Prevention Science, with Jessica Braymiller Knapp

Join us for an enlightening conversation with Jessica Braymiller Knapp, PhD, an expert in prevention science and a dedicated tobacco researcher. Dive into the core of addiction, prevention science, and more.

Jessica L. Braymiller (she/her) is a clinical assistant professor and public health researcher focused on understanding nicotine and cannabis use among adolescents and young adults. Her current work centers on e-cigarette use/vaping and associated health outcomes, other emerging modes of tobacco and cannabis delivery, and device characteristics that facilitate initiation and continued use of both substances. Prior to joining the faculty in Community Health and Health Behavior, Dr. Braymiller was a postdoctoral scholar at the University of Southern California in the Tobacco Center of Regulatory Science. Dr. Braymiller completed her PhD in Biobehavioral Health and her MS in Biobehavioral Health at The Pennsylvania State University. She received her BA in Psychology from Mercyhurst University.

Credits:
Hosts/Writer: Sarah Robinson, MPH 
Guest:  Jessica Braymiller Knapp, MS, PhD
Production Assistant/Audio Editor: Sarah Robinson, MPH 
Theme Music: Dr. Sungmin Shin, DMA 

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Transcript

Sarah Robinson  0:13 
Okay, hi. Welcome to another episode of Buffalo HealthCast. I'm your host, Sarah Robinson. And I'm here today with Dr. Jessica Braymiller Knapp. She's going to talk to us about prevention science. So just to start, can you share a little bit about your background, your primary research interests, and then just give a fun fact about yourself?

Jessica Braymiller Knapp  0:30 
Sure. So I am a Clinical Assistant Professor in Community Health and Health Behavior in the School of Public Health and Health Professions. I got my PhD in biobehavioral health from Penn State, and really my degree focused on how various biological, psychological, and behavioral and social factors impact health broadly. But the focus of my dissertation research was really on tobacco use behaviors, and substance use behaviors more broadly, specifically, in adolescence and young adulthood. I guess when I started my dissertation, e-cigarettes started to become very popular. So at the time I was in graduate school, e-cigarette use had just surpassed cigarette use among adolescents as the most popular product. So I became really interested in why that was, and what we could do to kind of prevent a new young generation from being hooked on another different nicotine product. So my focus was on that during graduate school, and you know, then I moved on in my postdoc training and went to the University of Southern California. They have a Tobacco Center of Regulatory Science. So all of their research really focuses on that exact problem. So how can we gain a big evidence base for why adolescents and young folks are using tobacco products and use it for good and to kind of create policies and regulations, or I guess, inform policies and regulations about tobacco use broadly. So I'm still engaged in some of that work now, here at UB. But most of my time is spent teaching. So I teach in the Master of Public Health program here. I teach the Addictions course, that focuses on understanding public health perspectives on addiction science and the development of substance use behaviors and disorders. And really social ecological perspectives on how we can understand and treat substance use disorders. Fun fact. So a fun fact about me is I actually grew up here in Buffalo. So it was really special to be able to come back and work at UB now. And be back in the town I grew up and close to family. So it's been really great. Being back and being a part of this community.

Sarah Robinson  2:58 
Awesome. Well, we're glad to have you back. Was it always a goal to come back to Buffalo? Or were you just open to going wherever your research took you?

Jessica Braymiller Knapp  3:06 
Yeah, it wasn't always a goal. I became more interested in the department here - Community Health and Health Behavior, because I saw a job posting, and it really sounded familiar in terms of my graduate training. So I like that our department in our school really has a biopsychosocial approach to health. And that's what my training was in. And it attracted me to this department into this program. And it felt like home for a number of reasons. So it just felt right to come back. But I wouldn't say it was always my goal to be back in the area.

Sarah Robinson  3:49
Nice. Well, I'm glad that you came back. I actually had Dr. Braymiller for many of my courses in the MPH program. And I also took your Addictions course. So as an instructor for our Addictions course at UB, you're clearly very familiar with how addiction works and what methods we use in public health to combat substance use disorders. As a tobacco researcher, you primarily study prevention science. So can you explain what prevention science is?

Jessica Braymiller Knapp  4:17
Yeah, so prevention science is essentially a field of research that focuses on building the evidence base for the development of prevention and intervention efforts that ultimately reduce risk factors and enhance protective factors to improve health and wellbeing, and it's a pretty diverse field in terms of who's involved in this type of research. It's really multidisciplinary, but it's also diverse in the terms of, you know, the specific health outcomes that are studied and the social and health outcomes that are studied. But prevention science can be the development of evidence based public policies, it can be the development and implementation of prevention and intervention programs and their evaluation. It can be the implementation of evidence based practices and healthcare settings. So it can be a lot of different things.

