Attachments X, Y

2020 NSDUH, Supporting Statement
Attachment X – Comment Received

August 12, 2019
Janet Heekin
SAMHSA Reports Clearance Officer
Room 15E21B
5600 Fishers Lane
Rockville, MD 20857
Re:

2020 National Survey on Drug Use and Health Clinical
Validation Study and Redesign Field Test (OMB No. 09300110) – Revision to 2019 NSDUH collection

Dear Ms. Heekin:
Truth Initiative® welcomes the opportunity to submit comments on the
2020 National Survey on Drug Use and Health Clinical Validation
Study and Redesign Field Test. We value the data this survey
provides as we examine trends in the use of different tobacco
products in the U.S.
Truth Initiative is committed to creating a generation of Americans for
whom tobacco use is a thing of the past. Truth Initiative’s flagship
program is the proven-effective and nationally recognized youth
smoking prevention campaign, truth®. Other programs include EX®,
an innovative smoking cessation program; research initiatives
exploring the causes, consequences and approaches to reducing
tobacco use; and programs to address the health effects of tobacco
use – with a focus on priority populations disproportionately affected
by the toll of tobacco. Our cessation program for young adults, This is
Quitting, originally designed to help young people quit smoking, has
been updated to be the first-of-its kind to help young people quit ecigarettes.
Truth Initiative appreciates SAMHSA for the addition of lifetime and
recency questions about vaping nicotine or tobacco to the 2020
NSDUH but would like to suggest changes to the wording of these
questions.
Since their introduction in the United States market, awareness,
interest and use of electronic cigarettes (e-cigarettes) has steadily
grown. It is important to gather information about the prevalence of
these products, especially as a relatively new high-nicotine product,
JUUL, has become so popular that it has captured 73.4 percent of the
e-cigarette market.1 A Truth Initiative study found that 25 percent of
survey respondents aged 15 to 24 recognized a JUUL e-cigarette

device when shown a photo of the product. Among those who recognized JUUL, 25 percent
reported that use of this product is called “JUULing,” indicating that this product is so
distinctive, it is perceived as its own category.2 Additional research from Truth Initiative
shows that youth ages 15 to 17 have over 16 times greater odds of being current JUUL
users compared to those between 25 and 34 years old.3 Thus, it is incredibly important to
ask about e-cigarette use on the National Survey on Drug Use and Health.
VPINTRO
We recommend changing the wording of the introduction to the vaping section to include
brand names, which is consistent with CDC’s National Youth Tobacco Survey (NYTS).
Currently, the NSDUH introduction states: The next questions are about vaping nicotine with
e-cigarettes or other vaping devices. These devices might also be called vape pens,
personal vaporizers, or mods. When answering, please include any device that heats a
liquid containing nicotine into a vapor. The NYTS states: “The next questions are about
electronic cigarettes or e-cigarettes. E-cigarettes are battery powered devices that usually
contain a nicotine-based liquid that is vaporized and inhaled. You may also know them as ecigs, vape-pens, hookah-pens, e-hookahs, e-cigars, e-pipes, personal vaporizers, or mods.
Some brand examples include JUUL, NJOY, Blu, Vuse, MarkTen, Logic, Vapin Plus, eGo,
and Halo.” We recommend changing the phrase “vaping nicotine” throughout this section to
“using an e-cigarette or other vaping device with nicotine” as some youth do not know that
these products contain nicotine. Additionally, it is important to include brand examples
because some youth do not know that these products contain nicotine.2
VPLIF and VPLIFREF
Have you ever, even once, vaped nicotine with an e-cigarette or other vaping device?
We recommend changing this question to: “Have you ever, even once, used an e-cigarette
or other vaping device with nicotine?”
VPFT
How old were you the first time you vaped nicotine with an e-cigarette or other vaping
device?
We recommend changing this question to: “How old were you the first time you used an ecigarette or other vaping device with nicotine, even one or two times?”
VPFTYRa and VPFTYRb
Did you first vape nicotine with an e-cigarette or other vaping device in…
We recommend changing this question to: “Did you first use an e-cigarette or other vaping
device with nicotine in…”
VPFTMOa and VPFTMOb
In what month in…did you first vape nicotine with an e-cigarette or other vaping
device?
We recommend changing this question to: “In what month in…did you first use an ecigarette or other vaping device with nicotine?”

