Dr. Amanda Graham Takes on the E-Cigarette Epidemic

Amanda L. Graham, PhD '99, MS '95, is in the vanguard of researchers who are taking on the e-cigarette epidemic, the latest front in the battle for tobacco control.

While smoking, or combusted tobacco use, is no longer the norm — down from nearly 50 percent among adults in the 1960s to about 14 percent today — youth e-cigarette use, also called vaping or Juuling, has been declared an epidemic by the surgeon general. E-cigarette use increased by 78 percent among high school students and 50 percent among middle schoolers from 2017 to 2018, according to the 2018 National Youth Tobacco Survey. Battery-operated e-cigarettes or vape pens are now used by 3.6 million young people to inhale nicotine and non-nicotine solutions, including cannabis.

"The tragedy is that 20 percent of high school kids are now using e-cigarettes — exposing themselves to nicotine at a very young age, which we know is harmful for a developing brain," Dr. Graham said. "Kids who start with an e-cigarette are four times more likely to become cigarette smokers."

Dr. Graham is senior vice president of the Innovations Center at Truth Initiative in Washington, DC, the largest nonprofit public health organization in the United States dedicated to tobacco control. In early 2019, Dr. Graham and her team launched This is Quitting, a text message program for young people who want to quit vaping. Created with input from teens and young adults, the program delivers proactive prompts tailored by age group, including customized support and information on quitting. It also serves as a resource for parents, more than 3,000 of whom enrolled after the platform was featured by NBC's "Today" show on Jan. 18.

More than 30,000 young people between the ages of 13 and 24 enrolled within 24 hours after the program was highlighted by Mashable on its Snapchat channel. More than two-thirds of those enrolled have set a quit date, and the most common quit date is the day they enroll. Early outcome data — both quit rates and qualitative feedback from users — show the program's potential impact.

"We were stunned at the response," said Dr. Graham. "We knew that digital platforms and social networks are how young people get information and connect with peers. But the volume of young people that enrolled that first day is likely the tip of the iceberg of kids who are addicted and desperate to find something to help them quit."

Young people confront a confusing message about vaping, which is marketed as both an alternative to smoking and a cessation tool. Is it safe?

"The data are clear: Young people should not use nicotine," Dr. Graham said. "Their brains are still growing — up until about age 25 — and early use of nicotine puts them at risk for addiction, both to nicotine and other drugs. Although e-cigarettes are safer than combusted cigarettes, they are not safe, and it's important for kids to know that. As for e-cigarettes as a way for adults to quit smoking, there is research emerging every day. The most important thing is to quit smoking entirely — there's no health benefit to vaping and smoking. If adults can't quit smoking with a combination of behavioral support and medication, e-cigarettes may be helpful and are a safer alternative."

Dr. Graham faced a tough decision in choosing her graduate school path: A large university had offered a full ride, but she chose RFU, where she earned a master's degree and PhD in clinical health psychology.

"I was drawn by the smaller class size, by the Chicago Medical School's smaller labs, the individual attention and ability to create and shape my own program of research," she said.

After a postdoctoral fellowship and seven years in the Department of Psychiatry at Brown University's medical school in Providence, RI, Dr. Graham relocated to Washington, DC, in 2006. In 2008, she faced another tough career decision: stay in a tenure-track position at Georgetown University Medical Center or help build a new research institute at the American Legacy Foundation, now the Truth Initiative. She took on the new challenge. The Schroeder Institute for Tobacco Research and Policy Studies at Truth Initiative grew over the next five years under her leadership, and Dr. Graham's program of research on digital smoking cessation interventions flourished with NIH funding. In addition to This is Quitting, Dr. Graham and her team run BecomeAnEX, a free, digital quit-smoking program developed in collaboration with Mayo Clinic, which has helped more than 800,000 individuals on their quitting journey. Based on the success of BecomeAnEX, they launched the enterprise EX Program, designed specifically for health plans and employers, for whom one smoking employee poses an additional annual cost of $6,000.

Truth Initiative's quit-smoking suite of resources is centered around mobile platforms, social community and personalization.

"We know that social connections and social media content are sticky — the reason people keep coming back to online interventions," Dr. Graham said. "We've designed our programs around those powerful human connections — whether they are one to one through digital coaching or with a group of people in an online community — and deliver them in a way that is convenient and accessible through a digital platform. We see every day in the EX Community the real impact that these connections have in helping people to quit smoking, and our research confirms these observations."

Dr. Graham, who is an adjunct professor of oncology at Georgetown University Medical Center and a member of the university's Lombardi Comprehensive Cancer Center, is investigating digital smoking cessation interventions through a variety of NIH-funded grants.

"What we learn from our federally funded research and ongoing program evaluations is folded back into our products for the benefit of our users, whether they arrive at our programs via a Google ad or the encouragement of their employer," Dr. Graham said. "That's the R&D cycle that makes this work truly exciting and gratifying to me: build, measure and learn, all while helping people free themselves from a really tenacious addiction."

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