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Multi-Level Prevention Strategies to 

Address Teen E-Cigarette Use

National Prevention Week Webinar

February 26, 2019 

Disclaimer: The views, opinions, and content expressed in this presentation do not necessarily reflect 

the views, opinions, or policies of the Center for Substance Abuse Prevention (CSAP), the Substance 

Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and 

Human Services (HHS).
Recording in Progress!

This meeting will be recorded for 

archiving purposes.

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David Lamont Wilson 

NPW Coordinator

Public Health Analyst, Center for Substance Abuse Prevention

Substance Abuse and Mental Health Services Administration
Today’s Presenters

• Brian A. King, PhD, MPH, Deputy Director for Research Translation, 

Office on Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, CDC

• John O’Donnell, MA, Acting Synar Lead, Division of State Programs, 

Center for Substance Abuse Prevention, SAMHSA

• Donna Vallone, PhD, MPH, Chief Research Officer, Truth Initiative

• Emily D’Iorio, MPH, Health Communication Specialist, Center for 

Tobacco Products, FDA

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NPW 2019

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• To involve communities in raising 

awareness of behavioral health issues and 

in implementing prevention strategies, and 

showcasing effectiveness of evidencebased prevention programs.

• To foster partnerships and collaboration

with federal agencies and national 

organizations dedicated to behavioral and 

public health.

• To promote and disseminate quality 

behavioral health resources and 

publications.

NPW Goals

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NPW 2019 Daily Health Themes

Monday, May 13 Prevention of Prescription & Opioid Drug 

Misuse

Tuesday, May 14 Prevention of Underage Drinking & 

Alcohol Misuse

Wednesday, May 15 Prevention of Illicit Drug Use & Youth 

Marijuana Use

Thursday, May 16 Prevention of Youth Tobacco Use

Friday, May 17 Prevention of Suicide

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Prevention Challenge

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Pre·ven·tion Cham·pi·on 

Noun: a person, activity, program, or organization 

that inspires others to take prevention actions

every day that change lives.
Prevention Challenge

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Take the Prevention Challenge

1. Take a photo or video.

2. Add one word to best describe your Prevention 

Champion.

3. Share your #PreventionChampion photo or video on social 

media.

4. Use the hashtags #PreventionChampion and #NPW2019.
Prevention Challenge

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What one word best describes your #PreventionChampion?
Get Involved in NPW

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Get Involved with NPW Today

❑ Visit samhsa.gov/prevention-week for the latest resources.

❑ Take the #PreventionChampion challenge.

❑ Plan prevention activities and events in your community.

❑ Join the conversation on social media using #NPW2019.
Prevention Every Day

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Brian A. King, PhD, MPH 

Deputy Director for Research Translation

Office on Smoking and Health

National Center for Chronic Disease 

Prevention and Health Promotion

Centers for Disease Control and Prevention
E-cigarette Use Among

Youth and Young Adults

B R I A N A . K I N G, P H D, M P H

D E P U T Y D I R E C TO R F O R R E S E A R C H T R A N S L A T I O N

O F F I C E O N S M O K I N G A N D H E A L T H

SAMHSA’s National Prevention Week Webinar Series • February 26, 2019
Smokeless

Snus

Bidis

Kreteks

Pipes

Dissolvables

E-cigarettes

Tobacco

Hookah

Cigars, Cigarillos 

Cigarettes Little Cigars

Heated Tobacco 

Products

The Tobacco Landscape Is Evolving
The Rise 

of JUUL
The “4th Generation” E-cigarette Has Arrived: 

The “Pod Mod”

Source: Campaign for Tobacco-Free Kids

MarkTen Elite 

(Altria)

myBlu

(Imperial Tobacco)

Vuse Alto 

(RJR) Myle Phix

Suorin Drop Suorin Air KandyPens Feather Daze MFG ZOOR
Source: Gentzke AS, Creamer M, Cullen KA, Ambrose BK, Willis G, Jamal A, King BA. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 

2019; 68(6):1-8. 