VPPM
Now think about the past 30 days, that is, from [DATEFILL] up to and including today.
During the past 30 days, have you vaped nicotine with an e-cigarette or other vaping
device?
We recommend changing this question to: “Now think about the past 30 days, that is, from
[DATEFILL] up to and including today. During the past 30 days, have you used an ecigarette or other vaping device with nicotine?”
VPREC
How long has it been since you last vaped nicotine with an e-cigarette or other vaping
device?
We recommend changing this question to: “How long has it been since you last used an ecigarette or other vaping device with nicotine?”
VPRECDK
What is your best guess of how long it has been since you last vaped nicotine with an
e-cigarette or other vaping device?
We recommend changing this question to: “What is your best guess of how long it has been
since you last used an e-cigarette or other vaping device with nicotine?”
VPRECREF
How long has it been since you last vaped nicotine with an e-cigarette or other vaping
device?
We recommend changing this question to: “How long has it been since you last used an ecigarette or other vaping device with nicotine?”
VPPMNUM
During the past 30 days, that is, since [DATEFILL], on how many days did you vape
nicotine with an e-cigarette or other vaping device?
We recommend changing this question to: “During the past 30 days, that is, since
[DATEFILL], on how many days did you use an e-cigarette or other vaping device with
nicotine?”
VPPMNUNR
What is your best estimate of the number of days you vaped nicotine with an ecigarette or other vaping device during the past 30 days?
We recommend changing this question to: “What is your best estimate of the number of
days you used an e-cigarette or other vaping device with nicotine during the past 30 days?”
Additionally, the answers to this question should be continuous, not categorical. For
analyses purposes, a continuous measure of use would allow for stronger models, and
would still allow for data to be collapsed into categories, thus allowing for flexibility in
analyses. Thus, the options in answering should be as follows:
1
0 days

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

1 day
2 days
3 days
4 days
5 days
6 days
7 days
8 days
9 days
10 days
11 days
12 days
13 days
14 days
15 days
16 days
17 days
18 days
19 days
20 days
21 days
22 days
23 days
24 days
25 days
26 days
27 days
28 days
29 days
All 30 days

Additional Questions
We recommend adding a question asking about the type of e-cigarette used. This question
should include photos with the answer choices. The CDC has asked this question in the
following way:
Which of the following best describes the type of e-cigarette or other vaping device with
nicotine you have used in the past 30 days? If you have used more than one type, please
think about the one you use most often.
1. A disposable e-cigarette
2. An e-cigarette that uses pre-filled pods or cartridges (e.g. JUUL)
3. An e-cigarette with a tank that you refill with liquids
4. A mod system (an e-cigarette that can be customized by the user with their own
combination of batteries or other parts)

5. I don’t know the type
We also recommend adding a question asking about the brand of e-cigarette used. We have
inserted below the top e-cigarette brands by market share.1
The next question is about the brand of e-cigarette you use. During the past 30 days, what
brand of e-cigarettes did you use most often?
1
JUUL
2
Vuse
3
Blu
4
Logic
5
NJOY
6
Vapin Plus
7
A brand not on this list
Thank you for considering these comments and recommendations. These changes will
improve the quality and utility of the National Survey on Drug Use and Health. If you have
questions or need more information, please contact Maham Akbar, Manager of Public Policy
at Truth Initiative, at [email protected] or 202-454-5932.
Sincerely,

M. David Dobbins
Chief Operating Officer

References
1. Bonnie Herzog. Wells Fargo Securities Equity Research. Nielsen: Tobacco All Channel
Data Thru 7/13. July 23, 2019.
2. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among
youth and young adults. Tobacco control. 2018.
3. Vallone DM, Bennett M, Xiao H, Pitzer L, Hair EC. Prevalence and correlates of JUUL
use among a national sample of youth and young adults. Tobacco control. 2018.

2020 NSDUH, Supporting Statement
Attachment Y – SAMHSA’s Response to
Comment

September 10, 2019 

Mr. M. David Dobbins  
Chief Operating Officer  
Truth Initiative  
900 G Street, NW 
Fourth Floor 
Washington, DC 20001 

Dear Mr. Dobbins 

Re: 2020 National Survey on Drug Use and Health Clinical Validation Study and Redesign Field 
Test (0930‐0110)  

Thank you for your interest in the new vaping items we plan to test in the NSDUH 2020 
redesign field test.  Also, thank you for your suggestions on item content and wording.  
We have wrestled with many of the issues you have raised. Our decisions about the best 
approaches to take when asking items about vaping nicotine were influenced by advice 
received from expert advisory panel members.  Expert advisors were particularly helpful as we 
identified key measurement goals, and they made useful suggestions for draft item wordings.  
In addition, we tested alternative item wordings in cognitive interviews with both youth and 
adult volunteer participants recruited to reflect the breadth of our respondent population. The 
cognitive interview results helped us refine item wordings to ensure redesign items capture the 
intended measurement goals. 