Sarah Robinson  5:14 
Do you have any examples of specific ways that you're studying prevention science right now?

Jessica Braymiller Knapp  5:18 
Right now my research is focusing on college student populations in general, and how instructors and other university figures or settings can enhance college student mental health and well being in a variety of ways. I like to think of college students as a unique and high risk population and thinking about different access points for promoting healthy behaviors or reducing risk for the development of unhealthy behaviors among college students. That's kind of where my research is at right now. And thinking about well being and health more holistically. So yes, alcohol use, tobacco use, substance use outcomes, but also more wellbeing focused outcomes. So not just the absence of negative and risky behaviors, but flourishing, we want students to be thriving. So how can instructors and universities enhance that, is kind of what I'm thinking about right now.

Sarah Robinson  6:30 
Yeah, and that's really important, because college-age populations are so susceptible to so many things. It's really a formative period. I was a college student not too long ago, I know it's a time of self discovery and a time of trying a lot of new things. And some of those new things are not great. So it's really important that you're studying this and really getting into it.

Jessica Braymiller Knapp  6:54 
Yeah, I think right now, too, in the years following the onset of the COVID-19 pandemic, the college population is still dealing with a lot of the mental health and well being challenges that kind of started during that time and still kind of adjusting to this time, in the years after COVID. And we're seeing a lot of mental health symptoms of depression and anxiety in this population. And so how are students coping with that? Are they using substances? Are they engaging in, you know, withdraw behaviors or things like that? So what can we do to intervene at that point in time?

Sarah Robinson  7:42 
A really common, maybe not so common now, but becoming more common strategy for substance use disorders is harm reduction. So would you say that prevention science is considered a type of harm reduction strategy?

Jessica Braymiller Knapp  7:55 
Yeah, so I think that prevention science and harm reduction are really closely related. And especially when you're thinking about substance use, in particular, I think they're kind of two sides of the same continuum. So for example, if you think about adolescent or college student substance use, you can imagine some sort of sliding scale. And on the far left would be strategies that focus on preventing or delaying that initial use of substances. So you know, stopping substance use before it even starts. Then as we move towards the center of that sliding scale, we have efforts that focus on reducing substance use behaviors after they've already begun, but before problems associated with substance use begin to really escalate. This could be your typical treatment strategies for substance use disorders or, you know, strategies at reducing substance use behaviors. But then as you move towards the other end of the scale, the far right side, that would be more like harm reduction strategies that are focused on really preventing serious harms or even death from substance use. So in public health, we like to think about this idea as primary, secondary, and tertiary prevention. But I also think in the case of substance use, we can think about it as a scale from prevention to harm reduction, and they're some of the same ideas, but the outcomes that we're hoping for at each end of that continuum are a little bit different, but they're definitely related and intertwined.

Sarah Robinson  9:30 
Yeah. And in public health, I think we think so much about prevention, but we don't really hear about it that much when we're talking about substance use disorders, I've noticed. I feel like the main thing I learned about is harm reduction, when really prevention is like - it's the first step. You know, that's something that we should be doing more of.

Jessica Braymiller Knapp  9:49 
Yeah, I think that, especially in recent years, harm reduction has been gaining traction as an important strategy. So I think we did talk a lot about prevention, primary prevention specifically related to tobacco use, a few several years ago, maybe. But harm reduction is really gaining some traction right now, especially as it relates to things like alcohol use and opioid use and things like that. It's just kind of the zeitgeist, I guess. The movement right now.

Sarah Robinson  10:23 
Yeah, so how would you say that prevention science relates to substance use disorders in general? And how could it be used to promote health equity?

Jessica Braymiller Knapp  10:31 
Yeah, so one of the foundational principles of prevention science is the promotion of health equity, and the reduction of health disparities. And we do this by first building an evidence base regarding how social, economic, and racial inequalities influenced the development of specific behaviors, like substance use behaviors, and the development of substance use disorders, and really how these factors can ultimately impact treatment of substance use disorders. And then once we have that evidence base, it's really about how we can use that information to effectively address the inequalities that are occurring. So how can we develop and implement evidence-based policies and practices and programs that consider all of these social determinants and the systematic and structural inequalities that are contributing to differences in the development of substance use behaviors, disorders, and the effectiveness of treatment? So it's definitely intertwined with health disparity. It's really a foundational principle of prevention science.