2011 2012 2013 2014 2015 2016 2017 2018

YEAR

Pipe

Hookah

E-cigarette

Smokeless

Cigarette

Cigar

1.5%

4.1%

11.6%

7.9%

4.0%

15.8 %

20.8%

1.1%

4.1%

5.9%

7.6%

8.1%

Current Tobacco Product Use Among U.S. 

High School Students – NYTS 2011–2018
Advertising Flavors Nicotine

Youth E-cigarette Initiation and Use 
Youth Initiation Adult Cessation

Net Public Health Benefit or Harm?
Leads to 

initiation of 

combustible 

tobacco use 

among nonsmokers, 

particularly 

children

Leads to 

relapse 

among former 

smokers

Diminishes the 

chances that a 

smoker will 

quit

Discourages 

smokers from 

using proven 

quit methods

Exposes 

children, 

pregnant 

women, and 

non-users to 

secondhand 

aerosol

Glamorizes or 

renormalizes 

tobacco use

Results in 

poisonings 

among users 

or non-users

Potential Health Risks of E-cigarettes
Nicotine Poses Unique 

Dangers to Young People

Chapter 3 

Conclusion 1, 2, & 5 
Juul Contains Nicotine Salts Nicotine salts allow particularly high levels of nicotine to be inhaled 

more easily and with less irritation than free base nicotine.

Benzoic Acid

Nicotine 

Salts

Free Base 00

Nicotine
Sources: Singh T, Kennedy S, Marynak K, Persoskie A, Melstrom P, King BA. Characteristics of Electronic Cigarette Use Among Middle and High School Students — United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1425–

1429. Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth. JAMA Pediatr. Published online September 17, 2018. doi:10.1001/jamapediatrics.2018.1920

E-cigarettes and Cannabinoids

Conclusion: 

Nearly 1 in 11 U.S. students, 

including 1/3 of those who ever 

used e-cigarettes, had used 

cannabis in e-cigarettes in 2016. 

Conclusion: E-cigarette products 

can be used as a delivery system 

for cannabinoids and potentially for 

other illicit drugs.
https://e-cigarettes.surgeongeneral.gov/
State, Local, Territory

Potential Sub-National Action:

Federal Regulation 

Family Smoking Prevention 

and Tobacco Control Act

• Signed into law on June 22, 2009

• Granted FDA the authority to regulate 

tobacco products

• Enhanced the ability to intensify policy to 

reduce tobacco industry influence:

o Manufacturing

o Marketing 

o Sale

• Including e-cigarettes in smoke free indoor air policies

• Restricting youth access to e-cigarettes in retail 

settings

• Licensing retailers

• Establishing specific package requirements

• Setting price policies

• Increasing the minimum age of sale of tobacco 

products to 21 years of age

• Prohibiting the sale of flavored tobacco products

Public Health Actions to Address E-cigarettes
12345

As the tobacco product landscape continues to 

diversify, it’s important to modernize tobacco 

control strategies to adapt. 

Youth use of any tobacco product, including e-cigarettes, is unsafe. E-cigarettes are a tobacco product that produces an 

aerosol by heating a liquid that typically contains 

nicotine, flavorings, and other chemicals. E-cigarette use is higher among young people than 

adults. As of 2014, e-cigarettes were the most 

commonly used tobacco product among U.S. youth. 

Several factors have contributed to the popularity of e-cigarettes, including advertising and the vast array 

of available flavors. 
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for 

Disease Control and Prevention.