Background 
As you know, the National Survey on Drug Use and Health (NSDUH) is designed to provide 
prevalence estimates for substance use across a range of substances and time frames.  A major 
goal is to establish and maintain trends in estimated prevalences between redesigns.  In 
undertaking the current redesign, an important consideration has been monitoring changes and 
using available literature and external experts to help us anticipate developments in the area of 
substance use that are likely to be of interest in 2025 and beyond. Vaping represents a 
challenge because it is not a substance, but rather a mode for ingesting substances. Nicotine is 
one substance that can be ingested by vaping, but it is not the only substance that can be 
ingested by vaping. The distinction between a substance and a mode for ingesting various 
substances was central in decisions made about how to word vaping items. NSDUH’s mission is 
to estimate trends in substance use. In NSDUH, mode of administration is of interest because 
questions about modes of administration will help respondents provide complete reports of the 
substances used.  

Based on your careful review, we identified two general issues influencing item wordings across 
the full set of items on vaping nicotine.  The two general issues are:  
 Measuring substances delivered contrasted with measuring electronic delivery devices 
used to deliver them, and 
1 

 Using brand names to help identify delivery devices 

In addition you suggested the following item‐specific considerations: 
 Revising item VPPMNUNR to use a continuous rather than categorical response scale, 
and  
 Adding items to measure the types of vaping devices and brands used most often, 
possibly using photographs to help respondents identify their delivery devices. 

This document begins by considering the first two general issues listed above, and then turns to 
the latter two item‐specific issues raised by your review. 

Measuring devices contrasted with measuring substances 

Based on input from expert panel members, we chose item wordings that focused on vaping as 
an activity rather than on the electronic delivery systems used to vape nicotine. It is possible 
that in the context of a tobacco survey, respondent reports about their use of electronic 
delivery devices will include only tobacco‐ or nicotine‐based vaping.  Thinking about the larger 
NSDUH context, expert panel members were unequivocal in their assessment that if we focus 
items on the delivery systems, we should not assume that the vaping reported is restricted to 
tobacco or nicotine products. Electronic delivery systems, including JUUL, are easily modified to 
deliver other substances and can also be used to deliver only flavoring, without the addition of 
tobacco or other drugs. Notably for NSDUH, marijuana is one substance that can be vaped using 
electronic delivery systems1 . There are reports of other substances delivered via electronic 
delivery systems,2 and we anticipate that users’ creativity in adapting these devices will spur 
even more cross‐over from nicotine delivery to the delivery of other substances.  

For VPINTRO, We selected the wording, “The next questions are about vaping nicotine” 
because we want respondents to report only nicotine use.  Items later in the survey ask more 
general questions about vaping other substances using electronic delivery systems.3  

Items VPLIF, VPLIFFFFREF, VPFT, VPFTYRa and VPFTYRb, VPFTMOa and VPFTMOb, VPPM, 
VPREC, VPRECDK, VPRECREF, VPPMNUM, and VPPMNUNR all ask about ‘vaping nicotine’ rather 
than ‘using an e‐cigarette or other vaping device’ for the same reason – to elicit reports of 
nicotine use and only nicotine use. Additionally, the expert panel agreed that the wording 
should emphasize the action of vaping, rather than asking about ‘using an e‐cigarette or other 

1

 Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). 
Monitoring the Future national survey results on drug use 1975‐2018: Overview, key findings on adolescent drug 
use. Ann Arbor: Institute for Social Research, University of Michigan. 
(http://monitoringthefuture.org//pubs/monographs/mtf‐overview2018.pdf; accessed Aug 29 2019) 
2
 Breitbarth, A.K., Morgan, J. & Jones, A.L. (2018).E‐cigarettes – An unintended illicit drug delivery system. Drug and 
Alcohol Dependence, 192, 98‐111. ( http://monitoringthefuture.org//pubs/monographs/mtf‐overview2018.pdf, 
accessed Aug 29, 2019). 
3
 (SPDONTR1, the introduction to the set of more general vaping items says, “The next questions are about vaping 
flavoring and other substances using e‐cigarettes or other vaping devices.”) 

