 4) a respiratory symptoms questionnaire will be included with the four-week follow-up survey, and with the urine bio-sample collection. 5) Meetings and involvement of two advisory groups throughout. _x000D_ Timelines for Delivery: 1) Main and follow-up surveys are already in place and will continue until 2022; 2) biomarker collection for this project will begin in 2020, with 2 cycles of collection; 3) respiratory symptoms questionnaire will begin in 2020. Dissemination will be delivered starting in year 1 and continue up to 1 year after project completion. _x000D_ Anticipated Impact and Dissemination: Involving our advisory groups, we will provide briefings and presentations for policy makers, write press releases to reach a wider audience, and present findings at conferences. The findings may impact decisions on e-cigarette policies in England and internationally to prevent youth uptake, reduce nicotine and toxicant exposure, and reduce health risks.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE