HHS Template for Reports, with Full Instructions

Electronic Nicotine

Delivery Systems

(E-Cigarette) Report

As Required by

Texas Health and Safety Code,

Section 161.0902

January 2021

i 
 
Table of Contents 
Executive Summary ............................................................................... 2 
1.  Introduction ...................................................................................... 4 
2.  Background ....................................................................................... 5 
3.  Regulating Tobacco Access in Texas .................................................. 8 
Legal Age of Access to Tobacco ............................................................... 8 
Enforcement of State Legal Age of Sale Law ......................................... 9 
Enforcement of Federal Legal Age of Sale Law in Texas ....................... 10 
4.  Prevalence of ENDS Use in Texas .................................................... 11 
Adult Use of ENDS ............................................................................... 11 
Youth Use of ENDS .............................................................................. 12 
ENDS Use Among Conventional Tobacco Users ........................................ 13 
5.  DSHS E-Cigarette Controls and Initiatives ....................................... 14 
Current Initiatives ............................................................................... 14 
E-Cigarettes and Vaping Associated Lung Illnesses .............................. 14 
DSHS-Funded Community Coalitions ................................................. 15 
Regional Coordinators ..................................................................... 16 
Local Policies and Environmental Strategies ....................................... 16 
Texas Tobacco Quitline .................................................................... 17 
Texas Youth Tobacco Prevention – Say What! ..................................... 17 
Texas College Student Tobacco Prevention - Peers Against Tobacco ...... 18 
Tobacco Prevention Awareness Campaign .......................................... 18 
Future Goals and Plans ......................................................................... 20 
6.  Conclusion ....................................................................................... 21 
List of Acronyms .................................................................................. 22 
Appendix A. EVALI Data ...................................................................... A-1 
Appendix B. Youth and Adult ENDS Prevalence Rates ......................... B-1 
Appendix C. Tobacco Prevention and Control Coalitions ...................... C-1 
Appendix D. Say What! ........................................................................ D-1 
Appendix E. Peers Against Tobacco ..................................................... E-1 
Appendix F. Vapes Down Media Campaign .......................................... F-1 

Executive Summary

Texas Health and Safety Code, Section 161.0902, requires the Department of State

Health Services (DSHS) to report to the Governor, Lieutenant Governor, and

Speaker of the House of Representatives on the use of e-cigarettes in Texas, state

enforcement efforts, and prevention and control initiatives conducted by DSHS.

Electronic cigarettes (e-cigarettes), also known as Electronic Nicotine Delivery

Systems (ENDS), are devices that simulate smoking by using a mechanical heating

element, battery, or electronic circuit to deliver nicotine or other substances by

inhalation. ENDS are marketed by tobacco companies as a safer alternative to

smoking and as a tool to help people quit smoking, but these devices are not

approved by the Food and Drug Administration (FDA) to aid in smoking cessation.

These products have become popular with youth and have been the most

commonly used tobacco product among U.S youths since 2014.

Statewide survey data indicates that the following about e-cigarette use in Texas.

● 3.6 percent of adults in Texas report currently using ENDS in 2019.

● 14.3 percent of high school students, and 7.1 percent of middle school

students used ENDS in the past 30 days in 2020.

DSHS updated enforcement practices to align with state and federal law changes

regarding the sale of tobacco to persons under age 21. To enforce state law, the

Texas Tobacco Enforcement Program conducted 22,659 controlled buy/stings and

recorded of 1,198 violations from May 1, 2019 to August 31, 2020. To enforce

federal law, DSHS also worked through a contract with the FDA to perform State

Retail Compliance Checks. From September 1, 2018 to August 31, 2020, 9,124

retail compliance checks were completed that resulted in 852 violations of federal

law.

Between August 2019 to September 2020, 262 cases of probable or confirmed e-

cigarette and vaping associated lung illnesses (EVALI) were identified in Texas and

four deaths occurred. The Centers for Disease Control and Prevention has identified

vitamin E acetate, a thickening agent used in some e-liquids, as a chemical

exposure of concern among people with EVALI.

DSHS has worked to include ENDS into its existing comprehensive tobacco

prevention and control activities through multiple initiatives. Additionally, DSHS

implemented a multimedia awareness campaign in 2020 to promote an ENDS

prevention message to Texas youth and young adults. DSHS will continue to

implement evidence-based prevention and cessation interventions to address ENDS

use in Texas.

1. Introduction

Texas Health and Safety Code, Section 161.0902, requires the Department of State

Health Services (DSHS) to report to the Governor, Lieutenant Governor, and

Speaker of the House of Representatives on the use of e-cigarettes in Texas.

The report must be submitted no later than January 5 of each odd-numbered year,

and at a minimum, must include the following information:

● A baseline of statistics and analysis regarding retail compliance with Texas

statute.

● A baseline of statistics and analysis regarding illegal e-cigarette sales,

including sales to minors, enforcement actions concerning minors, and

sources of citations.

● E-cigarette controls and initiatives by DSHS, or any other state agency,

including an evaluation of the effectiveness of the controls and initiatives.

● The future goals and plans of DSHS to decrease the use of e-cigarettes.

● The educational programs of DSHS and the effectiveness of those

programs.

● The incidence of use of e-cigarettes by region in the state, including use

of e-cigarettes by ethnicity.

This report provides data on e-cigarette use and retailer compliance, as well as the

initiatives carried out by DSHS and other state agencies to prevent e-cigarette use

and promote cessation. This report also provides summary information on DSHS’

investigation into e-cigarette and vaping associated lung illnesses in Texas.

2. Background

The term for e-cigarettes preferred by the Centers for Disease Control and

Prevention (CDC) is Electronic Nicotine Delivery Systems (ENDS). An ENDS is any

device that simulates smoking by using a mechanical heating element, battery, or

electronic circuit to deliver nicotine or other substances by inhalation.

Use of an

ENDS is called “vaping”, and retailers with a significant focus on selling ENDS are

called “vape shops.”

Many ENDS may look like conventional cigarettes, cigars, or pipes, but others

resemble pens, USB sticks, highlighters, and other non-tobacco products. ENDS are

comprised of three components: a battery; a cartridge containing a fluid called e-

liquid or e-juice comprised of propylene glycol and/or vegetable glycerin, nicotine,

and various chemicals; and a vaporizer that transforms the e-liquid into an

aerosol.

As the user draws on the ENDS, the battery heats the e-liquid to produce

aerosol, which is inhaled into the lungs.

