Resources

  1. King, BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in United States, 2013-2017. JAMA. October 2, 2018. Volume 320, Number 13.
  2. Levinson AH, Ma M, Jason LA, et al. Assessment of the US Federal Retailer Violation Rate as an Estimate of the Proportion of Retailers That Illegally Sell Tobacco to Adolescents. JAMA Pediatr. 2018;172(10):966–972. doi:10.1001/jamapediatrics.2018.2038
  3. Morin JFG, Afazli MH, Borque J, Stewart SH, Sequin JR, O’Leary-Barrett M, Conrod PJ. A Population-Based Analysis of the Relationship Between Substance Use and Adolescent Cognitive Development. AJP in Advance. July 2018. (doi: 10.1176/appi.ajp.2018.18020202)
  4. Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth. JAMA Pediatr. Published online September 17, 2018. doi:10.1001/jamapediatrics.2018.1920





Transcript

Dr. Frank Domino:

Linda comes in today for her yearly physical. She feels fine, but she's quite worried about her son Ryan who's 14 years old, and a freshman in high school. This is the most important thing on her mind today. She tells you that the high school recently sent out an email notification that there was an increase in the number of students using e-cigarettes at the school to vape not only nicotine, but also marijuana. In fact, a friend of hers recently told her that she found a vaping device in her son's room and when the mother confronted the son, he admitted to using marijuana with it. What can we do today to help address Linda's concerns? Hi this is Frank Domino, Professor in Department of Family Medicine and Community Health, at the University of Massachusetts Medical School, and joining me today is Susan Feeney, Assistant Professor in the Graduate School of Nursing, and Coordinator of the Family Nurse Practitioner in Adult Primary Care Nurse Practitioner Programs at the University of Massachusetts Medical School. Susan, thanks so much for coming today to talk about e-cigarettes, and marijuana.

Susan Feeney:

My pleasure.

Dr. Domino:

So can you catch us up to date? What is the current literature about adolescent use of e-cigarettes and what are the concerns about that?

Susan Feeney:

Well, it's really kind of stunning. So the CDC estimated in 2016 that 2.3% of US adults, about 11.3% of high school students were current e-cigarette users, and this is to those national self-reported surveys which they think are pretty accurate. Looking back to 2015, about one-third of US middle schoolers and high schoolers said they have used e-cigarettes with non-nicotine substances.

Including in that would be marijuana. And what was really stunning was that over two million middle and high schoolers who admit to using e-cigarettes. And if you look at retail sales, which was stunning to me, the market share for these vaporising units have just shot through the roof, and there's one particular one that's a small, looks like a thumb drive, and it's very popular, its sales went up 641% [chuckle] in one year, 2016 to 2017, from 2.2 million to 16.2 million. And they have really cornered the market. And what's worrisome about or concerning about this particular product is it's very simple to use, there's no additional additives. It comes with a little battery. It's ready to go, it's the size and shape of a thumb drive, so easily concealed. It delivers a high nicotine concentration when used. And you can also... It comes with flavors. So it's very attractive to especially to middle schoolers and teenagers. The studies couldn't really tease out in these retail studies with the age of the people buying these things, but certainly when you combine this with the knowledge of how many, with the high percentage of kids using it, does make your word that they're buying it.

And so our concern is obviously that if they're using it for nicotine and cannabis that these are worrisome ingredients for especially the developing brain. Nicotine is highly addictive, and supposedly, kids under the age of 21, aren't supposed to have access to these things, but they can get them in pharmacies, they can get them in the big box stores, grocery stores and they can get them online and in the smoke shops. And some of the literature I looked at showed that some of the smoke shops are selling to kids, even though they're supposed to be using IDs and not selling.

Dr. Domino:

That's not surprising, but it's still startling data. Okay. So that's about e-cigarettes. Tell us a little bit about the use of cannabis.

