Dr. Karen Wilson: 21% oxygen in the air is really not something that you should be putting into your lungs. And if somebody is telling you that, even if they're just saying that, "This essential oil is going to be great and helping out your lungs." No, it's air that goes in lungs, and anything else should stay out of them. Speaker 1: This podcast episode is brought to you by the Aetna Foundation, an independent, charitable, and philanthropic affiliate of CVS Health with the mission of promoting wellness, health, and access to high quality health care for everyone. The Aetna Foundation dedicates its work to improving health and local communities and large populations alike. Donna Mazyck: Hello. Welcome to School Nurse Chat. In this first episode of a two-part series, we're taking a deep dive on vaping. I'm your host, Donna Mazyck, NASN's executive director. Today, I'm joined by Allyssa Williams, who's a youth leader in vaping prevention, as well as Dr. Karen Wilson, a pediatrician and researcher on smoking and vaping, and Dr. Jose Torradas, a physician focused on healthcare, leadership, and equity. Also joining us is Liz Clark, the National Association of School Nurses' nursing education and practice specialist, and she'll share the perspective of school nursing in vaping prevention. Donna Mazyck: Welcome to all of you. Elizabeth Clark: Hello. Dr. Karen Wilson: Hi. Donna Mazyck: I'd like to start with you, Dr. Wilson. Share with us the short and long-term effects of vaping. Dr. Karen Wilson: Thank you so much for inviting me to be here today. So we are very concerned about the effects of vaping, particularly on adolescents. If you think about what is coming from the aerosol, from electronic cigarettes, there are particulates, there are chemicals, and, of course, there's nicotine. We do worry about the short-term effects, like effects on the respiratory system and increased risk of asthma, which we've seen both with adolescents who are using electronic cigarettes. But also, adolescents who are being exposed to their friends, in cars in particular, by their electronic cigarette aerosol, they have a higher risk of having an asthma exacerbation. Dr. Karen Wilson: We're also definitely concerned about the long-term effects, many of which we're not going to be able to see because this is still a very new epidemic. And it will be 10 or 20 years down the road when we start to see some of the long-term negative effects from electronic cigarette use. And finally, we're really concerned about the use of electronic cigarettes as a nicotine delivery system for the adolescent brain. Teenagers have a brain that is really susceptible to nicotine. They have receptors in the brain that are designed to be working harder during adolescence because of the growth that they're doing. And when those are blocked by nicotine, we really don't know what those long-term effects are going to be on their intelligence levels, on their attention, on their executive function. Dr. Karen Wilson: Now, we do know from some of the animal models that there's a real concern for this, that they're maybe doing things to the brain that'll have long-term effects. But as I said, since this is a fairly new epidemic, it's going to be a long time before we know for sure. And right now, it's really an experiment on the kids in our communities that are using these products. Donna Mazyck: Dr. Torradas, I understand you're referred to as Dr. Jose, and we'll call you that today. There's students who say, "Do I need to vape every day to be addicted to vaping?" Or sometimes they'll say, "How do I know if I'm addicted?" Dr. Jose Torradas: Well, you definitely don't need to vape every day to become addicted. Pretty much, from the first moment that anybody takes the first drag off of an e-cigarette, the brain and the body are already starting to get primed to almost a ritual type of effect, which psychologically has its own potential addictive properties. But then, you talk about nicotine, like Dr. Wilson mentioned, or other components like cannabis, for example, which are also found in a lot of e-cigarette type products. In terms of withdrawal symptoms, or how does somebody know whether they're getting addicted or not, think about how you're reacting, or how your body's reacting, or your child seems to be acting when they don't have access to what they've been using. Oftentimes the body finds it cravings, which could be irritability, could be decreased sleeping or increased sleeping, could be changes in mood. So if you're noticing a pattern, for example, of just behavioral differences that are pretty noticeable over a period of time, it's at least something to consider as part of the addiction and withdrawal profile. Donna Mazyck: And I'd like to bring you on right now, Alyssa, our youth leader in vaping prevention. Share with us your story about how a student you know started vaping. Allyssa Williams: The first time I ever had a friend that began vaping was actually my first week in high school. And that's when the vaping epidemic really started, so it wasn't something that a lot of us in high school really knew about. It was just kind of one of those, "Why not try it?" And I remember one of my best friends started using the first week because it was given to her by an upperclassmen, and the result of peer pressure just got to her. And she started using. And at that time, I had started my first year in my first tobacco prevention program, which was called SWAT. So I already was kind of familiar with why I shouldn't vape and stuff like that. Allyssa Williams: And I tried to educate her about it. And eventually, I did get through to her, but it took a year. And after that, it just kind of affected her for a long time. She didn't what to do in her free time other than vape. So when she quit, it was hard for her. She has to start picking up hobbies so she wouldn't do it again. And then after that, I was like, "I don't want this to happen to any of my friends ever again." So I try to have the conversation early on with the rest of my friends to keep them away from it and to keep them educated so that they could