Eligible participants who provided informed consent were scheduled for a baseline session where they completed self-report measures and provided a saliva sample for cotinine testing. Participants returned for follow-up measures and cotinine testing 6 and 12 months after baseline. Study incentives were $30 for the baseline, $35 for the 6-month, and $40 for the 12-month follow-up visits. Parental consent was waived under California law 6929. Cessation information and local treatment options were provided. The research design and study procedures were approved by the University of California, San Francisco Institutional Review Board.Demographic characteristics of age, sex, race/ethnicity, and mother’s level of education were reported by participants. Ecigarette use frequency in a typical month was self-reported ranging from 0 to 30 days. E-cigarette dependence was measured using the 10-item Penn State Electronic Cigarette Dependence Index, which was strongly correlated with cotinine levels in this sample. Salivary cotinine was measured at baseline, 6, and 12 months. Saliva samples were analyzed at the Clinical Pharmacology Laboratory at the University of California, San Francisco. Levels of salivary cotinine were measured using liquid chromatography-tandem mass spectrometry,4×8 grow table with wheels reported in nanogram per milliliter, and log-transformed to normalize the distribution. Past-month traditional cigarette smoking was assessed with the item: “Have you smoked a cigarette in the past 30 days?” . Product preference was assessed by asking participants: “What kind of e-cigarette device do you use most often?” .
Given the popularity of Juul among adolescents at the time the study was conducted, Juul was added as its own option separate from other brand name e-cigarettes. Participants who selected “other” were asked to specify their device. Responses were recoded into mod , Juul, vape pen, or other /unknown based on prior work . E-cigarette flavors were assessed with the item: “What flavor e-cigarette do you usually use?” Choices included fruit, candy, menthol, tobacco, and others. Those who selected “other” were asked to specify their flavor of choice. Reasons for e-cigarette initiation were assessed at baseline by asking participants to report up to three reasons for starting to use e-cigarettes . Reasons for e-cigarette continued use were assessed at 6 and 12 months by having participants select up to three reasons for continuing to use e-cigarettes from the following options: my friends are using them, my family members are using them, they look cool, I am addicted , I want to quit smoking regular cigarettes, I think they are safer than regular cigarettes, I like the taste, they are fun, they are easy to hide from adults, or other. Those who selected “other” were asked to specify their reason. Reasons for quitting e-cigarettes were assessed with an open-ended item at 12 months among those who reported quitting using e-cigarettes.For the open-ended responses, two independent coders read participants’ reasons for initiating and quitting e-cigarette use and created initial codes for each. E.A.V. reviewed both sets of codes, drafted a coding scheme, coded all data, and refined the coding scheme. All data were coded again by both E.A.V. and J.A. . Coders discussed discrepancies until consensus was reached.
Each response was coded into one best-fitting category. Reasons for continuing use were closed-ended and did not require coding. Descriptive statistics were run on baseline and follow-up data to examine the frequency of e-cigarette and cigarette use; preferred devices; preferred flavors; and reasons for initiating, continuing, and quitting e-cigarette use. Among e-cigarette only users and those reporting recent dual use of combustibles at baseline, we examined transitions in nicotine product use categories. Repeated-measures analyses of variance were used to assess differences in e-cigarette use frequency, dependence symptoms, self-perceived dependence, and cotinine levels from baseline to 6- and 12-month follow-up. A lower-bound correction was used when Mauchly’s test indicated a violation of the assumption of sphericity. When the omnibus test was significant, we ran simple contrasts to identify where the changes over time were significant. Cochran’s Q tests were used to assess differences in device preference and reasons for initiating and continuing use over time.In this longitudinal study of adolescent e-cigarette use with self-reported and biomarker data, 80.3% of the sample continued to use e-cigarettes at 12 months, with significantly greater ecigarette use frequency, dependence, and nicotine exposure. The percentage of daily e-cigarette users doubled from 14.5% at baseline to 29.8% at 12-month follow-up. The patterns of ecigarette use observed over time indicate substantial persistence and the use of greater amounts of nicotine over time .In the United States, prevalence of past-month e-cigarette use increased dramatically among adolescents in 2018, whereas cigarette use declined and cannabis use remained constant.