ENDS were invented in 2003 and several generations of the device have been

developed since then. The first generation of ENDS consists of a device that

resembles a conventional cigarette and are generally a disposable, closed-system

(non-refillable) device. The second generation of ENDS resembles a pen, is typically

an open-system (refillable), and is rechargeable. The second generation introduced

the sale of e-juice or e-liquids. E-liquids usually contain nicotine and are necessary

to use the device. The third generation of ENDS consists of a device with a much

larger battery, tank, and heating device. This generation of ENDS is also used to

smoke forms of liquid tetrahydrocannabinol (THC) or hash oils.

E-liquid is often flavored, with thousands of flavors available in disposable or

refillable devices.

Most recent data from the 2020 National Youth Tobacco Survey

reported that among current ENDS users in middle and high school, 89.9 percent

Other common names for ENDS include electronic smoking device, e-cigarette, e-cig, e-cigar, e-hookah, mod,

hookah pen, vape pen, vape stick, personal vaporizer, tank system, or by the brand names JUUL, and Puff Bar

Americans for Nonsmokers’ Rights. 2014. Electronic smoking devices and secondhand aerosol. no-

smoke.org/electronic-smoking-devices-secondhand-aerosol/

U.S. Department of Health and Human Services. E-Cigarette 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,

2016.

used flavored ENDS.

Recent regulation from FDA restricted the sale of prefilled

cartridge ENDS in any flavor other than tobacco or menthol. As a result, some

ENDS that are entirely disposable (do not contain a pod cartridge or refillable tank)

have become more popular with youth because they are exempt from the federal

flavor restriction. CDC reported an increase in sales of disposable ENDS and a

decrease in the sale of cartridge-based ENDS between August 2019-May 2020.

ENDS are marketed by tobacco companies as a safer alternative to smoking and as

a tool to help people quit smoking. However, these devices are not approved by the

Food and Drug Administration (FDA) to aid in smoking cessation. Although ENDS

may help some smokers quit, others may transfer their nicotine addiction from

cigarettes to ENDS.

These products have also become popular with youth and have

been the most commonly used tobacco product among U.S youths since 2014.

The research on long-term health and safety consequences of ENDS product use is

still unclear. However, ENDS contain nicotine, volatile organic chemicals, and

carcinogens, all of which can have negative effects on health. The U.S. Surgeon

General reports that 99 percent of ENDS contain nicotine, the same addictive

chemical found in conventional tobacco products. Aside from potential addiction,

long-term nicotine exposure can lead to increased blood pressure, heart rate, and

problems associated with diabetes. E-liquids can have toxic effects, especially to

children, and can cause nicotine poisoning if e-liquid is consumed or absorbed

through the skin. Preliminary studies have shown that nicotine exposure can harm

developing brains and may prime adolescents for addictive behaviors.

In August 2019, a cluster of severe and unusual lung illnesses was reported to the

CDC. Similar cases occurred in all 50 states, many resulting in hospitalization and

even death. A joint investigation between state and local health departments, with

the support of CDC and the FDA, determined that the lung illnesses were likely

Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette Use Among Middle and High School

Students — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1310–1312. DOI:

dx.doi.org/10.15585/mmwr.mm6937e1

Ali FRM, Diaz MC, Vallone D, et al. E-cigarette Unit Sales, by Product and Flavor Type — United States, 2014–

2020. MMWR Morb Mortal Wkly Rep 2020;69:1313–1318. DOI: dx.doi.org/10.15585/mmwr.mm6937e2

Rahman, M.A., Nicholas, H., Wilson, A., Worrall-Carter, L. (2014). Electronic cigarettes: patterns of use, health

effects, use in smoking cessation, and regulatory issues. Tobacco Induced Diseases, 12(21).

tobaccoinduceddiseases.com/content/12/1/21

Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and associated factors among middle and high

school students—United States, 2019. MMWR Surveill Summ 2019;68(No. SS-12).

doi.org/10.15585/mmwr.ss6812a

associated with a chemical exposure linked to ENDS and became known as e-

cigarettes and vaping associated lung illnesses (EVALI).

Perrine CG, Pickens CM, Boehmer TK, et al. Characteristics of a Multistate Outbreak of Lung Injury Associated

with E-cigarette Use, or Vaping — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:860–864. DOI.

dx.doi.org/10.15585/mmwr.mm6839e1

3. Regulating Tobacco Access in Texas

Health and Safety Code, Chapter 161, Subchapters H and R largely pertain to the

regulation of tobacco access and distribution in Texas. Subchapter H contains

provisions related to the legal age of tobacco access, verifying identification, retail

warning notices and training, tobacco vending machines, the distribution of free

tobacco products, and e-liquid packaging. Subchapter R relates to delivery sales of

tobacco products. The Texas Comptroller of Public Accounts (CPA) is the enforcing

agency of these provisions. Statute allows the CPA to work with law enforcement to

enforce legal age of access law through unannounced inspections using underage

decoys.

More information on the tobacco regulations enforced by CPA can be found at CPA’s

Tobacco Enforcement Program website.

Legal Age of Access to Tobacco

The legal age of access to tobacco products is regulated at both the state and

federal levels. The following describes how both state and federal agencies enforce

tobacco age restrictions and the results of this enforcement since the last iteration

of this report in 2019.

As a measure to combat youth tobacco use in Texas, the 86th Texas Legislature

passed Senate Bill 21, which increased the legal age for the sale, distribution,

possession, purchase, consumption, or receipt of cigarettes, e-cigarettes or tobacco

products from 18 to 21 years-of-age in the state. Senate Bill 21 became effective

September 1, 2019.

This new state law does have exemptions. For instance, members of the military (at

least 18 years old with a valid military ID) and individuals born on or before Aug.

31, 2001 may purchase tobacco products under Senate Bill 21. The new law also

removed the provision allowing minors to possess tobacco products in the presence

of a parent, a guardian, or a spouse.

S.B. 21, 86

Texas Legislature, Regular Session, 2019.

capitol.texas.gov/BillLookup/History.aspx?LegSess=86R&Bill=SB21

However, in December 2019, the federal government amended the Federal Food,

Drug, and Cosmetic Act and raised the minimum age of sale of tobacco products

from 18 to 21 years nationwide.

With this new federal regulation, it is now illegal

for a retailer to sell any tobacco product—including cigarettes, cigars, and e-

cigarettes—to anyone under 21 years. Federal law does not provide any exemptions

from the minimum sale age for tobacco products.