Brian A. King, PhD, MPH

Office on Smoking and Health 

baking@cdc.gov

www.cdc.gov/tobacco
John O’Donnell, MA

Acting Synar Lead

Public Health Advisor, Center for Substance Abuse Prevention

Division of State Programs

SAMHSA
National Prevention Week 

Multi-Level Prevention Strategies to Address Teen 

E-Cigarette Use: The Synar Program and Electronic Products 

February 26, 2019

John O’Donnell

Public Health Advisor

Center for Substance Abuse Prevention

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

Webinar Presentation
Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA is the agency within the U.S. Department of Health 

and Human Services that leads public health efforts to 

advance the behavioral health of the nation. 
Substance Abuse Prevention and Treatment Block Grant (SABG)

SAMHSA’s Strategic Initiatives

The SABG program provides funds to all 50 states, the District of Columbia, 

Puerto Rico, the U.S. Virgin Islands, 6 Pacific jurisdictions, and 1 tribal entity. 

• States use the funds to plan, implement, and evaluate activities that prevent 

and treat substance abuse and promote public health.

• Preventing substance abuse includes youth tobacco access prevention.

• States may use SABG funds to support certain youth tobacco access 

prevention activities.

References to states in this presentation include the 50 states, DC, Puerto Rico, the U.S. Virgin Islands, and the Pacific 

jurisdictions.
Tobacco Use

“Tobacco addiction is the single most 

preventable cause of death in our 

society.”

Centers for Disease Control and Prevention
21st-Century Tobacco Use

Between 2010 and 2014, smoking caused:

• Nearly half a million premature deaths per year;

• More than 87 percent of all lung cancer deaths;

• 61 percent of all pulmonary deaths; and

• 32 percent of all coronary deaths.1

1. U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking—50 Years of Progress: A 

Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
Tobacco and Youth

Tobacco Use Is a Pediatric Disease

• 88 percent of adults who have ever smoked daily report that 

they first smoked by the age of 18, and 99 percent report that 

they first smoked by the age of 26.2

• More than one-third of adults who have ever smoked report 

trying their first cigarette by the age of 14.2

• 80 percent of adult smokers who are nicotine-dependent report 

that they started smoking before they were 18 years old.3

2. U.S. Department of Health and Human Services. (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the 

Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 

3. U.S. Department of Health and Human Services. (2010). Results from the 2009 National Survey on Drug Use and Health. 
The History Behind the Synar Legislation

• The Synar legislation reflects 

former Oklahoma congressman 

Michael Synar’s vision for reducing 

youth access to tobacco products. 

• The Synar Amendment and its 

implementing regulation require 

states to enact and enforce laws 

prohibiting the sale and 

distribution of tobacco products to 

individuals under the age of 18.

Michael Synar
Implementing the Synar Amendment

To implement the Synar Amendment, SAMHSA issued the Synar 

Regulation in January 1996, requiring states to:

• Have in effect laws prohibiting any manufacturer, retailer, or distributor of tobacco 

products from selling or distributing such products to any individual younger than age 

18.

• Enforce their laws.

• Conduct annual random, unannounced inspections in a way that provides a valid 

probability sample of outlets accessible to minors.

• Negotiate interim targets and a date to achieve a noncompliance rate of no more 

than 20 percent.

o Federal target of 20 percent established for states and U.S. jurisdictions for the 

FFY 2003 Annual Synar Report.

• Submit an Annual Synar Report detailing state activities to enforce their laws.

References to states in this presentation include the 50 states, DC, Puerto Rico, the U.S. Virgin Islands, and the Pacific jurisdictions.
Synar Is a Success

In FFY 2017, all 50 

states and the District 

of Columbia met the 

20 percent target 

retailer violation rate 

(RVR).

Youth tobacco use 

prevalence rates have 

dropped, but have 

leveled off. 

Synar is a critical 

component of the 

success of youth 

tobacco prevention 

efforts.
Synar and E-Cigarettes

States may propose to revise their Synar inspection protocols to include 

attempted buys of electronic nicotine delivery systems (ENDS) if state 

law defines such devices as tobacco products. 

• It is up to the state to interpret state law. 

• Advise consulting state’s Office of the Attorney General. 