Sarah Robinson  11:37 
So let's dive a little bit into tobacco regulatory science. What would you say are some key strategies and research areas that aim to prevent people from using tobacco? Especially in adolescents and young adults, which is what you primarily study right now?

Jessica Braymiller Knapp  11:52 
Yeah. So I think an important place to start is by talking about the Tobacco Control Act. So in 2009, President Obama signed the Family Smoking Prevention and Tobacco Control Act, which is a mouthful, so people typically just call it the Tobacco Control Act. And this gave the FDA, the Food and Drug Administration, authority over cigarettes and some other tobacco products. And it gave the FDA the ability to take regulatory actions that are appropriate for the protection of public health. And I like to start off with this because, you know, what does that mean? What does "appropriate for the protection of public health" really mean?

Sarah Robinson  12:37 
It's very vague.

Jessica Braymiller Knapp  12:38 
It's very vague. And, you know, we're talking about any government actions and regulations that are intended to reduce tobacco use behaviors, and their related harms at the population level. And so to be clear, the FDA didn't have regulatory authority over tobacco products until 2009, which is pretty recently in our history. And they didn't have regulatory authority over e-cigarettes specifically, until May of 2016, when there was a new deeming rule that kind of clarified what is considered a tobacco product. And I still don't think we have clear standards about e-cigarettes and over things like little cigars and cigarillos, which are really important when thinking about health disparities, because, you know, certain special populations are more at risk for using these products that aren't necessarily clearly regulated still, to this day. So now that said, what are some of the actions that the FDA decided to take after this Tobacco Control Act was passed? So importantly, they restricted marketing and sales of tobacco products to youth, so they banned sales to minors specifically. And in 2019. The definition or the age limit for who was considered a minor was updated from age 18 to age 21. So that was big in just restricting access to youth. They also banned things like vending machine sales, and free giveaways of cigarettes and tobacco branded merchandise. So you used to be able to go into the bar, if you were of age and people would give out free samples, people will give out hats with branded tobacco, you know, swag. Now that doesn't happen anymore. And the FDA also banned brand sponsorships of sporting and entertainment events, so we don't see NASCAR drivers wearing Marlboro gear anymore. We don't see cars with the the brand logos on the hood of the car. But that was really popular before thi. The FDA also started to require warning labels on tobacco products. So large black and white text that says, "Warning! This product contains nicotine, nicotine is an addictive chemical," or "Warning! This product can cause mouth cancer or can cause lung cancer. This product is not an alternative, or a safe alternative to cigarettes," - all these things, and they standardize, you know, how big it has to be and where it needs to be placed. But I think for youth and young adults in particular, one of the big things that came out of this was prevention, and public health education campaigns. So you might have heard of the Real Cost campaign. And these were ads in print and media that kind of emphasized the specific harms that can come from smoking in kind of a catchy or sensationalized way. There were ads that were targeting 11 to 18 year olds, and really preventing youth from starting and continuing to use tobacco products by, again, bringing awareness to all those negative health effects, and mental health effects associated with vaping and smoking. So I think those are the main things that the FDA has done so far. And we've seen some success, especially with public education campaigns and things like that - cigarette smoking is way down. But we're still seeing some, you know, increases in vaping among these populations. So it'll be interesting to see how we kind of shift some of our strategies to focus more on e-cigarettes instead of cigarettes. And if we can have some of those same effects.

Sarah Robinson  12:46
Do you think you could elaborate a bit on the systems-level factors that play a role on tobacco prevention, particularly in school and university settings, but also anywhere? And how do you think these factors would impact health equity?

Jessica Braymiller Knapp  17:07
Yeah, so thinking about systems level factors, you know, I mentioned some of the things that the FDA was doing, which are kind of public policies that are aimed at reducing young people's use to tobacco. So I think that's really important. But also things like, you know, smoke free communities. I know here at UB, there are signs everywhere that say this is a smoke free community, this is a vape free community, outside/inside, right. So I think having smoke free communities, or vape free communities is kind of a community level factor that can impact use. But I think harm reduction programs more broadly at universities are also important. So universities tend to really focus on alcohol use prevention and alcohol use harm reduction strategies, because college students are really high risk group for binge drinking, for high intensity drinking. So I think, thinking about tobacco use and tobacco prevention, maybe targeting folks who smoke or vape, while they also drink could be an interesting strategy, to kind of team up on some of these risky behaviors, we know that vaping is a really social activity. So you know, linking up with some of these alcohol prevention strategies could be a step forward, in college settings, in particular, where a lot of this is happening.