Enforcement of State Legal Age of Sale Law

In terms of enforcing state law, the Department of State Health Services is focused

on activities related to the legal age of access. Government Code 403.105 allows

for this activity. The Tobacco Enforcement Program (TEP) is implemented through

contracts with the Texas Department of State Health Services (DSHS), and DSHS

and the Health and Human Services Commission (HHSC). Both agencies contract

with the Texas School Safety Center (TxSSC) at Texas State University to recruit

local law enforcement agencies to conduct controlled buys/stings and follow-up

controlled buy/stings of tobacco permitted and ENDS retail outlets statewide.

Controlled buys/stings involve local law enforcement agencies recruiting persons

who are younger than the legal tobacco sale age (underage purchasers) to attempt

to buy tobacco products or ENDS. If a retailer makes a sale to an underage

purchaser during these controlled buy/stings a citation is made by local law

enforcement. A report of these citations is sent to the Comptroller’s office monthly

by TxSSC. From May 1, 2019 to August 31, 2020, the TEP program, with funding

from both DSHS and HHSC, contracted with 59 law enforcement agencies that

conducted 22,659 controlled buy/stings with a total of 1,198 violations. The overall

violation rate was 5.29 percent. Out of those totals, there were 8,864 ENDS

buys/stings and 399 ENDS violations. The ENDS violation rate was 4.50 percent.

As the TEP program did not receive funding in FY2018-2019, DSHS is unable to do

a comparison of violation rates with previous years.

The majority of retailer compliance and efforts to reduce youth access to cigarettes,

e-cigarettes, and other tobacco products is conducted through TEP. The CPA’s office

does perform some retailer compliance efforts on a limited basis through its

Criminal Investigation Division (CID). The CID conducts fewer inspections based on

anonymous, public submissions to the E-Cigarette and Tobacco Hotline.

Family Smoking Prevention and Tobacco Control Act (“Tobacco Control Act”), Title 21 USC § 301

Family Smoking Prevention and Tobacco Control Act (“Tobacco Control Act”), Title 21 USC § 1140

Enforcement of Federal Legal Age of Sale Law in Texas

The Food and Drug Administration (FDA) contracts with states to help enforce

federal tobacco regulations through its State Tobacco Retail Compliance Inspection

program. In Texas, the FDA program is administered by DSHS through a

subcontract with TxSSC. TxSSC hires and trains commissioned inspectors, to

perform retail compliance checks at the direction of the FDA. Underage purchasers

go with commissioned inspectors to perform unannounced compliance checks to

ensure tobacco retailers comply with federal regulations. The underage purchasers

will attempt to buy tobacco products and, if a sale is made, FDA may issue

penalties including warning letters, civil money penalty complaints, no-tobacco sale

order complaints, and seizures, injunctions, and criminal prosecution.

Between September 1, 2018 and August 31, 2020, a total of 9,124 inspections

were completed in Texas, resulting in 852 retail violations.

Of the 852 retail

violations, 212 were charged a civil money penalty based on the number of past

violations, 640 were issued a warning letter, and one received a no tobacco sale

order. Of the violations, 243 included ENDS and/or e-liquids sold to minors, of

which 44 were charged a civil money penalty based on the number of past

violations and 199 received a warning letter. No undercover buys/stings resulted in

a no tobacco sale order.

Between September 1, 2016 and August 31, 2018,

11,357 undercover buy compliance inspections were conducted with 228 ENDS and

e-liquid products sold by a retailer to a minor.

DSHS’ contract with the FDA for the State Tobacco Retail Compliance Inspection

program ended at the end of September 2020. TxSSC was awarded the contract in

September 2020.

Stop work order due to COVID-19 was in place from 3/19/2020-8/31/2020

U.S. Food and Drug Administration (2020, July 24). Compliance Check Inspections of Tobacco Product Retailers.

accessdata.fda.gov/scripts/oce/inspections/oce_insp_searching.cfm

4. Prevalence of ENDS Use in Texas

The Texas Department of State Health Services (DSHS) uses multiple data sources

to monitor tobacco use trends, including Electronic Nicotine Delivery Systems

(ENDS). These sources allow DSHS to track ENDS use among adults, youth, and

conventional tobacco users.

Adult Use of ENDS

Centers for Disease Control and Prevention (CDC) estimated that in 2017, 20.4

percent of American adults had used or tried ENDS products and 4.4 percent

reported currently using an ENDS product.

The most recent national data is from

2017, however, Texas data is available for 2019 and indicates ENDS use in Texas

was on par with national use for 2017.

The CDC’s 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey

provides the latest figures on the prevalence of ENDS use among adults in Texas.

Appendix B references additional survey details.

● In 2019, 18.7 percent of Texas adults had used or tried an ENDS product,

compared to the 22.0 percent of Texas adults who had used or tried an ENDS

product in 2018. This decrease was not statistically significant.

● 3.6 percent of Texas adults reported currently using an ENDS product, which

is consistent with previous years.

14,15

● Males, at 22.8 percent, were more likely to report having ever used an ENDS

product, compared to 15.0 percent of females. Males, at 5.0 percent,

reported almost double the rate of current ENDS use compared to females

(2.5 percent).

● 21.6 percent of white adults in Texas reported ever using or trying ENDS

products, compared to 18.2 percent of Black Texans, 16.2 percent of

Hispanics, and 15.5 percent of respondents identifying as other/multiracial.

Behavioral Risk Factor Surveillance System (BRFSS) Web Analysis Tool. Centers for Disease Control and

Prevention. nccd.cdc.gov/weat/#/analysis

Texas Behavioral Risk Factor Surveillance Public Use Data File, 2019. Texas Department of State Health

Services, Center of Health Statistics, Austin, Texas.

Texas Behavioral Risk Factor Surveillance Public Use Data File, 2018. Texas Department of State Health Services,

Center of Health Statistics, Austin, Texas.

● 5.3 percent of white adults and 2.3 percent of Hispanics reported currently

using ENDS products. There was not sufficient sample size to yield reliable

estimates for Black respondents or respondents identifying as

other/multiracial.

● The highest prevalence of ever using ENDS in Texas was among adults ages

18 to 29 years (36.6 percent).

● In Texas, current cigarette smokers were the most likely to report having

tried (52.9 percent) and currently using (11.3 percent) ENDS products.

Among former smokers, 24.2 percent reported having ever tried ENDS

products and 5.5 percent reported currently using ENDS. Among those who

never smoked, 9.0 percent reported having tried ENDS and 1.3 percent

reported currently used ENDS.