• As of FFY 2018, 19 states have added ENDS to their protocols as 

products that can be requested during Synar inspections. 
Including ENDS in Synar Inspections 

States that include ENDS in their Synar inspections determine how often 

ENDS will be requested during the inspections unless the Synar checks 

are combined with FDA tobacco inspections.

When Synar and FDA inspections are combined, the FDA protocol, 

including any requirements on the variety of products to be requested, 

MUST be followed.
Data Trends

Merely comparing violation rates in states that did and did not include 

ENDS among products that might be requested by Synar inspectors can 

be misleading.

States might be able to detect possible data trends using a new optional 

feature in the Synar Survey Estimation System (SSES). 

Even with more detailed data, note that many variables besides product 

choice might be associated with violation rates. 
How Can Communities Help? 

• Identify your State’s Synar Coordinator 

– Check website of the state agency that receives the Substance 

Abuse Prevention and Treatment Block Grant for your state.

– Email or call me. My contact info is given in the last slide. 
How Can Communities Help? 

• Learn about and comment on your state’s Annual Synar Report (ASR).

• States must make their ASRs available to the public for comment.

• Depending on the state, the ASR might be available online, at public 

hearings, at public libraries, etc. Your State Synar Coordinator will 

know. 

• If it is posted on a state website, you might find it by searching the 

name of your state and “Annual Synar Report.” 
How Can Communities Help? 

Find out which agency or organization recruits and trains Synar youth 

inspectors in your state and how to get youth in your community 

involved. Your State Synar Coordinator will know. 

• Youth work with adult inspectors to conduct Synar survey inspections 

of stores and vending machines.

• Age range for youth inspectors is 15 through 17 in most states.

• Opportunities to fulfill community service requirements and for 

youth interested in careers in law enforcement, prevention, public 

service, etc. 
How Can Communities Help? 

Other roles for youth and other community members: 

• Community mobilization

• Educating the public about youth tobacco access laws 

• Merchant education efforts 
Why Synar Matters to Your Communities 

• Penalties to state substance abuse prevention and 

treatment agency if retailer violation rate exceeds the 

maximum.

• Consequences of underage tobacco use, including the use 

of ENDS, for young people in your communities.
For More Information

Synar Website

https://www.samhsa.gov/synar

John O’Donnell

john.odonnell@samhsa.hhs.gov

240-276-0633
Donna Vallone, PhD, MPH

Chief Research Officer

Truth Initiative®
Public Education Strategies to 

Prevent Youth and Young Adult 

E-Cigarette Use

Donna M. Vallone, PhD, MPH

Chief Research Officer

Truth Initiative Schroeder Institute®
• Formative Research

• Messaging Strategies

• Quit-smoking resources for young e-cigarette users and their parents

Agenda
Formative Research: Ethnographic 

Field dates: November 2018

Participants

Mobile: 

• Young adults (18–24) 

• Teens (15–17) 

In-home Interviews: 

• Young adults 

Focus Groups: 

• Young adults

• Teens 
• They are introduced to JUULing through friends.

• “JUUL” is synonymous with e-cigs. 

• JUULs are ubiquitous.

• JUULs act as a social lubricant.

• Flavors and smoke tricks are the most appealing aspects.

• JUUL users are split into ...

• those who own a JUUL and share it; and

• those who don’t own a JUUL but use others’ devices.

• They don’t perceive the risks of vaping to outweigh the benefits. 

Young people told us that ...
• Friends are usually the point of entry for most JUULers; sharing among 

friends is common.

• For many teens and young adults, only JUUL appeals – other “e-cigs” or 

vapes are for heavy users, or nicotine-addicted people.

https://twitter.com/CapnBarb/status/1099130866746511360?s=20

Young people told us that ...
• JUULs are everywhere: not just at parties, but in school, and when hanging 

out with friends. 

• JUULs are a conversation-starter, something to hold besides a drink or a 

phone at parties.

• Flavors are appealing.

• They don’t perceive the risks of vaping.