spread the message as well. Donna Mazyck: Liz Clark, what have you seen as some subtle ways that e-cigarettes are being marketed to young people? Elizabeth Clark: Donna, marketing is a very powerful weapon that tobacco companies have used for our youth. Many youth have been marketed in the gaming that they do online, social media sort of posting, and even free products and things that have been given to them. And so, the whole piece about not really understanding when products came out, really, that how dangerous they were. And so, that education lag really impacted our students, and the epidemic really snuck up on the adults and the school communities, particularly the school nurses, who are our frontline healthcare providers. Donna Mazyck: Dr. Wilson, what products are being used most often by teens? Dr. Karen Wilson: So, of course, in the last couple of years, many, many teenagers have been using Juul and these other pod based products. So the pod products are things that you buy, and there's a cartridge that attaches to a [part 00:07:21]. It for looks for all the world like a flash drive. In many cases, they've got different designs. Dr. Karen Wilson: However, there's another type of electronic cigarette that has hit the market, which they call the disposable, so Puff Bar would be an example of this. And these are designed to be used, and then thrown away. So you don't have the replaceable cartridge. And what has happened with the transition, what we're hearing about, because the federal government has now prohibited flavors, but they're only prohibited in a pod based systems, not the disposable system. And so we're seeing, at least anecdotally now, we expect to see in the data that there is going to be a transition towards the teenagers using the disposables because those are the ones that they can get in the flavors. And the flavors are the things that really drive adolescent and young adult users. Donna Mazyck: So the disposables and the pods. It's curious that the flavors are prohibited in one format, but not in another. Dr. Karen Wilson: Yes, it is curious. And it's really a reflection of how our system makes regulations and laws, where you have so many opportunities to have a loophole, where there is a product that just doesn't happen to be mentioned. For instance, also, the liquids that are sold in tank systems are also not covered under this particular regulation. Dr. Karen Wilson: And so, I think, teenagers, they really need to be suspicious of anything that is inhaling chemicals into their body. anything but 21% oxygen in the air is really not something that you should be putting into your lungs. And if somebody is telling you that, even if they're just saying that, "This essential oil is going to be great in helping out your lungs." No, it's air that goes in lungs, and anything else should stay out of them. And so, I think it's important to understand why these things are still being marketed with flavors, and sold with flavors because of the regulations and the gaps. But overall, the message needs to be that teenagers need to stay away from these products. Donna Mazyck: Liz, I've heard from school nurses that manufacturers are disguising vape pens so they can be smuggled into schools. Have you seen anything like that? Elizabeth Clark: Yes, I have. It's very interesting that our youth have very stealth techniques for vaping in school. We have seen sweatshirts or hoodies that have the vaping device either in the hood or inside the sleeve. Students are able to vape and then put the vaper also back into their sleeve. And many of the vaping devices also can look like a flash drive or other common sort of things that a student would have in their backpack so that parents aren't aware what these devices are. It's very common that they're carrying these devices with them. And staff has really had to be on the lookout, and educate themselves on what to look for so that they can be identified, and taken away from students. And the other thing I think that is really concerning is the toxic components of those devices. It's a huge concern about exposing our youth to those, and then disposing of them in a careful way. Speaker 1: For more information on the National Hispanic Health Foundation's Stop Vaping campaign, visit nhmafoundation.org/stopvapingcampaign Donna Mazyck: Dr. Jose, we understand that it's not just teens that we worry about. In some homes, there are parents who vape and other family members who vape. What are some safety and storage concerns? Dr. Jose Torradas: Anytime that you physically have a vaping device in the house, the likelihood that it could fall into the wrong hands increases almost by an infinity, if you compare it to somebody who just doesn't. Therefore, the access component is different. And the reason that there's so much buy-in, initially, with vaping is that some of the first marketing language that came out spoke towards it being an alternative to traditional combustion inhalation mechanisms and that it was a way to quit. So that was an easy jumping off point, initially. That's why it's no surprise that traditional smokers who are currently adults are part of this. Dr. Jose Torradas: I, myself, am an emergency medicine doctor, so I have experienced in seeing when vaping goes sort of more horribly wrong. And yeah, we've been talking about more regulated products and products that have come market being sold through companies that you know about. But one thing that's truly concerning, especially in certain parts of the country, is these bootleg vaping liquids that have very dangerous components that leave kids in intensive care and on ventilators because of additives that get put into the liquid solutions. So regulated products are bad, but what doesn't get regulated at all is truly what's very scary. Donna Mazyck: Dr. Wilson, speaking of safety concerns, while we're in this COVID-19 pandemic, I'm wonder if there are some concerns about the novel coronavirus for people who use e-cigarettes. Dr. Karen Wilson: Yes, Donna, that is a really important question and something that is being actively looked at. There was one