Youth Use of ENDS

Nationally, in 2018, the CDC estimated that 20.8 percent of high school students

and 4.9 percent of middle school students had used ENDS products in the past

month.

The 2020 Texas Youth Tobacco Survey (YTS) provides the latest figures, below, on

the prevalence of ENDS use among youths in Texas.

Additional data is available in

Appendix B.

● 21.1 percent of middle and high school students in Texas reported having

used or tried ENDS in 2020. This is similar to the percent of Texas students

in 2018 (22.8 percent) and 2016 (25.4 percent).

● 11.1 percent of middle and high school students in Texas reported using

ENDS in the past month, which is also similar to previous years.

● 27.2 percent of Texas high school students reported ever using ENDS. For

students in 12

grade, 31.8 percent reported having ever used ENDS.

● The proportion of Texas middle school students ever using ENDS was 13.5

percent.

● The prevalence of having ever used conventional cigarettes was 19.9 percent

among high school and 10.0 percent among middle school students.

Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic

Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR

Morb Mortal Wkly Rep 2018;67:1276–1277. DOI: dx.doi.org/10.15585/mmwr.mm6745a5external icon.

Texas Youth Tobacco Survey (YTS), 2020, Texas A&M University, College Station, Texas.

Texas Youth Tobacco Survey (YTS), 2016, Texas A&M University, College Station, Texas.

Texas Youth Tobacco Survey (YTS), 2018, Texas A&M University, College Station, Texas.

● 14.3 percent of Texas high school students reported using ENDS in the past

month compared to 7.1 percent of middle school students.

● 11.3 percent of males and 10.5 percent of female students in Texas reported

use of ENDS in the past month.

● 25.8 percent of white students in Texas reported ever using ENDS, compared

to 20.1 percent of Hispanic students, 14.4 percent of Black students, and

21.0 percent of students reporting other race/ethnicity.

● 13.9 percent of white students in Texas reported using ENDS in the past

month, compared to 10.7 percent of Hispanic students, 6.7 percent of Black

students, and 10.5 percent of students reporting other race/ethnicity.

● Comparatively, the past month use of conventional cigarettes among high

school and middle school students in Texas was 5.7 percent and 3.3 percent,

respectively.

● Due to the sampling method used to conduct the YTS, regional-level data is

not available (Appendix B, Table 1).

ENDS Use Among Conventional Tobacco Users

DSHS used the 2019 Texas BRFSS survey results to better understand the dual use

of ENDS and cigarettes.

● 52.9 percent of current smokers in Texas reported having used or tried an

ENDS product.

● The prevalence of current ENDS use was two times higher among current

smokers (11.3 percent) than former smokers (5.5 percent).

● Current smokers were significantly more likely to report having used or

currently be using ENDS than former smokers or people who have never

smoked.

5. DSHS E-Cigarette Controls and Initiatives

The Texas Department of State Health Services (DSHS) follows Centers for Disease

Control and Prevention’s (CDC) Best Practices for Comprehensive Tobacco Control

Programs, which treats Electronic Nicotine Delivery Systems (ENDS) the same way

as conventional tobacco products in its tobacco control efforts. DSHS also includes

ENDS education and prevention in existing outreach efforts.

Current Initiatives

E-Cigarettes and Vaping Associated Lung Illnesses

In August 2019, a cluster of severe and unusual lung illnesses was reported to the

Centers for Disease Control and Prevention (CDC). The symptoms of this unknown

illness included cough, shortness of breath, chest pain, nausea, vomiting, stomach

pain, diarrhea, fever, chills, and weight loss. After the initial reports, similar cases

occurred in all 50 states, many resulting in hospitalization and even death. A joint

investigation between state and local health departments, with the support of CDC

and the Food and Drug Administration, determined that the lung illnesses were

likely associated with a chemical exposure. These unknown lung illnesses were

linked to ENDS and became known as e-cigarettes and vaping associated lung

illnesses (EVALI).

As of September 2020, there have been 262 confirmed or probable EVALI cases

reported in Texas. A person with a confirmed case of EVALI must have used an

ENDS within 90 days prior to symptom onset and have a chest x-ray that showed

an abnormality in the lungs not caused by a lung infection. A person classified as a

probable case of EVALI meets the same criteria as a confirmed case, however, a

lung infection was also identified. Of the 262 Texas cases, 139 were classified as

confirmed cases and 123 as probable cases. Four deaths were reported in Texas.

Information on case characteristics and demographic data are in Appendix A.

The CDC has identified vitamin E acetate as a chemical exposure of concern among

people with EVALI. CDC testing of lung fluid samples from 51 patients with EVALI

Regional and local health departments, and medical facilities reported possible cases of EVALI to DSHS

Environmental Surveillance and Toxicology Branch (ESTB). ESTB staff reviewed EVALI case report forms and

patient medical records, and conducted follow-up with the reporting person or health department or medical facility

for additional information. DSHS followed CDC surveillance case definitions to classify reported cases as confirmed

or probable EVALI.

from 16 states found vitamin E acetate in 94 percent of the samples. In

comparison, no vitamin E acetate was found in 99 samples submitted from nicotine

e-cigarettes users, tobacco smokers, and nonusers enrolled in a separate tobacco

study. Vitamin E acetate might be used as an additive, most notably as a thickening

agent in THC-containing e-cigarette, or vaping, products.

DSHS continues to receive reports of possible EVALI cases. Staff evaluate case

reports and conduct follow-up to request missing information or medical records

necessary to determine a probable or confirmed case.

DSHS-Funded Community Coalitions

In 2018, DSHS awarded funds to three organizations to organize and operate

comprehensive community coalitions in six counties for five years, from September

1, 2018, to August 31, 2023. Comprehensive community coalitions follow the CDC’s

Best Practices for Comprehensive Tobacco Control Programs and the Substance

Abuse Mental Health Services Administration’s Strategic Prevention Framework to

create the following six goals:

● Prevent tobacco use among young people

● Ensure compliance with state and local tobacco laws with adequate

enforcement

● Increase cessation among young people and adults

● Eliminate exposure to secondhand smoke

● Reduce tobacco use among populations with the highest burden of tobacco

related health disparities

● Develop and maintain state and community capacity for comprehensive

tobacco prevention and control

The coalitions have adapted their outreach to integrate ENDS education into various

platforms and tailor their strategy based on the audience. The total impact of the

coalitions outreach efforts is outlined in Appendix C, Table 1 and Figures 1-3. In

Fiscal Year 2019, the coalitions adopted the Stanford Prevention Toolkit curriculum.