Young people told us that ...
• Knowledge of Health Consequences

• Reframe Appeal

• Reduce Social Acceptability

Anti-Vape Scale Constructs
Creative: “Mind Blown” & “Horn”
Message Testing: “Mind Blown” & “Horn”

Methods: N=200 each; 15- to 24-year-olds

11-item Anti-Vape Scale, measuring: 

✓ Knowledge of Vaping Harms

✓ Appeal (or Un-Appeal) of Vaping

✓ Social Acceptability of Vaping

Contributions

“Mind Blown” and “Horn” found to be strong performers, with:

✓ High likeability, strong relevancy, and generates buzz with strong social media 

sharing;

✓ Strong communication and branding; and

✓ Effectively reduces the intention to vape with strong message registration.
Anti-Industry Approach: JUUL x Altria
First-of-Its-Kind e-Quit Program

• Supports e-cigarette quitters of all ages

• Also a resource for parents to help their children quit

• Easy sign-up

• Text QUIT to 202-804-9884.

• Users can opt-in via BecomeAnEX or This is Quitting text 

message programs.
thank you

dvallone@truthinitiative.org
Emily D’Iorio

Health Communication Specialist

The Real Cost Campaign

U.S. Food and Drug Administration
CENTER FOR TOBACCO PRODUCTS

THE REAL COST: YOUTH 

E-CIGARETTE PREVENTION CAMPAIGN

This information is not a formal dissemination of information by FDA/CTP 

and does not represent Agency position or policy.
Center for Tobacco Products

• Research has demonstrated that public education campaigns can prevent and reduce 

tobacco use. 

• Campaigns have contributed to major declines in tobacco use in the U.S.

• CTP has several campaigns, each one targeting different groups of people:

✓ The Real Cost: Teens at risk of using cigarettes, e-cigarettes, and smokeless tobacco

✓ Fresh Empire: Multicultural teens at risk of smoking 

✓ This Free Life: LGBT young adults at risk of smoking

✓ Every Try Counts: Adult smokers who want to quit smoking

PUBLIC EDUCATION
Center for Tobacco Products

The Real Cost campaign 

started as a campaign to 

prevent youth cigarette 

smoking.

The campaign expanded to 

include messages for rural 

boys about the harms of 

smokeless tobacco.

The campaign expanded again 

to include messages to teens 

at risk for e-cigarette use, or 

“vaping.”

THE REAL COST CAMPAIGN 

Our goal

Snap youth out of their “cost-free” mentality 

when it comes to the risks of tobacco use.

2014

2016

2018
Center for Tobacco Products

2018 National Youth Tobacco Survey data show an 

alarming surge in youth e-cigarette use, with more than 

3.6 million teens currently vaping.

From 2017 to 2018:

• The number of high-school-age children reporting use of e-cigarettes 

rose by 78 percent;

• Use among middle-schoolers increased by 48 percent; and

• Almost 30 percent of high school students who currently used 

e-cigarettes used them on 20 or more of the last 30 days.

YOUTH USE OF E-CIGARETTES
Center for Tobacco Products

SOCIAL MEDIA NORMING
Center for Tobacco Products

E-CIGARETTES ARE A SOCIAL CURRENCY
Center for Tobacco Products

The end result is that teens see 

using e-cigarettes as largely 

consequence-free 

and a cool thing to do.

LOW RISK PERCEPTIONS
Center for Tobacco Products

We conducted focus group testing with nearly 160 youth ages 12–17. We showed 

them draft ads and asked questions about how motivating, believable, and 

understandable each ad was. Our learnings include:

• Ads tested well when they were paired with a strong health effects message, such as facts 

about inhaling acrolein and metal particles.

• Nicotine addiction messages aren’t enough—teens aren’t afraid of being addicted to ecigarettes because they don’t see them as harmful.

• Flavor ads did not perform well, primarily because youth were confused about the main 

message.

We then refined our ads before we produced them to reflect these research learnings.

