For the CBIs listed that did not mention use of a broad theory , but mentioned using a specific construct or technique, all provided a description of how it was applied in the intervention ; however the amount and quality of information provided about the application of the construct/techniques varied considerable across this group of CBIs.Of the 21 CBIs that mentioned use/application of theory , all but two included at least one measure of a construct associated with the theory. If a CBI mentioned use of a theory, it was more likely to include a measure of specific constructs associated with the theory compared to CBIs that did not mention use of a broad theory. Specifically, of the CBIs, that did not explicitly mention use of a theory, but did include a specific construct, only five included corresponding measures of the theoretical construct . Tables 1 and 2 lists the classification of each CBI and provides a list of the measure associated with the theory, construct or intervention technique.This study identified 100 unique articles covering 42 unique computer-based interventions aimed at preventing or reducing alcohol use among adolescents and young adults.Thus, this review includes a total of 21 new CBIs and 43 new articles. This review is the first to provide an in-depth examination of how CBI’s integrate theories of behavior change to address alcohol use among adolescents and young adults. While theories of behavior change are a critical component of effective interventions that have been developed and evaluated over the past several decades,cannabis equipment attention to the application of theory in CBIs has been limited. We utilized a simple classification system to examine if theories were mentioned, applied or measured in any of the publications that corresponded with the CBIs.
Only half of the CBIs reviewed mentioned use of an overarching, established theory of behavior change. The other half mentioned used of a single construct and/or intervention technique but did not state use of a broader theory. CBIs that were based on a broad theoretical framework were more likely to include measures of constructs associated with the theory than those that used a discrete construct or intervention technique. However, greater attention to what theory was used, articulating how theory informed the intervention and including measures of the theoretical constructs is critical to assess and understand the causal pathways between intervention components/mechanisms and behavioral outcomes . When mentioning the use of a theory or construct, almost all provided at least some description of how it informed the CBI; however, the amount and quality of information about how the theory was applied to the intervention varied considerably. Greater attention to what is inside the “black box” is critical in order to improve our understanding of not only what works, but why it works. While a few articles provided detailed information about the application of theory, the majority included limited information to examine the pathway between intervention approach and outcomes.Some researchers/intervention developers may not fully appreciate how theory can be used to inform intervention approaches. There is an emphasis on outcomes/effectiveness of interventions and less attention is placed on their development. In addition, to our knowledge, there are no publication guidelines/standards for describing the use of theoretical frameworks in intervention studies and the inclusion of this information is often up to individual authors and reviewers. Given the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed in publications. The classification system used in this review provided some form of personalized normative feedback and applied it relatively consistently across the CBIs.
Personalized normative feedback is designed to correct misperceptions about the frequency and acceptability of alcohol use among peers. It typically involves an assessment of a youth’s perceptions of peer norms around alcohol attitudes and use followed by tailored information about actual norms. In addition, some interventions have recently incorporated personal feedback to address individual’s motivations to change through assessing and providing feedback on drinking motives or in decisional balance exercises.The widespread use of personalized normative feedback in CBIs may be because it has been widely documented as an effective strategy and because it lends itself readily to an interactive, personalized computer-based intervention. Motivational interviewing was also used in several of the CBIs and is an effective face-to-face counseling technique. In contrast, this technique was applied to CBIs in a number of different ways, such as exercises designed to clarify goals and values, making both the description of how it was applied even more essential to examine differential effectiveness across various CBIs. This study builds on the growing evidence supporting the use of CBIs as a promising intervention approach. We found most of the CBIs improved knowledge, attitudes and reduced alcohol use among adolescents and young adults. In addition, this study suggests CBIs that use overarching theories more frequently reported significant behavioral outcomes than those that use just one specific construct or intervention technique . This finding is consistent with prior studies examining the use of theory in face to-face interventions targeting alcohol use in adolescents. However, it is important to acknowledge the wide variation across the CBIs not only in their use of theory, but in scope, the targeted populations, duration/dosage, and measured outcomes. It is encouraging that even brief/targeted CBIs demonstrated some effectiveness and thus can play an important role in improving knowledge and attitudes, which are important contributors to changes in behavior. There are limitations to this study.