This curriculum focuses on both conventional and emerging tobacco products

including ENDS.

Blount, B. C., Karwowski, M. P., Shields, P. G., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., & Corstvet,

J. (2020). Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. New England Journal of

Medicine, 382(8), 697-705.

Regional Coordinators

DSHS has eight Regional Tobacco Coordinators, covering all DSHS Public Health

Regions (PHRs) who work to promote Tobacco Prevention and Control branch

programs to areas without a local health department. Regional Tobacco

Coordinators are tobacco subject-matter experts and provide education on ENDS to

PHR staff, including nurses and community health workers, at local health

departments. They also provide education to multiple community-based stakeholder

organizations, including school districts, School Health Advisory Councils, worksites,

youth organizations, healthcare organizations, community-based coalitions, and law

enforcement.

Local Policies and Environmental Strategies

DSHS contracts with the University of Houston to maintain the Texas Smoke-Free

Ordinance Database website. This website tracks and details all known Texas

municipal ordinances enacted to reduce or eliminate exposure to secondhand

smoke. Local communities may create reports from the database when reviewing

local ordinances.

The University of Houston examines the five general settings that local ordinances

may cover: municipal worksites, private worksites, restaurants, bars in restaurants,

and bars not in restaurants. Ordinances designating all five settings as smoke-free

are categorized as strong or 100 percent smoke-free; those with three or more

smoke-free settings are classified as moderate smoke-free; and no smoke-free

settings or lack of an ordinance are classified as not smoke-free. The rating process

also examines ordinances to see if their definition of smoking includes ENDS.

Currently, there are 90 cities in Texas that have comprehensive smoke-free

ordinances as evaluated by the University of Houston.

At the end of fiscal year

2020, 60 percent of the Texas municipal population live in communities with strong

smoke-free policies, and 69 percent of the population live in areas with moderate

smoke-free policies.

The DSHS-funded community coalitions have educated their local communities

about comprehensive local ordinances. Since September 2019, 14 cities in coalition

areas have passed ordinances, and all include language regarding ENDS.

University of Houston Law Center Health Law & Policy Institute. (2020). Texas Smoke-Free Ordinance Database.

shsordinances.uh.edu/

Texas Tobacco Quitline

The Texas Tobacco Quitline (TTQL) is a free cessation hotline offered to all Texans.

TTQL offers phone and web counseling support to Texans 13 years of age or older

and free nicotine replacement therapy to select participants 18 years of age and

older. TTQL is available to help Texans quit all tobacco products, including ENDS.

Texas Youth Tobacco Prevention – Say What!

DSHS funds the Texas School Safety Center at Texas State University to lead the

Say What! (Students, Adults, and Youth Working Hard Against Tobacco) program

that is implemented in 344 middle and high schools. Developed in 2011, Say What!

has several initiatives that have incorporated ENDS education and awareness. Say

What! works with a Texas Youth Advisory Board (Teen Ambassadors) made up of

15-25 high school and college students from across Texas. Teen Ambassadors

provide guidance to the statewide Say What! program and educate peers, adults,

and stakeholders on the harmful effects of tobacco and ENDS use. Say What! also

offers several free resources to assist registered Say What! groups in their local

tobacco and ENDS prevention efforts. These resources include mini-grant kits, or

projects-in-a-box, consisting of educational materials that connect tobacco and

ENDS prevention messages with the overall statewide prevention messaging.

The free resources offered by Say What! are supported by regional, statewide, and

online trainings. Regional Action Summits focus on training youth to create change

by improving health and well-being while gaining experience and skills to become

leaders in their communities. Summit participants received prevention training to

guide youth and adult partners in increasing awareness and addressing ENDS use

within the community and social settings, including schools. Appendix D, Table 3

outlines total training participants per year.

The annual statewide summer conference focuses on advancing the work of

community and school-based youth groups around tobacco and ENDS prevention.

Educational workshops emphasized educating participants about the emerging body

of research on ENDS. The 2020 annual summer conference was hosted virtually and

primarily focused on ENDS prevention. Throughout the year, online trainings were

focused on ENDS, and Say What! also provided online training modules on the Say

What! website.

Texas College Student Tobacco Prevention - Peers Against Tobacco

Peers Against Tobacco (PAT) is a tobacco prevention program for colleges and

universities in Texas. Also referred to as the College Initiative, the program is

funded by DSHS and is coordinated by The University of Texas at Austin Tobacco

Research and Evaluation Team (UT Austin). PAT aims to reduce the use and

initiation of all tobacco, combustible and alternative tobacco products, including

ENDS, among college and university students ages 18-25 in Texas. The project

works to achieve this by raising awareness about the potential dangers of ENDS,

correcting misperceptions, and improving upon current tobacco-free campus

policies.

During the 2018-2019 school year, 21 schools (19 campuses; two schools have two

participating campuses each) participated in PAT implementation. During the 2019-

2020 school year, 20 schools (22 campuses; two schools each have two

participating campuses) participated in PAT implementation.

The program implements a media campaign to bring awareness to the dangers of

ENDS and other emerging tobacco products. Appendix E, Figure 1 provides an

example of this PAT outreach. Additionally, a college survey is administered every

year to participating schools to assess students’ knowledge, attitudes, and

behaviors related to commercial tobacco products and alternative tobacco products,

including ENDS. The survey was sent to 17 colleges in 2019, and 18 colleges in

2020. See Appendix E.

The Texas College Tobacco Policy Database, maintained by UT Austin, lists the

campus tobacco policies of all institutions of higher education in Texas and rates

each policy based on level of comprehensiveness. Specifically, each school’s policy

is broken down into several smaller components, including if the policies reference

conventional cigarettes, smokeless tobacco, and ENDS, and if advertising/sales

were comprehensively addressed (i.e., prohibited on campus completely). Policies

are also assessed on whether they prohibit ENDS in all indoor areas of any campus

building, on all campus outdoor grounds, and in campus-owned vehicles.

Tobacco Prevention Awareness Campaign

To increase the awareness of dangers associated with ENDS products among youth

and young adults, DSHS Tobacco Prevention and Control Branch (TPCB), with

funding from the Health Services Research Administration and Title V Maternal and

Child Health Services Block Grant Program, implemented a multimedia campaign.

The primary goal of this media campaign was to increase the awareness of the

dangers of vaping among youth, encourage youth to quit vaping, and raise

awareness of the change in tobacco minimum purchase age from 18 to 21 years.

The media campaign began in November 2019 and ran through August 2020.