RESEARCH LEARNINGS
Center for Tobacco Products

RESEARCH LEARNINGS

“I heard [vapes were] really not that bad. There weren’t any studies that showed otherwise. At least 

yet. A lot of people say that it is a lot better than smoking.”

—Group 15, ENDS Experimenters 12–14, Charlotte 

“Well, me. I don’t know what it’s going to do so I wouldn’t do it. At the same time, well, I haven’t 

heard anything bad about it so why not?” 

— Group 16, ENDS Experimenter 15–17, Charlotte 

“Cigarettes—like how they give you cancer because they have all the chemicals and stuff, and 

vapes don’t have any of that.” 

— Group 17, ENDS Experimenter 15–17, Charlotte 

“I feel like that’s what sets them apart from cigarettes. That’s what makes them more compelling 

than cigarettes. Cigarettes are like, ‘Ooh, that’s gross,’ and then vapes are like, it makes them 

seem harmless.” 

—Group 4, ENDS Experimenters 15–17, Philadelphia 

“I feel like people stick with vaping because what she said. It’s a healthier alternative. It’s cool. It’s 

supposedly better.” 

— Group 19, ENDS At-Risk 12–14, Phoenix 
Center for Tobacco Products

CAMPAIGN ADVERTISING
Center for Tobacco Products

After a year of development, we released almost 20 new 

online videos in September 2018.

• These ads are based on both qualitative and quantitative research 

with youth.

• We use innovative media tactics to reach youth.

• We’ve also created materials for high school bathrooms and 

partnerships with relevant groups.

• We created whatsinavape.com, an interactive web experience for 

teens to learn about vapes.

NEW ADVERTISING FOR YOUTH
Center for Tobacco Products

EPIDEMIC

Epidemic :30 — https://www.youtube.com/watch?v=zYuyS1Oq8gY
Center for Tobacco Products

CREATIVE EXTENSIONS: WEB, SOCIAL, DIGITAL ADS
Center for Tobacco Products

BRAINTROLL

Braintrolled — https://www.youtube.com/watch?v=tdWwsGdT4gw
Center for Tobacco Products

CAMPAIGN IMPLEMENTATION
Center for Tobacco Products

• The Real Cost Youth E-Cigarette Prevention Campaign is limited to age-verified 

digital media, hyper-targeting the media to reach 12- to 17-year-olds on digital and 

social channels

• This means that these messages will reach at least 60 percent of the target audience 

at least 28 times per quarter.

MEDIA PLAN
Center for Tobacco Products

• Collaborating with Scholastic to bring lesson plans, an infographic, and research to more than 

700,000 teachers and administrators throughout the U.S. 

- http://www.scholastic.com/youthvapingrisks/

SCHOLASTIC PARTNERSHIP
Center for Tobacco Products

Posters: Prevention posters available for order or print: 

https://digitalmedia.hhs.gov/tobacco/

Youth Vaping Risks Infographic (English and Spanish) 

https://digitalmedia.hhs.gov/tobacco/print_materials/CTP-119

2018 NYTS Infographic on Research Findings: 

https://www.fda.gov/TobaccoProducts/PublicHealthEducation/ProtectingKidsfromTobacco

/ucm405173.htm

RESOURCES
Resources

• NPW Webinar: Emerging Issues in Tobacco Use

https://www.youtube.com/watch?v=d24HUp7gXBo

• 2014 Annual Synar Reports: Tobacco Sales to Youth

https://store.samhsa.gov/product/2014-Annual-Synar-Reports-Tobacco-Sales-to-Youth/synar-15

• CDC February 2019 Vital Signs: E-Cigarette Ads and Youth

https://www.cdc.gov/vitalsigns/ecigarette-ads/index.html

• Youth Tobacco Use: Results from the National Youth Tobacco Survey

https://www.fda.gov/TobaccoProducts/PublicHealthEducation/ProtectingKidsfromTobacco/ucm4051

73.htm

• Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-Ecigarettes-for-Kids-Teens-and-Young-Adults.html

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