As discussed previously,vertical grow shelf many articles did not explicitly describe how theory was applied in the CBI. It is therefore possible that the theoretical pathways for the intervention were further developed than we have noted, and possibly included in other documents, such as logic models and/or funding applications; however, such information is not readily accessible and was outside the scope of this review. Thus, lack of mention of the name of a theory or construct or its application does not mean that the intervention did not integrate the theory in the intervention, only that the article did not provide information about its application. Thus, due to variations in the described use of theory along with the wide range of CBIs, it was not possible to draw comparisons about the relative effectiveness of CBIs according to the theory used.This review spanned articles published between 1995 and 2014. During this period, CBIs to address health issues have been rapidly evolving due to major advancements in technological innovations . These advancements coupled with greater interest and investments from federal agencies and philanthropic foundations.Electronic cigarettes are battery-powered devices that aerosolize e-liquids, which typically contain propylene glycol and vegetable glycerin , nicotine, flavors, and stabilizers/humectants such as triacetin.Although it is well known that combustible cigarettes cause multiple cardiovascular and pulmonary diseases, the effects of e-cigarettes on health have only begun to be studied. Alarmingly, there has been a rapid increase in e-cigarette use among adolescents and young adults, who could potentially be exposed to e-cigarette aerosols for decades if their use is lifelong.Indeed, the US Surgeon General concluded that the use of e-cigarettes among youth and young adults has become a major public health concern.A recent European Respiratory Society task force concluded that since the long-term effects of e-cigarettes are unknown, it is not clear whether they are in fact safer than tobacco and based on current knowledge, their negative health effects cannot be ruled out.In the USA, the Family Smoking Prevention and Tobacco Control Act of 2009 gave the Food and Drug Administration the power to regulate tobacco products. While e-cigarettes were not covered in the original act, the FDA has clarified its position with its “deeming” rule, and since 2016, has begun to exert its regulatory authority over e-cigarettes and other noncombustible products. In 2020, in response to the growing popularity among youth, the FDA issued a policy to limit the sales of some flavored e-cigarette products.As the FDA adheres to a public health impact standard, evidence on adverse health effects of e-cigarettes will be a consideration to impact on future sales of e-cigarettes and e-cigarette liquids. Such a regulation will likely be contingent upon their observed health effects, as well as effects on nicotine addiction.
In addition, the recent emergence of acute and severe e-cigarette, or vaping, product use-associated lung injury across the US underscores the need, complexity, urgency, and importance of basic and clinical research on the health effects of e-cigarettes, particularly focused on cardiopulmonary systems.With regard to public health impact and cardiopulmonary health, availability and use of e-cigarettes might benefit those who switch from combustible cigarettes to e-cigarettes, that is, harm reduction. However, the potential benefits from the use of these products are uncertain: they deliver a poorly defined, highly variable, and potentially toxic aerosol that may have adverse effects, which may be dependent on patterns of age, reproductive status, health of the user, and use. In addition, there are major public health concerns surrounding the availability of e-cigarettes for children, adolescents, and young adults.Nicotine addiction is of particular concern and the use of e-cigarettes is positively associated with increased risk of use of combustible cigarettes.These issues complicate the question of how e-cigarettes might impact cardiopulmonary health and are explored further in the later sections of this review. Recognizing the potential health impact of e-cigarettes when they first emerged, particularly impacting the heart and lung, the Division of Lung Diseases and the Division of Cardiovascular Sciences at the NIH’s National Heart, Lung, and Blood Institute conducted a workshop in the summer of 2015 entitled “Cardiovascular and Pulmonary Disease and the Emergence of E-cigarettes”, to identify key areas of needed research as well as opportunities and challenges of such research. The workshop was organized around a framework recognizing that the public health impact of e-cigarettes would be influenced by a complex network of factors in addition to direct health and biological effects, including device characteristics, chemical constituents , aerosol characteristics, and use patterns. In response to the significant gaps and research areas highlighted at the workshop, NHLBI subsequently directed research funding to projects aimed at understanding the cardiopulmonary health effects of e-cigarettes and inhaled nicotine. Funded investigators met in 2018, 2019, and 2020 to discuss their results, findings in the larger field, and remaining scientific questions. The focus of this review is the result of discussions recognizing a need for further understanding of cardiopulmonary health effects of e-cigarettes that occurred at these NHLBI-supported workshops and investigator meetings. This review takes a holistic view of e-cigarette use and cardiopulmonary health, with a major focus on the USA. A summary of the current understanding of the multitude of factors that ultimately affect health, including policies, behaviors, emissions, and biological effects associated with e-cigarette use, is provided herein, with the ultimate goal of identifying key research gaps that remain in the field. E-cigarettes inhabit a rapidly changing marketplace and an evolving pattern of use that typically precedes scientific exploration. Following a PubMed search for relevant literature using “e-cigarette” and/or “cardiopulmonary” and/or “pulmonary”, and/or “cardiovascular disease” as search terms, we break down the pertinent fields to uncover critical research questions that will better enable an understanding of how e-cigarettes affect cardiopulmonary health at an individual and community level.E-cigarettes are highly variable in design, and are comprised of a battery, a reservoir for holding the e-liquid, a heating element, an atomizer, and a mouthpiece. The first generation of e-cigarettes were similar in size and shape to combustible cigarettes. First-generation devices typically used a prefilled nicotine solution cartridge that directly contacted the heating element. Many second-generation devices were penshaped; some included refillable cartridges, while others were closed systems that held only prefilled sealed cartridges. Third generation devices were called “mods” since they are easily modified. They were more diverse, and featured customizable atomizers, resistance coils, and larger-sized batteries capable of heating made-to-order e-liquids to higher temperatures to create more aerosol and potentially deliver more nicotine.Fourth generation devices were smaller and some resembled familiar items such as USB drives. Their sleek design and ease by which they can be concealed from parents and teachers have contributed to their growing popularity in school-age children. These e-cigarettes operate at lower wattages than third generation devices.