Messages were created and disseminated about the ingredients found in a vape, the

unknown health effects of vaping, and the realities of nicotine addiction that come

with vaping. The campaign reached youth with a multipronged approach that

included ads on social media platforms, television, radio, and in-person outreach

events at middle schools, high schools, and colleges across the state. In addition to

ad buys and outreach, this campaign also partnered with social media influencers to

create authentic anti-vaping messages and promote peer-to-peer messaging.

Specific tobacco 21 messages were featured at convenience stores to reach the

target populations at point of purchase. These ads ran as pump toppers and in-

store window displays.

Highlights from the media campaign include the following:

● Television ads generated 5,078,000 impressions and total of 9,584 spots

aired during this 8-week media buy.

● 43,563,018 overall campaign social media involvements (i.e., the

combination of clicks on a digital ad or social media post, comments made on

a social media post, shares of a digital ad or social media post, or when a

user watches an entire video on social media).

● 73 percent of young Texans surveyed recalled one of the campaign spots.

Digital ads and influencer postings had the most reach. Of the teens and

young adults surveyed, 75 percent recalled one of the key messages of the

campaign.

● Purchased ads on mobile devices and social media platforms were viewed

over 12 million times and clicked on over 50,000 times.

● Social media posts by influencers garnered almost 60 million views, and their

posts were interacted with (liked, shared, or commented on) over 26 million

times.

● Outreach at schools in all 11 regions was planned but cut short by the

ongoing COVID-19 pandemic. Before school shut downs began, almost

140,000 students and family members were reached at 10 schools and a

University Interscholastic League event.

● Event reach totaled 138,120 people from February 19 through March 12,

2020. Due to the ongoing COVID-19 pandemic, all events after March 13,

2020, were canceled. An example outreach event set up is in Appendix F.

Campaign materials and information about hosting outreach events are available

for public use on the DSHS website. All campaign ads are also available on the

DSHS YouTube channel.

Future Goals and Plans

DSHS TPCB will continue to address ENDS as part of its comprehensive tobacco

control efforts. Specific plans include the following:

● Continue to monitor the tobacco use prevalence to recognize emerging

tobacco products, including ENDS.

● Continue to implement initiatives focused on youth and young adults, such as

Say What! and PAT, to reduce the initiation of all tobacco products in Texas.

● Continue to share information and resources from the state-wide Vapes

Down media campaign on the DSHS vaping website.

● Continue to educate the public on the changes in state and federal law to the

minimum purchase age to buy tobacco products.

● Tobacco prevention and control coalitions and Tobacco Regional Coordinators

will continue to engage trusted adults in their community to discuss the

danger of e-cigarettes and vaping. The coalitions will continue to train

schools to use the Stanford Prevention Toolkit.

● To address current youth tobacco prevalence rates, DSHS will monitor the

available youth cessation services to find an evidence-based program to aid

in youth cessation.

6. Conclusion

Research has yet to identify the long-term health effects of Electronic Nicotine

Delivery Systems (ENDS) use. However, due to increased use among Texas youth

and the potential harms posed by nicotine and other ENDS ingredients, many

national and local public health agencies have implemented policies and programs

to prevent youth use and encourage cessation.

Laws to prevent underage access to ENDS are enforced at the federal level by the

Food and Drug Administration (FDA) under the Tobacco Control Act. The FDA

contracts with states, including Texas, to help enforce federal regulations. At the

state level, retailer inspections for the Tobacco Enforcement Program are conducted

by the Texas Department of State Health Services (DSHS). The Comptroller’s

Criminal Investigation Division (CID) also conducts a limited number of retailer

inspections based on anonymous complaints.

Municipal ordinances place restrictions on exposure to secondhand smoke. The

University of Houston tracks and evaluates these ordinances. DSHS funded

coalitions work to increase the number of cities and municipalities within their

service areas to pass a comprehensive secondhand smoke ordinance.

DSHS supports state and local efforts to educate youth, parents, and young adults

about potential harmful health effects of ENDS use. This is accomplished through

engaging with community coalitions and regional coordinators, education on local

ordinances, coordinating the youth prevention initiatives such as Texas Say What!

program, and Peers Against Tobacco on college campuses and use of media

campaign.

DSHS will continue to make progress to address ENDS use as a part of its

comprehensive tobacco control efforts.

List of Acronyms

Acronym

Full Name

BRFSS

Behavioral Risk Factor Surveillance System

CDC

Centers for Disease Control and Prevention

CID

Criminal Investigative Division

DSHS

Department of State Health Services

ENDS

Electronic Nicotine Delivery Systems

EVALI

E-cigarette and Vaping Associated Lung Illness

FDA

Food and Drug Administration

PAT

Peers Against Tobacco

PHR

Public Health Region

Say What!

Students, Adults, and Youth Working Hard Against Tobacco!

TEP

Tobacco Enforcement Program

THC

Tetrahydrocannabinol

TPCB

Tobacco Prevention and Control Branch

TxSSC

Texas School Safety Center

University of Texas

YTS

Youth Tobacco Survey

A-1

Appendix A. EVALI Data

E-cigarette and Vaping Associated Lung Illness (EVALI) Case

Characteristics

The following statistics further describe the characteristics of the 262 confirmed or

probable cases of EVALI in Texas.

● In 26 percent of cases, those affected were under 18 years of age.

● Cases ranged in age from 13 through 75 years old, with a median age of 22

years.

● Males made up 71 percent of cases.

● Of cases with available substance use information, 89 percent of cases

reported vaping products containing tetrahydrocannabinol (THC), the primary

psychoactive ingredient in marijuana.

● Hospital length of stay ranged from 1 through 87 days, with a mean length of

stay of 8 days.

Table 1: Severe Pulmonary Illness among People Who Report Vaping, by Public

Health Region

Public Health Region

Number of Cases

Percentage

Region 1

2.3

Region 2/3

142

54.2

Region 4/5N

2.3

Region 6/5S

16.4

Region 7

13.0

Region 8

5.34

Region 9/10

1.2

Region 11

5.3

A-2

Table 2. Severe Pulmonary Illness among People Who Report Vaping, by

Demographics

Number

Percentage

Sex

Female

28.6

Male

187

71.4

Race

American Indian or Alaskan

Native

.76

Asian

1.2

Black or African American

1.2

Native Hawaiian or Other

Pacific Islander

White

183

69.9

Other

2.3

Unknown

24.1

Hispanic Ethnicity

Yes

23.3

36.6

Unknown

1.2

Age Group

<=12

0.0

12-17

25.6

18-23

32.8

24-44

36.6

>= 45

5.0

A-3

Table 3. Severe Pulmonary Illness among People Who Report Vaping: Admission to

Hospital

Admission to hospital

Number

Percentage

Yes

258

98.5

1.5

Unknown

0.0

Table 4. Severe Pulmonary Illness among People Who Report Vaping: Admission to

Intensive Care Unit

Admission to Intensive

Care Unit

Number

Percentage

Yes

36.1

118

45.7

Unknown

18.2

B-1

Appendix B. Youth and Adult ENDS Prevalence Rates

Table 1. Percentage of Youth, Grades 6 to 12, who Report Ever and Past Month Use

of Electronic Nicotine Delivery System (ENDS) Products, by Demographic

Characteristics, Texas, 2020.