Susan Feeney:

Sure, well there was a recent study published in JAMA, in fact last month, that looked at data from the National Use Tobacco survey, and they looked at children Grades 6-12, and it represented public and private schools, and they had almost 21,000 students with us, greater than 71% response rate, so pretty robust. And they asked them first of all, have they used any cigarette in the past and if they did, did they ever use it with something other than nicotine? And if they said yes to that, then they asked them, "Well, have you used marijuana, THC, THC wax or hash oil in it?" And the results were pretty stunning. They found for high school students, one in three who admitted to using e-cigarettes, admitted to have it using it with cannabis, and one in four middle schoolers admitted that if they used e-cigarettes, they used a cannabis in it, so that's pretty stunning. And what was also I thought an important part, and that we've seen this with kids who smoke or who use e-cigarettes, they had a higher percentage of use and e-cigarettes on kids who grew up or where we're living with a smoker in the household.

So these estimates were as high or higher than any previous study they've done, so it was I think this is a little bit alarming that the prevalence is so high. And again, the other thing that's concerning is that marijuana now is becoming more prevalent, it's becoming legalized in a lot of states, not just for medical purposes, but we're seeing, in Massachusetts, we're gonna start having our first retail shops. So understanding that this is a public health concern for our teenagers is really important.

Dr. Domino:

Alright. So you've presented a very startling case for us to start thinking about how we address our middle schooler and high school students with regard to e-cigarettes in particular, cannabis. What are some strategies that have been found to screen this population for using these substances?

Susan Feeney:

Well, I just wanna talk a little bit about some of the harms, is that we do know that nicotine is highly addictive and we know that that is very addictive and teenagers, so that's important. And that we do know that cannabis has a neuro-toxicity and it affects memory and long-term academic success. Even it seems to be even worse than alcohol use. So what do we do? There's a couple of websites, there's one here at UMass that will have on our website, that has some great advice for parents. But basically, what it says is, and what I would say to Linda, is that get the facts, go to some of these websites look at what these devices look like so you can see them and if you see them being used, you can address it. Understand the terms that are being used, and then talk to your kid, actually have a conversation. And what they recommend is open the door. Don't expect to get answers right away, but to say, "Hey you know they sent this thing home from school. Let's talk about it." And they also say there's no perfect time to talk about it.

And they also say there's no perfect time to talk about it. So choose, any time that seems available. Being in the car sometimes is a good place to start, and just say, "What do you know about it? Do you know anybody using it?" And listen, listen to what they're saying. And seek as much information out as you can. And certainly not burying your head in the sand and understanding that it's a conversation and you wanna start that with your child and make sure that they understand your concern, but trying to be as non-judgmental, and fraught with fear, as you may be feeling but to really have the door open for a conversation.

Dr. Domino:

How about in our practice? How do we talk to adolescents about e-cigarette use?

Susan Feeney:

I think it's the same way. I think it's having information disseminated in the office, so they can see some of the stuff, giving them literature, and then just asking them, "What do you know about it?" I think it's not enough to say, "Are you using these substances?" I think we really have to say, "Are you using?" And if you say, e-cigarette they may go, "I'm not using that." You have to use the terms like, "Are you using a vape apparatus?" And find out what the most prevalent are in your area. And if you want, "Have you used any marijuana in it?" And just sort of, "This is confidential, between you and I." And to really try to have a conversation with them about it and then talk about some of the concerns. That one of the things we do know is, it does affect memory, it affects academic performance, and it seems to have a long-lasting effect. So I think that would be good ways to counsel.

Dr. Domino:

I totally agree. I often will say to a young adolescent, "Many people your age are doing X and I don't know much about it. What can you tell me? What have you tried? What have your friends tried?" And that at least opens the door to a discussion.

Susan Feeney:

Yeah, that's a good approach. I agree.

Dr. Domino:

Susan, this is a great topic and startling data thank you again for bringing it to us.

Susan Feeney:

Thank you.

Dr. Domino:

There will be a link on our landing page to both the resources Susan mentioned, as well as a presentation on e-cigarettes and vaping from the 2018 primate East Conference. Practice pointer; screen adolescents and high school students for the use of e-cigarettes, impossible cannabis use. Open the door to a conversation that may help them prevent severe adverse outcomes. Join us next time, when we talk about perimenopausal depression. How to go about evaluating it? And treatment options. And for more timely relevant and practical medical education, check out pri-med.com.