Hutch trial will test new app to help teens stop vaping

Not a harmless habit

A clinical psychologist and director of the Hutch’s HABIT Lab (Health and Behavioral Innovations in Technology), Bricker has been studying and advocating for youth tobacco control since the start of his career at the Hutch in 1999. His early publications were devoted to understanding social and psychological influences on youth smoking initiation and cessation; he’s also testified to the Washington Legislature in support of the state’s Tobacco 21 legislation.

The measure prohibits the sale of all tobacco and nicotine products to individuals under age 21, but “we know that many kids are getting access to vaping devices despite the Tobacco 21 law,” he said.

And while vaping rates have reportedly declined in the past few years, Bricker said that may be only a short blip due to closed schools during the coronavirus pandemic.

“The latest CDC [Centers for Disease Control and Prevention] survey methods changed during the height of the pandemic — going online instead of through school interviews — so next year’s CDC data will give us a much better picture of where teen vaping rates are headed,” he said, adding that vapes still remain the most commonly used nicotine product among teens.

This is especially worrisome because not only does vaping expose them to damaging chemicals, it can lead to other harmful habits, like smoking regular cigarettes.

“Teens who vape are more likely to start smoking,” Bricker said. “Plus almost all e-cigs or vape pens contain nicotine, which alters the development of the adolescent brain. Stopping now, while in their teenage years, could help prevent a lifetime of smoking and improve brain development. It’s the best period of life to stop.”

Bricker said the prefrontal cortex, the part of the brain that affects executive function — working memory, problem solving, planning, impulse control — doesn’t fully develop until the age of 25. Preclinical imaging studies suggest vaping harms that development.

“It’s not just about cancer and physical health, it’s about brain health and functioning,” he said. “A big part of our effort will be education. Letting them know what’s in a vaping device, like formaldehyde and nicotine and cancer-causing elements. There are chemicals in vaping pens and Juuls these kids never imagined.”

And these chemicals can cause harm, as Natalie Rice learned when her son began having seizures after overdoing it with a vape pen.

“One morning he was in bed and he felt a tightness around his head,” said Rice, a 48-year-old real estate agent from Oklahoma City. “He reached for the light, but instead fell to the floor and started seizing. He bit his tongue, sliced his head on the table. We called 911 and they took him away by ambulance. It was terrifying. We didn’t know what happened to him. There were no drugs in his system, no alcohol. The ER ran a million tests.”

After another seizure a few weeks later, followed by more tests and scans and a new seizure medication, courtesy of a neurologist, Rice said her son finally came clean.

“After the second episode, he admitted he’d been vaping menthol Juuls,” she said. “Both times it happened. He said he just kept hitting the vape, like the entire pod. It was like smoking a whole pack of cigarettes. I don’t think he knew what nicotine was. I don’t think that little device even registered as a cigarette.”

Setting the stage for the trial

Bricker said he and the HABIT team, which includes co-principal investigator Dr. Sean David of the University of Chicago, are completing the first phase of the project, interviewing teens about what a vaping app for teens should entail. They’re also starting to create new content.

“We’re currently in the user-centered design phase, which is an iterative process, doing what we need to do change the adult quit-smoking app into a teen quit-vaping app,” he said.

When the trial launches next year, Bricker said half the teens who enroll will be randomized to receive the new app and half will receive the NCI program. His team will keep track of participants in both groups for a few months to determine which app is the most effective.

Although participants are under 18, they will not require a parent or guardian’s consent thanks to an exemption Bricker received from the ethics board overseeing the trial.

“This will be very private,” Bricker said. “They won’t have to worry about their parents or caregivers or guardians knowing about it. It’s discreet.”

Bricker said it was essential for a number of reasons to give teens a chance to sign up to quit vaping without the knowledge of their parents, caregivers or guardians.

“We did our research and learned that teens tend to avoid participating in programs that require parental or guardian consent, especially those that pertain to stigmatized behaviors,” he said. “Many hide smoking or vaping from their parents. Requiring consent would undermine that privacy and confidentiality as well as their willingness to participate in the program.”

If anything, forcing young participants to get consent could result in them not participating in the study and continuing to vape.

“Basically, it would do harm to these kids to require parental consent,” he said. “They would either get in trouble or just not enroll. At that age, we know they want to develop a sense of agency; they want to be able to develop that confidence that they can do something for themselves. This is a tool we can give them to do that.”

And while cannabis vaping is also prevalent in this age group, Bricker will stick with e-cigs for his study, although he won’t discourage kids to sign up if they want to quit both.

“If they concurrently vape other substances, they are certainly welcome to join and will be encouraged to use the skills taught in the apps to help them quit these other substances,” he said. “But they must be wanting to quit vaping nicotine in order to be in the study.”

Tailoring a successful quit-smoking app

As with previous apps created by Bricker’s HABIT lab, the new vaping cessation app will use Acceptance and Commitment Therapy, or ACT, a type of behavioral therapy that drives change by helping people notice, then move past, unhealthy cravings. Bricker has successfully paired ACT therapy with coaching via telephone, chatbot and smartphone app to help people get past cigarette cravings; he’s also used it to help people overcome food cravings.

“We’ve shown that this approach is effective in helping adults stop smoking, so it’s exciting to be able to use it with teenagers,” he said. “We’ll educate them about vaping and ask them to set a date to stop. But we’ll also teach them to be open to cravings, to let them observe the cravings and feel them pass and realize they don’t have to act on them.”

Bricker said the ACT approach also helps people focus on their values and why they want to stop vaping (or smoking or overeating).

“We ask them what kind of a friend do you want to be? What kind of athlete do you want to be? What’s important to you as a person?” Bricker said. “We ask them what they care about and what they aspire to. We’re just taking that ACT approach and tailoring it for teens.”

And teens desperately need it, Rice said.

“My son said 95% of the people he knew in high school were vaping,” she said. “They took the doors off the bathrooms because the kids were all vaping in there. They’re vaping at the proms and other dances. The kids love the styling. They love the flavors. They’re easy to hide. There’s just a wisp of smoke that’s gone in a second. They’re undetectable.”

Rice’s son, now in college, no longer vapes, but his mom remains concerned about the harmful effects of e-cigs and vape pens. As do the parents she’s met through the group Parents Against Vaping E-cigarettes, or PAVe, some of whom have had kids become addicted, suffer seizures, move on to more harmful drugs and even die.

“I’ve had cancer twice, have never smoked and have always been firmly against smoking,” Rice said. “But Juul and e-cigarettes have taken over high schools and middle schools. These things are so easy to get, they’re full of chemicals and they get kids addicted so young. It’s just awful.”