Data Source: Texas Youth Tobacco Survey (YTS), 2020, Texas A&M University,

College Station, Texas

Students reporting ever having used tried an electronic cigarette.

Students reporting use of an electronic cigarette in the past 30 days.

Demographics

Percent of Ever

ENDS Use

Percent of Past Month

ENDS Use

All Youth

(Grades 6-12)

21.1

11.1

Sex

Male

20.7

11.3

Female

21.1

10.5

Race/Ethnicity

White

25.8

13.9

Hispanic

20.1

10.7

Black

14.4

6.7

Other

21.0

10.5

School Level

Middle School

13.5

7.1

High School

27.2

14.3

Grade

Grade 6

7.6

11.1

Grade 7

13.9

4.0

Grade 8

19.0

7.3

Grade 9

26.3

10.1

Grade 10

27.0

16.0

Grade 11

24.4

11.6

Grade 12

31.8

15.9

B-2

Table 2. Percentage Number and Percentage of Adults, 18 Years and Older, Who Report Ever and Current ENDS Use, by

Demographics, Texas 2019.

Ever ENDS Use

Current ENDS Use

Demographics

Estimated

No. of Adults

Percent

95% CI

Estimated

No. of Adults

Percent

95% CI

All Adults

2,912,773

18.7

17.2 – 20.3

566,003

3.6

3.0 – 4.4

Sex

Male

1,684,187

22.8

20.3 – 25.4

365,419

5.0

4.0 – 6.2

Female

1,228,585

15.0

13.3 – 16.9

200,583

2.5

1.8 – 3.3

Age Group

18 to 29

1,079,391

36.6

31.7 – 41.8

268,356

9.2

7.0 – 12.0

30 to 44

1,017,355

25.6

22.1 – 29.5

182,529

4.6

3.2 – 6.5

45 to 64

606,228

11.7

10.0 – 13.6

80,220

1.6

1.1 – 2.2

65 and older

196,503

6.1

4.7– 7.7

30,501

0.9

0.6 – 1.6

Race Ethnicity

White

1,460,446

21.6

19.5 – 23.7

360,337

5.3

5.3 – 8.6

Black

281,483

18.2

13.4 – 24.2

Hispanic

988,455

16.2

13.7 – 19.1

142,425

2.3

2.2 – 5.0

Other/

Multiracial

143,716

15.5

9.9 – 23.5

Data Source: Texas Behavioral Risk Factor Surveillance Public Use Data File, 2019. Texas Department of State Health Services, Center

of Health Statistics, Austin, Texas.

Respondents who answered “yes” to the question, “Have you ever used or tried an e-cigarette, vape pen, or e-hookah?”

Ever ENDS users who answered “every day” or “some days” to the question “Do you currently use this/these products every day, some

days, or not at all?”

CI: (Confidence Interval) Statistical significance is based upon evaluation of overlap among the 95% confidence intervals, which are

defined as a range of values where there is a specified probability that the value of a parameter lies within it.

B-3

Table 3. Number and Percentage of Adults, 18 Years and Older, Who Report Ever and Current ENDS Use, by

Demographics, Texas 2019.

Ever ENDS Use

Current ENDS Use

Place of

Residence

Estimated

No. of Adults

Percent

95% CI

Estimated No. of

Adults

Percent

95% CI

All Adults

2,912,773

18.7

17.2 – 20.3

566,003

3.6

3.0 – 4.4

Health Service

Region

91,565

19.1

12.5 – 28.2

2/3

762,450

20.1

16.7 – 24.0

170,500

4.3

3.1 – 5.9

4/5N

165,220

17.3

12.9 – 22.8

35,618

4.4

2.6 – 7.5

6/5S

645,809

17.0

13.8 – 20.9

153,822

6.3

3.5 – 11.2

479,650

24.1

20.7 – 27.8

166,852

8.1

5.9 – 11.0

319,475

19.2

15.1 – 24.2

9/10

124,432

15.9

11.5 – 22.5

237,901

18.9

15.2 – 23.3

Data Source: Texas Behavioral Risk Factor Surveillance Public Use Data File, 2019. Texas Department of State Health Services, Center of

Health Statistics, Austin, Texas.

Respondents who answered “yes” to the question, “Have you ever used or tried an e-cigarette, vape pen, or e-hookah?”

Ever ENDS users who answered “every day” or “some days” to the question “Do you currently use this/these products every day, some

days, or not at all?”

CI: (Confidence Interval) Statistical significance is based upon evaluation of overlap among the 95% confidence intervals, which are defined

as a range of values where there is a specified probability that the value of a parameter lies within it.

B-4

Table 4. Number and Percentage of Adults, 18 Years and Older, Who Report Ever and Current ENDS Use, by Smoker Status,

Texas 2019.

Ever ENDS Use

Current ENDS Use

Smoker Status

Estimated No.

of Adults

Percent

95 % CI

Estimated

No. of Adults

Percent

95 % CI

All Adults

2,912,773

18.7

17.2 – 20.3

566,003

3.6

3.0 – 4.4

Smoker Status

Current Smoker

1,217,551

52.9

47.7 – 58.1

256,691

11.3

8.5 – 14.7

Former Smoker

805,236

24.2

21.0 – 27.8

181,709

5.5

4.0 – 7.5

Never Smoker

887,978

9.0

7.6 – 10.6

126,363

1.3

0.9 – 1.8

Data Source: Texas Behavioral Risk Factor Surveillance Public Use Data File, 2019. Texas Department of State Health Services,

Center of Health Statistics, Austin, Texas.

Respondents who answered “yes” to the question, “Have you ever used or tried an e-cigarette, vape pen, or e-hookah?”