study, recently, that looked at adolescent and young adult vaping, and found that those that use both combustive tobacco and electronic cigarettes were more likely to have gotten COVID. We're still analyzing the data on this. Obviously, this is a fairly new epidemic, but we are very concerned about the fact that vaping may increase your risk for having more severe coronavirus infection. And the other piece that we're seeing is that there are some interesting similarities between the presentation of EVALI, which is the electronic cigarette and vaping induced lung injury, which Dr. Jose was referring to, I think, when he was talking about the kids on the ventilators, and the use of the bootleg products that have things in them that are dangerous. What we're seeing is that sometimes these presentations are fairly similar between COVID and EVALI. We're worried that the use of these products could increase that COVID risk even more. Dr. Jose Torradas: That's actually a very interesting point that Dr. Wilson mentions because that was a trend that before the COVID discussion was full-blown in the United States, we were dealing with this e-cigarette associated lung injury, where we were seeing it in states, mostly in the middle of the country, states where cannabis was not legal. So folks were usually making it in their garage with vitamin E acetate was the most commonly identified culprit, in terms of these kids. So very interesting to see that commonality, which most absolutely suggests a higher risk for those kids who are vaping, smoking in times like this, of a viral pandemic. Donna Mazyck: Dr. Wilson, we know that vaping is an on-ramp to nicotine dependency. It has nicotine in it, and you can get addicted to nicotine pretty quickly. But some people have thought of e-cigarettes as an off-ramp to nicotine dependency. Can you help us untangle that? Dr. Karen Wilson: This is a question that we're asked a lot, particularly by parents, and asking if they want to quit combustion tobacco, should they start using electronic cigarette? And the data out there, there's been a number of studies, I think more than 90, if you include all of the observational and clinical trials that have happened. And there's still very conflicting information about how helpful they could be. I think there's one study that might've suggested if it were used as a clinical product, so that was something that was prescribed by a doctor or given not just when you go down to the drug store to pick it up, that there was some possibility that could be helpful. Dr. Karen Wilson: But overall, the use of electronic cigarettes and the way that Americans are using electronic cigarettes today is not something that has been shown to be effective at smoking cessation. And, in fact, either you substitute, and you're still addicted, and most people are still continuing to use both products, and so you are just increasing the amount of nicotine you're getting because you're also getting it from the electronic cigarettes, or it doesn't work altogether. I think that, while as a pediatrician, I would never tell a parent to go back to using combustive tobacco. If they've switched entirely to an electronic cigarette, I would never ever recommend it as a smoking cessation device. What we recommend is that we connect parents with evidence-based programs to help them quit smoking, along with FDA-approved medications that we know can help them quit. Donna Mazyck: Very clear recommendation. Thank you. Dr. Jose Torradas: Just in terms of discussing real quick. What we've been talking about as why it's not a useful cessation aid, think about one tiny little Juul packet could be 20 cigarettes worth of nicotine. And it just doesn't smell. So I was on a train the other day ... well, before COVID, I guess, at this point. But I was on a train and noticed these kids just taking these drags from a vape pen in the middle of the train. And I thought to myself, "There's no way you would do that with a cigarette because it just smells so much." But if it doesn't smell almost at all, and you can sort of cheat and take extra drags, you've got to be very serious about quitting if you think that something that makes it that easy to get nicotine or cannabis is going to make it more likely to quit. Very interesting in terms of the reasons why it is not a smoking cessation tool. Donna Mazyck: Allyssa, we'll ask you to have a final word, just what you've done in the communities that you reach out to about this health crisis. Allyssa Williams: In my work with tobacco control and youth advocacy in my smaller local areas, I really focus on educating youth. I understand once you start something, it's hard to quit. but I think it's very important for you to want to take that control of their lives, to understand that quitting is something that they want to not because somebody is making them do it. And, always in my experience, once they are educated and well-informed on what's really happening and what is really going on when they're using these products, they take that initiative and they become advocates themselves. They share their stories and encourage others to share their stories and use this information to really help create the tobacco-free future that I envision. Allyssa Williams: And we start small. It started in my high school, and then as a community thing. Hopefully, I can continue my work in college, so that's really what I'm focusing on, the education portion. Donna Mazyck: Wonderful. Thank you to our guests, Alissa Williams, youth leader in vaping prevention, Dr. Karen Wilson, who's brought in her work as a pediatrician and researcher to this space today. And for Dr. Jose Torradas, a physician who focuses on healthcare leadership and equity, and Liz Clark, nursing education and practice specialist at the National Association of School Nurses. We really appreciate all that you've shared in this deep dive on vaping. And we'll continue the conversation another time. Thank you for joining School Nurse Chat. Speaker 1: To view the American Academy of Pediatrics' parent information on vaping, visit healthychildren.org/vaping