Sarah Robinson  18:32 
Yeah. And I definitely see what you mean there. I've heard over and over again, people say like, "Oh, I won't have a cigarette unless I'm drinking," you know, they really do go hand in hand. And yet, we haven't really seen any sort of strategy that ties them together. They're, you know, treated really separately. What would you say are the main access points within schools and universities where tobacco prevention efforts can be most effective? And how do you think they can address disparities in tobacco use among different demographics?

Jessica Braymiller Knapp  19:04 
Yeah, so I think the clearest setting is through Student Health Services, and college health care providers. So most college campuses in the US have some sort of student health center that allows enrolled students to get health care for a really low cost or a lot of cases, no cost. And so, having health care providers that are knowledgeable about vaping, and tobacco use behaviors and cannabis use behaviors and alcohol use behaviors among their population and being able to screen for these behaviors and you know, being able to feel comfortable talking with college kids about these behaviors is really important. So, again, increasing awareness among providers about the behaviors and in increasing comfort around discussing these things during routine visit. It's, I think, is really important. And Dr. Kulak, Dr. Jessica Kulak, who's also in the Department of Community Health and Health Behavior, has done some work in this area. So she would be a good person, a good resource for that. But I also think that, again, offices of health promotion on college campuses, these are the folks that are typically doing the prevention programming or intervention programming around risky behaviors on college campuses. So leveraging these offices in leveraging the education and awareness campaigns that are being put out, again, like I mentioned, many times they focus on alcohol use. So how can we add in, you know, smoking and vaping in the context of alcohol use and in social settings, I think would be great starts in accessing this population.

Sarah Robinson  20:54 
Speaking of demographics, could you share some insights into the disparities or differences in tobacco use, just among all populations? Would you say there are certain groups that are more at risk?

Jessica Braymiller Knapp  21:06 
Yeah, so there are a lot of tobacco related health disparities that exist in the US more broadly, a lot of the data that's out there is specific to adults. And the CDC's Office on Smoking and Health puts out a really nice summary of these disparities. I encourage folks to check out their website, but just a few examples. Black Americans and American Indians and Alaskan Natives are more likely to die from tobacco related diseases, compared to non Hispanic white people. And specifically, we're talking about cardiovascular diseases and diabetes. And what's really interesting, I think, is that black individuals usually start smoking at an older age compared to white individuals, but they're still more likely to die from these tobacco related diseases. So there's something going on there. That is an important health disparity, an important difference in the burden of tobacco related diseases. LGBTQ plus individuals are also experiencing a greater burden from tobacco use. So sexual and gender minority adults are more likely to smoke cigarettes, and use other forms of tobacco compared to heterosexual and cisgender peers. And this one's you know, really striking because the prevalence of current e-cigarette use, or vaping is more than four times higher among transgender adults compared to cisgender adult. I think it's been estimated that about 21% of trans adults use e-cigarettes compared to 5% of cisgender adults. So there's a really striking difference there as well. We also know that people of low socioeconomic status also experienced a greater health burden from tobacco use. So people with lower income have higher incidence of tobacco related diseases than people with higher levels of income. We know that current tobacco product use is higher among individuals who are uninsured or enrolled in Medicaid compared to those who have other forms of insurance. That could be because they don't have access to quitting aids, or they aren't having the same provider interactions that could encourage quitting or provide support for quitting. So there are lots of differences based on race and ethnicity, socioeconomic status, sexual and gender minority status, you know, even mental health diagnoses and geographic location in the US. So, I don't just want to spew out various statistics. But again, the CDC website is really a great resource for learning more about all these health disparities. But many of these differences come down to how the tobacco industry has historically targeted minority groups with their marketing. So as an example, neighborhoods in areas with more African American residents tend to have more stores that sell tobacco. And tobacco companies advertise more heavily in these stores. You know, when customers are mostly African American individuals, and they specifically promote flavored products, especially menthol products, in these neighborhoods, where black Americans live, and menthol is unique because it masks the harshness of tobacco, right? Menthol is in your cough drops. It cools your throat, right. So it makes it easier to inhale, smoke when you have that ice that's cooling down your throat, right, and studies have shown that menthol cigarettes are much harder to quit smoking. They're easier to start smoking and they're harder to stop smoking, right? And about 85% of non Hispanic black adults who smoke cigarettes, use menthol cigarettes. So that tells you something about the success of this increased marketing and promotional strategies in these neighborhoods. So I think that's a big driver of these disparities. But also stress is a huge driver of these disparities. So stress caused by financial problems, stress caused by chronic exposure to racism and discrimination, and even sexual violence can increase tobacco use, right? So using substances as a coping mechanism, could be a main driver of these health disparities as well.