2 

vaping device’ because the action of vaping was likely to be the most universally understood 
and stable terminology for the desired measure. While the specific devices and brands are 
evolving quickly, the term ‘vaping’ to refer to use of any of these devices appears to be 
consistent.     

Cognitive testing with these items indicates that adolescent and adult respondents understand 
the items as intended.  The focus on “vaping nicotine” does not seem to confuse cognitive 
interview respondents or throw them off track. (The experts also confirmed your observation 
that people, particularly youth, do not always know what substances they are consuming with 
their electronic delivery systems.) 

Using brand names or pictures to help identify delivery devices 

In general, NSDUH avoids using brand names in item wording other than for prescription drugs.  
Expert panel members discussed the pros and cons of including specific brand names for 
electronic delivery systems. While experts agreed that brand names can be useful for 
facilitating recall, it was decided not to include brand names because the market is rapidly 
changing.4 The redesigned NSDUH should be worded to be relevant in 2025 and it should 
remain consistent and relevant over the years that follow in order to maintain trends. It cannot 
be assumed that JUUL and other currently popular devices will continue to be the most popular 
brands into the future, particularly given the present uncertainty about legal status and FDA 
standing. Finally, there is a class of heat‐not‐burn products under review by the FDA, and it is 
unclear what effect these products will have on the marketplace. Brand names were avoided in 
order to ensure that NSDUH items remain relevant as the marketplace changes. For similar 
reasons, it was decided to avoid using pictures to illustrate various types of electronic delivery 
systems. The latter point about pictures is related to the suggestion to add an item on type of 
electronic delivery system used most often in the past 30 days. 

Instead of relying on brand names or pictures, VPINTRO gives a few generic examples of 
electronic delivery systems and focuses on the function of the delivery device – heating a liquid 
into a vapor for ingestion.  (VPINTRO: “These devices might also be called vapes, vape pens, or 
mods. When answering, please include any device that heats a liquid containing nicotine into a 
vapor“.) Additionally, expert panel members considered using terminology from the PATH 
study describing how vaping devices work, but ultimately the majority of experts recommended 
against it. 

Cognitive testing with this introduction and the items that follow indicates that adolescent and 
adult respondents understand the introduction and items as intended. We have observed no 
clear patterns of under‐ or over‐reporting for vaping based on how the devices are described.  

4

 E.g., The New York Times, https://www.nytimes.com/2019/08/13/health/juul‐flavors‐nicotine.html, accessed 
15Aug2019. 

3 

Revising item VPPMNUNR  

Item VPPMNNUMR is a follow‐up to item VPPMNUM:  

VPPNMNUM asks, “During the past 30 days, that is, since [DATE THAT IS 30 DAYS PRIOR TO   
INTERVIEW DATE], on how many days did you vape nicotine with an e‐cigarette or other vaping 
device? 

                days in the past 30 days [RANGE: 1‐30] 

VPPMNNUM gathers an open‐ended, continuously scaled response for number of days in the 
past 30 days. VPPMNNUMR is asked only of respondents who either (1) answer “don’t know” at 
VPPMNNUM or (2) refuse to answer VPPMNNUM.  The goal of VPPMNNUMR is to encourage 
respondents to give some kind of estimate of days vaped nicotine in the past 30 days when 
they don’t give a continuous response at VPPMNNUM.  We use response categories in the 
follow up item to encourage some kind of report by making the recall task easier and the 
reporting potentially less sensitive. 

Adding a measure of vaping devices used most often 
As noted above, NSDUH estimates focus on substances rather than mode of administration.  
Even if we know what device respondents use most often, we don’t know what substances 
were used.  The redesigned NSDUH items refer to devices and delivery modes to prompt 
complete reports for substances.  

Also, we already mentioned rapid changes in the marketplace for electronic delivery systems.  
At this time, it is difficult to identify a set of response options that will (1) be appropriate for 
2025 and (2) remain consistently appropriate after 2025.  

Sincerely,  

Peter Tice  
NSDUH Project Officer 
Center for Behavioral Health and Survey Quality, SAMHSA 

4