Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia.
To address this need, the team at the University of Sydney’s Matilda Centre for Research in Mental Health and Substance Use have developed the OurFutures Vaping Program. They are now running a large multi-site trial to evaluate the efficacy and cost-effectiveness of the intervention in 41 schools across New South Wales, Queensland and Western Australia.
If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without prevention and early intervention programs such as OurFutures, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control.
To find out more about the study, view the full published protocol here or read the background section below.
Background
Despite only emerging in recent years, e-cigarette use, particularly among adolescents who do not smoke, has become a global public health concern [1]. The most recent (2017) representative survey of Australian secondary school students, aged 12–17 years, found 14% had used an e-cigarette, among whom 32% had done so in the past month [2]. Global data suggests these numbers are rapidly climbing, with over 40% of young people in other high-income countries (e.g., the United States [US], France, Italy and Spain) now having used e-cigarettes [3]. This dramatic increase contrasts with the steady declines in youth alcohol and other drug use observed over the past decade [4]. The surge has been fuelled by e-cigarette companies and marketing campaigns targeting youth through the use of bright colours, flavours (e.g., fairy floss), and a strong social media presence. This is problematic as e-cigarettes often contain harmful chemicals and the long-term effects are currently unknown [5]. Although, in Australia, it is illegal to buy or sell e-cigarettes containing nicotine without a prescription [6], they are surprisingly easy to purchase unlawfully from tobacconists, vape stores and online. Further, many e-cigarettes contain high doses of nicotine (up to 50 mg – equivalent to approximately one pack of cigarettes [7]), even when labelled as nicotine free [8]. Nicotine is highly addictive and can impede healthy brain development [9]. Indeed, more than half of adolescent e-cigarette users experience symptoms of nicotine dependence [10].
A major recent review found e-cigarettes can also cause a range of acute health problems, including e-cigarette or vaping use-associated lung injury (EVALI), seizures, poisoning and burns [11]. E-cigarette use has also been associated with mental health problems, such as depression and suicidal ideation in adolescence (although causality has not been established) [12]. Alarmingly, young people who use e-cigarettes are three times more likely to take up tobacco smoking when compared to people who have never used e-cigarettes, putting them at risk of the substantial harm and burden of disease that tobacco smoking can cause [13]. Whilst e-cigarettes may help some individuals to quit smoking, the health risks significantly outweigh any benefits [11]. Despite this knowledge, perceived harm of e-cigarettes by adolescents is low [14], and they are now the most commonly used nicotine product among youth [15]. Effective and scalable interventions are urgently needed to address this critical health issue which has the potential to undo decades of successful tobacco control in Australia.
Drug harm prevention initiatives delivered during adolescence are an efficient and effective way to deliver long-term health and economic benefits [16, 17]. Schools are an ideal setting as they provide an opportunity to reach large numbers of young people and intervene prior to the onset of harmful drug use [2]. In addition, drug education is mandatory within the health curriculum across many countries, including Australia [18]. School-based preventive interventions targeting tobacco, alcohol and other drugs can be effective at preventing, delaying, and reducing substance use and related harms [16, 19]. The strongest evidence exists for interventions that help adolescents overcome social influences to use tobacco or other drugs, and improve social competence, by developing problem solving, decision-making, resistance and assertiveness skills [19, 20]. Such interventions are best implemented alongside policy-level prevention initiatives, such as laws to reduce access, use and supply [21, 22].
Despite the demonstrated potential of school-based substance use prevention, an evidence-practice gap exists, with less than one in four teachers implementing a drug prevention program with evidence of effectiveness [23, 24]. Amongst schools that do deliver evidence-based prevention, many do so ‘off-label’, with teachers making adaptations over 95% of the time, undermining the fidelity and established efficacy of the programs [23, 25]. This is often due to implementation barriers, such as limited time and resources, or a lack of suitability due to end-users not being involved in program design. eHealth interventions can overcome common implementation barriers within the school environment. For example, pre-programmed content reduces reliance on teacher training, and limits the potential for adaptations that could compromise intervention fidelity. Further, online interactive components can increase student engagement, accessibility and scalability [26].
Whilst evidence supports the effectiveness of school-based preventive eHealth interventions in addressing alcohol and other drug use among adolescents [19], there is a dearth of eHealth interventions targeting e-cigarette use. Developed in the US and based on successful tobacco and other substance use prevention techniques, the ‘CATCH My Breath’ intervention is, to our knowledge, currently the only school-based eHealth intervention with demonstrated efficacy at preventing e-cigarette use [27]. However, lessons consist of teacher presentations and peer-led group work which may vary and compromise effectiveness in real-world settings. Moreover, the need for specialised teacher and peer-leader training may limit scalability. An urgent need remains for new scalable approaches to prevent e-cigarette use, specifically within the unique Australian context where it is illegal to buy or sell e-cigarettes containing nicotine [6].
To address these gaps, we developed the first school-based eHealth preventive intervention to target e-cigarette use among young Australians – the OurFutures Vaping Program. OurFutures is an innovative, universal prevention model that adopts a harm minimisation and comprehensive social influence approach to drug prevention. The model was designed to maximise intervention fidelity and overcome common implementation barriers for school-based interventions. For example, the core intervention component is the cartoon storyboards which cannot be adapted by teachers. The cartoons follow the lives of a group of young people around the same age as the target students who, through their experiences, impart knowledge, skills and values related to alcohol and other drug use. In essence, this provides peer-led education, which is more effective at addressing adolescent substance use compared to adult-led education [28]. Further, online delivery makes the program readily accessible and scalable, regardless of location. To reduce the burden on teachers, the content is aligned with the Health & Physical Education Curriculum and offers a direct replacement for regular health education lessons.
The effectiveness of the OurFutures programs has been established through 8 large randomised controlled trials (RCTs) across Australia (240 schools, > 21,000 students). These studies demonstrated that the OurFutures programs targeting alcohol, cannabis, psychostimulants and emerging drugs, are more effective than school-based health education as usual in reducing alcohol consumption, binge drinking, cannabis use, ecstasy use, harms from substance use, intentions to use substances, and in increasing knowledge about substance use harms, up to 3 years following intervention delivery [29,30,31]. Notably, reductions in harmful alcohol use have also been observed up to age 20 (i.e., 7 years following intervention delivery) [16]. Moreover, a recent independent review found OurFutures to be one of only two school-based alcohol and other drug education programs in Australia with a strong evidence base [32]. Capitalising on this world-first program of research, we have applied the successful OurFutures model to the prevention of e-cigarette use through the OurFutures Vaping Program. This study aims to evaluate the efficacy of the program through a multisite cluster RCT.