Sarah Robinson  25:53 
Yeah, and it's so unfortunate that our populations that are, you know, experiencing higher levels of stress based on all those factors are more susceptible to this, because of the marketing. I remember learning about that a lot in my public health program. And it's frustrating, but you know, if they're going to be marketing something, you think that, oh, let's market it everywhere. And then everyone could be equally at risk. But no, they're just taking these populations of people that already have enough problems, and just adding on to that. So it really sucks. So when it comes to interventions targeted towards specific populations, can you provide examples of effective approaches that have been used to address these disparities in tobacco use?

Jessica Braymiller Knapp  26:40 
Yeah, so building off what we were just talking about in terms of menthol products. In 2011, there was a study by David Levy at the University of Baltimore that actually modeled what could happen if the United States banned sales of menthol flavored products. And it was estimated that by the year 2050, a policy like that could save more than 600,000 lives, including nearly 250,000 Black lives. So I think that's a big one preventing disparities through banning the sales of mentholated products. And there's currently a ban on flavored cigarette products, and flavored e-cigarette products. But there's an exception of menthol flavors. So menthol is not currently included in that ban on flavors. And I think this is really critical in preventing young people from picking up these products, like especially when it comes to e-cigarettes. We know that fruity flavors and minty flavors and even combination flavors like berry ice or mango ice are really appealing to young people. They're easy to use, they cool your throat, they're not as harsh, they taste good. So users are more likely more likely to start. And they're more likely to continue when they're using these flavors. So I think that flavor ban needs to be extended to include menthol products. And there's also an unfortunate enforcement problem when it comes to these flavor regulations. And you know, a lot of them are still available, even though there's these bans. So increasing enforcement of these things is also really important.

Sarah Robinson  28:26 
So we know that a lot of the fruity flavors were really marketed towards younger populations. And that's why they are banned because we're so concerned about younger populations picking up on tobacco use. Do you think that there's a reason that you can think of that they decided not to ban menthol? Like, did they just intentionally leave that out? To help with sales?

Jessica Braymiller Knapp  28:48 
I think part of it is, you know, the sale of products. But there's actually a lot of groups that are kind of community members that don't want to see menthol products banned. It's interesting - folks kind of see that banning of specific products as being a specific target towards one group of people without kind of recognizing that the bigger picture of the reason behind wanting to ban menthol products is really for long term health benefit for easier quitting, easier prevention of these behaviors, but folks who are currently using these products are very loud about not wanting them to go away. So I think, you know, that that's part of it as well. I used to, when I lived in Los Angeles when I was working at the University of Southern California, I actually attended several kind of community board meetings in Los Angeles County, you know, meetings when they were discussing the ban of flavored products and a lot of people from both sides would show up and really have strong arguments for and against these menthol flavor bans. So I think it's important in our efforts to ban menthol or you know, reduce menthol use to, to communicate clearly why menthol products, you know, are harmful to health and communicate how menthol keeps people using and kind of increasing education around those issues could be an important strategy forward. When there's, you know, community members in black communities specifically who don't want menthol products go away. And they feel like we're targeting them specifically with those policies, when in reality, were trying to reduce health disparities because of this. So I think there's a misunderstanding maybe of where these policies are coming from that kind of prevents progress in some of these areas.

Sarah Robinson  31:02 
Yeah, that makes perfect sense. There's a lot of overlap and, you know, struggles of power between people wanting to control their own decisions and public health wanting to improve the health of the population. It's a very fine line to walk. So like I mentioned, like we've been talking about, young adults are often seen as a critical population for prevention. Can - and we talked about this a little bit, but can you explain further why this age group is so important? And maybe what specific challenges they face in terms of substance use prevention?