Ever ENDS users who answered “every day” or “some days” to the question “Do you currently use this/these products every day, some

days, or not at all?”

CI: (Confidence Interval) Statistical significance is based upon evaluation of overlap among the 95% confidence intervals, which are defined

as a range of values where there is a specified probability that the value of a parameter lies within it.

B-5

9.0

24.2

52.9

18.9

15.9

19.2

24.1

17.0

17.3

20.1

19.1

15.5

16.2

18.2

21.6

6.1

11.7

25.6

36.6

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Never Smoker

Former Smoker

Current Smoker

Region 11

Region 9/10

Region 8

Region 7

Region 6/5S

Region 4/5N

Region 2/3

Region 1

Other/Multiracial

Hispanic

Black

White

65 and older

45 to 64

30 to 44

18 to 29

Graph 1. Percentage of Adults, 18 Years and Older, who Report Ever ENDS Use,

by Demographics, Place of Residence, and Smoker Status, Texas 2019

Prevalence of Ever ENDS Users

B-6

Graph 2: Trends in use of Electronic Nicotine Delivery Systems Texas Adults, 2015-2019

Source: Texas Behavioral Risk Factor Surveillance Public Use Data File, 2015-2019. Texas

Department of State Health Services, Center of Health Statistics, Austin, Texas.

Graph 3: Trends in Use of Electronic Nicotine Delivery Systems among Texas Youth,

2012-2020

Source: Texas Youth Tobacco Survey (YTS), 2012-2020, Texas A&M University,

College Station, Texas

10%

15%

20%

25%

2015 2016 2017 2018 2019

Current ENDS use Ever ENDS use

10%

15%

20%

25%

30%

2012 2014 2016 2018 2020

ENDS use past month ENDS use ever

C-1

Appendix C. Tobacco Prevention and Control Coalitions

C-2

Figure 1: Coalition Social Media Screenshot

C-3

Figure 2 and 3: Coalition Print Media

C-4

Table 1: Coalition ENDS Outreach Impact

List of Activities

Reporting Year

Goal 1: Prevention

September 1, 2018 -

August 31, 2019

September 1, 2019 -

August 31, 2020

# of ENDS educational materials

disseminated to the public

5,553

13,177

# of in-person ENDS

presentations conducted for

youth

203

# of youth attending ENDS

presentations

2,789

13,058

# of in-person ENDS

presentations conducted for

adults

# of adults attending ENDS

presentations

899

1,891

# of unique media messages

have been created for the public

188

291

Goal 2: Enforcement &

Compliance

May 1, 2019* - August

31, 2019

September 1, 2019 -

August 31, 2020

# of total controlled buys

conducted (any tobacco product

purchase attempted)

4,241

13,276

# of controlled buys conducted

(ENDS purchase attempted)

1,755

5,161

Goal 3: Increase Cessation

September 1, 2018 -

August 31, 2019

September 1, 2019 -

August 31, 2020

# of worksite consultations

conducted that included

information about ENDS

104

# of healthcare consultations

conducted that included

information about ENDS

Goal 4: Secondhand Smoke

September 1, 2018 -

August 31, 2019

September 1, 2019 -

August 31, 2020

# of communities educated about

including ENDS in their smoke-

free policies

# of communities that have

adopted a smoke-free ordinance

that includes ENDS

# of worksites have adopted a

new policy to include ENDS

C-5

List of Activities

Reporting Year

# of worksites have changed

their existing worksite policy to

include ENDS

D-1

Appendix D. Say What!

Table 1: Say What! ENDS Social Media Reach 1/1/2019 - 8/31/2020*

Platform

Total Reach (Youth and Adults Combined)

Instagram

5652

Facebook

17214

Twitter

439

YouTube

672

* Say What! does not promote any social media posts; all reported reach is earned without

monetary sponsorship (organic reach).

D-2

Figure 1: Say What! Social Post

D-3

Table 2: Say What! Action Summit Metrics by Year

Description

September 1, 2018 – August

31, 2019

September 1, 2019 –

August 31, 2020

Number of summits

conducted

Number of youth

attending the

summits

594

207

Number of adults

attending the

summits

148

Total number of

summit participants

742

301

*one in-person event and one virtual event to account for the four scheduled Action Summits that

were canceled due to COVID-19 restrictions.

Table 3: Texas Tobacco-Free Conference Metrics by Year

Conference Metric

2019 Conference (July 28-

31, 2019)

2020 Virtual Conference

(July 26-27, 2020)

Number of Youth

Groups

Number of Youth

Participants

161

158

Number of Adult

Participants

118

175

Total number of

Participants

279

333

E-1

Appendix E. Peers Against Tobacco

College Survey

A college survey is administered every year to participating schools to assess

students’ knowledge, attitudes, and behaviors related to tobacco products and

alternative tobacco products, including ENDS. The survey was sent to 17 colleges in

Spring 2019, and 18 colleges in Spring 2020. In academic year 2018-2019, a total

of 8,363 complete responses from students ages 18-29 were received. Participants

were predominately female (63.1 percent), white (66.5 percent), and 1

year

undergraduates (27 percent).

● In 2018-2019 academic year, 32.2 percent of students reported ever having

used ENDS.

● In academic year 2019-2020, a total of 17,156 complete responses from

students ages 18-29 were received. Participants were predominately female

(61.4 percent), white (65.3 percent), and 1

year undergraduates (25.5

percent).

● In 2019-2020 academic year, 49.3 percent of students reported ever having

used ENDS.

● For current use (in the last 30-days), in 2018-2019 academic year the most

prevalent products used by respondents were ENDS (45.6 percent), cigars

(26.9 percent), conventional cigarettes (26.6 percent), and smokeless

tobacco (21.9 percent).

● For current use (in the last 30-days), in 2019-2020 academic year the most

prevalent products used by respondents were ENDS (46.1 percent),

smokeless tobacco (31.6 percent), conventional cigarettes (30.8 percent)

and cigars (25.2 percent).

Table 1: Peers Against Tobacco ENDS Social Media Reach 1/1/2019 - 8/31/2020

Platform

Organic Reach

(prior to 9/1/2019)

Promoted Reach

(after 9/1/2019)

Total

Reach

Instagram

835

73,000

73,835

Facebook

947

400,000

400,947

Twitter

86,000

E-2

Figure 1: Peers Against Tobacco (PAT) Better Bad Habit Campaign Print Ad

F-1

Appendix F. Vapes Down Media Campaign

Figure 1. Picture of Vapes Down Campaign School Outreach Tour at Westlake High

School in Austin, Texas