Results of this study suggest that increased prevalence of recent e-cigarette use may lead to frequent use, dependence, and greater nicotine exposure. Dependence scores at baseline were low on average, with most participants meeting a classification of “not dependent,” and 13.3% meeting a classification of moderate to heavy dependence. By 12 months, the percentage classified with moderate to heavy dependence increased to 23.3%. These findings would suggest that factors other than dependence are driving early use of e-cigarettes, and that over the course of just 1 year, more teens become daily users and more heavily dependent. Along with the self-reported increase in frequency of e-cigarette use and dependence, cotinine levels increased over time, reflecting increased exposure to nicotine. The increase in cotinine levels may be both the result of increased dependence and a catalyst for the development of dependence. Adolescents who become increasingly dependent on e-cigarettes may increase their nicotine use, thereby worsening dependence. Notably, devices with higher nicotine yield became increasingly popular over the course of the 12-month trial, consistent with the reports of greater nicotine dependence and higher cotinine levels. Transitions from single to dual and dual to single nicotine product use were observed in approximately one in three users over the study period. None of the baseline dual users abstained from both products at either follow-up, which may be partially due to their higher dependence on e-cigarettes at baseline, as well as the normalization of smoking behavior and associations between smoking cues that can perpetuate use of both products. Consistent with prior research ,grow tray stand adolescent participants offered a wide range of reasons for e-cigarette use. The top three reasons for initiating and continuing use were socializing, enjoyment, and flavors. The top three reasons for quitting were a desire for self-improvement, difficulty maintaining an e-cigarette device, and getting in trouble for vaping at home or school. The top flavors were fruit, menthol/mint, and candy. Taken together with experimental research demonstrating the influence of flavors on adolescents’ product choices, these findings suggest that efforts to reduce adolescent e-cigarette use ought to include regulatory action that addresses kid-friendly flavors. Little research has examined adolescents’ reasons for quitting e-cigarette use, and our findings preliminarily suggest that adolescents perceive parental controls and appropriate disciplinary consequences to be impactful.Over three million refugees have been resettled in the United States since Congress passed the Refugee Act of 1980.1 In 2015, there were nearly 70,000 new refugee arrivals, representing 69 different countries.Refugees undergo predeparture health screening prior to arrival in the U.S., and are typically seen by a physician for an evaluation shortly after arrival.Refugees are resettled in areas with designated resettlement agencies that assist them with time-limited cash assistance, enrollment in temporary health coverage, and employment options. Refugees are initially granted six to eight months of dedicated Refugee Medical Assistance, which is roughly equivalent to services provided by a state’s Medicaid program.Following this period, refugees are subject to the standard eligibility requirements of Medicaid.It is important to highlight the differences between a refugee, an asylum seeker and a migrant, as this study focuses specifically on refugees. A refugee is an individual who has been forced to leave his or her home country due to fear of persecution based on race, religion, nationality, membership in a social group, or policital opinion. Refugees undergo robust background checks and screening prior to receiving designated refugee status.
They are relocated only after undergoing this screening process, and have legal protection under the Refugee Act of 1980 given their status as a refugee. An asylum seeker, on the other hand, is an individual who has fled his or her home country for similar reasons but has not received legal recognition prior to arrival in the U.S. and may only be granted legal recognition if the asylum claim is reviewed and granted. As a result, asylum seekers do not have access to services such as Refugee Medical Assistance, time-limited cash assistance, or similar employment opportunities. Migrant is a general term and refers to an individual who has left his or her home country for a variety of reasons.Prior studies have shown differences in utilization of the emergency department by refugees in comparison to native-born individuals.In Australia, refugees from non-English speaking countries are more likely to use ambulance services, have longer lengths of stay in the ED, and are less likely to be admitted to the hospital.A study conducted in the U.S. evaluated refugees one year post-resettlement and demonstrated that language, communication, and acculturation barriers continue to negatively affect their ability to obtain care. These data suggest that there may be unidentified opportunities for improving the acute care process for refugee populations; however, little is known about how refugees interface with acute care facilities. Therefore, the goal of this study was to use in-depth qualitative interviews to understand barriers to access of acute care by newly arrived refugees, and identify potential improvements from refugees and community resettlement agencies. Because the healthcare experience of refugees has not been well described and they cannot be reliably identified in administrative datasets,we chose to conduct an in-depth interview study to identify the potential barriers and facilitators to accessing acute care as a newly arrived refugee. We included the following in the definition of acute care: sick visits, urgent appointments with the patient’s primary care doctor, urgent follow-up with specialists and dentists, urgent care visits, and ED visits. Because our goal was to understand the range of experiences rather than the number of times an experience is identified, we chose in-depth interviews to obtain a detailed understanding of the perspective of each respondent. Interviews were conducted until thematic saturation was reached, when the data no longer identified new perspectives or themes.We used purposive sampling to balance across gender to ensure that the fullest range of perspectives was included.We conducted the study at a refugee clinic and at resettlement and post-resettlement agencies. The refugee clinic was located at a tertiary care hospital in a city in the Northeast U.S. The clinic has been in operation for approximately five years and has cared for approximately 200 refugee patients yearly. At the time of the study, the clinic received referrals from one of the three resettlement agencies in the city. Refugee patients were seen within 30 days of arrival. Most refugees were seen for screening evaluations and transitioned to clinics near their homes after two to three clinic visits. Refugee patients were eligible for this study if they were over 18 years of age, had capacity to consent, and had no hearing difficulties. We excluded refugees if they were deaf, unable to answer questions from an interpreter, or had acute medical or psychiatric illnesses. In the city in which the study was performed, there are three main resettlement agencies and approximately three well-known post-resettlement agencies. Resettlement agencies are responsible for receiving new refugee arrivals and assisting individuals with support for three to six months after arrival. Resettlement employees assist refugees with establishing housing, employment, transportation, primary care, and language services. After three to six months, refugees are able to seek additional assistance at post-resettlement agencies. Post-resettlement agencies provide additional support in terms of support groups, language services, cultural activities, and case management. Employees were eligible for this study if they worked at a resettlement or post-resettlement agency, were over 18 years of age, and had no hearing difficulties. This was an in-depth interview study using semi-structured, open-ended interviews. Separate interview guides for refugees and resettlement agency employers were developed by all members of the study team.