Jessica Braymiller Knapp  31:36 
Yeah, so recent data has shown that, you know, 45 to 50% of college students have reported ever using e-cigarettes in their lifetime. So that's a pretty high portion proportion of college students. We all know that college students, again, are engaging in alcohol use at higher levels, as well. You know, there's been this long standing statistic out there that 90% of adult smokers report initiating cigarette use at or before the age of 18 years, and that 90% figure, it increases through young adulthood. So I think it's up to, you know, 95% of folks start using before the age 22 or 25. But, you know, what does that mean? Our field has pretty much concluded that tobacco product use is more often than not started during adolescence and young adulthood specifically. So as a result, most tobacco and cigarette smoking prevention efforts have been focused on young people, as young as middle school and high school people who are under age 18. Right. And we've seen age restrictions for the purchasing of products. We've seen lots of public education and media campaigns, educational materials that are presented in schools. All of these efforts have been created with this statistic in mind that, you know, more often than not people start using tobacco in adolescence and young adulthood. I worked on a paper recently with some colleagues at the University of Southern California that used more recent data. So from data, you know, in 2002, to 2018, that demonstrated most new daily cigarette smokers are young adults now. So that 90% statistic was based on data from the late 90s, early 2000s. And so, now that we've had all of these prevention efforts, all of these new restrictions, has that statistic changed at all? And we actually did see that most new daily cigarette smokers are young adults now. So they're actually starting between the ages of 18 and 23. So, you know, that population was historically considered beyond that super critical risk period for smoking onset. But we know that young adults also need to be a part of that critical window for smoking prevention efforts, especially now. And that was specific for cigarette smoking. And now that we know that e-cigarettes have kind of surpassed cigarettes, in terms of popularity among these groups, more than ever, we need to focus on adolescents and young adults and that 18 to 23 year old window because this is really when people are starting. We know this is a super prevalent behavior. We know that e-cigarette use is a prevalent behavior and the health effects of this phenomenon are still kind of yet to be seen longterm. So I think it's really important to not forget about these young adults in our prevention strategies.

Sarah Robinson  35:08 
I think about that a lot, because the Juul was really popular when I was in college. And so many people around me were very clearly addicted, like running to their dorm rooms, because they forgot their Juul or like leaving in the middle of class because they have to go hit their Juul.

Jessica Braymiller Knapp  35:23 
And I think that dependence on e-cigarettes among adolescents and young adults is still kind of misunderstood. It seems to look a little bit different than cigarette dependence, especially because you can use more discreetly, you can use it more easily due to the nature of the product. So this more habitual style of use is really important in terms of dependence on these products. And we're still figuring out what that means and what treatment of e-cigarette dependence means, especially among young people.

Sarah Robinson  36:08
Yeah, and e-cigarettes, they have much higher levels of nicotine, they use them so much more, because they are more discreet. So now, my generation is having a really hard time quitting this behavior that they picked up when they were in college, so it's hard to see.

Jessica Braymiller Knapp  36:28
But yes, that's a really great point. So e-cigarettes, because of the way the e-liquid is formulated, it allows for much higher concentrations of nicotine to be delivered into the body. In a way, that's not as harsh, right. So if you packed that much nicotine into a regular cigarette, it would taste bad, it would be really harsh, it would be really hard to smoke. And because of the formulation of e-liquids, it's much easier to inhale and intake large amounts of nicotine, which is really contributing to this dependence problem - you're building up a tolerance to more and more amounts of nicotine. And then you need more and more to kind of continue this habit. So that's a really great point in terms of the development of dependence among young people specifically who are using these products and what makes it really hard for them to quit.

Sarah Robinson  37:23 
Yeah, well, all the more reason to focus on prevention and harm reduction. Just to conclude, do you want to provide any key takeaways, regarding health equity, prevention science, tobacco, anything you would want to end with?

Jessica Braymiller Knapp  37:39 
Yeah, so I think the most important takeaway is that for prevention science, it's a scale, it's that sliding scale - we want to prevent substance use from even being started in the first place. But it's also important to think about folks who have started, how can we prevent use from escalating and becoming really harmful to their health and really detrimental in a way that there are serious consequences? So I think hitting all points of that sliding scale is really important. And when thinking about college students, in particular, how we can kind of link up with existing health promotion efforts that exist on college campuses and include vaping prevention strategies in with alcohol and risky sexual behavior prevention, you know, how do we include that into our standard health promotion materials on college campuses, I think is really important. Because this is a really critical population for the development of those behaviors and the escalation of those behaviors. So I think that's really important. And I think, really just building our evidence base for why health disparities exist in the development of substance use behaviors in general, I think a lot of the health disparities research is focused on adult population. So understanding differences in use behaviors among young people is important as well. Especially for e-cigarettes, which are kind of newer to the scene. I think that's critical.

Sarah Robinson  39:28 
All right. Well, thank you so much. This was a really interesting conversation.

Jessica Braymiller Knapp  39:32 
Thank you for having me.