Transcript for Dr. Bonnie Halpern-Felsher: Vaping, Alcohol Use & Other Risky Youth Behaviors

Thank you so much for having me.

Yes, it is. It can be.

Sure. So first of all, ages at a lessons can be anywhere from starting roughly around age 10. Some people would say ending around age 18, maybe 21, if you want to go into young adulthood, then maybe mid-20s. And really, adolescence is a wonderful time of, as you said, exploration. It's a time when, first of all, marked by puberty changes on sedimentses for girls. And really, the puberty and physical development, secondary sexual characteristics are coming out. We also have a lot of emotional development going on during this time. high changes are occurring during this time, but we're getting a lot of social changes as well, as you said, peer pressures. So, one misnobler is parents think that they don't matter during adolescence. They still really matter. But peers also come in and matter quite a bit. And then teens are really trying to figure out who they are. You get a lot of questions, who am I? Where am I going in life? What do I want to do when I grow up? what's important to me, how do other people feel about me and then how do I feel about other people? So a lot of the social and psychosocial development is happening as well. And you get a synchronous development too if a young person, for example, starts puberty at a young grade, say, 10 where they're physically looking older, more mature, but emotionally It's like, socially, they still might be young versus the late matures, physical matures who may be not having a looking like an older teen or an adult till 16, 17, 18, but they're more mature emotionally than others than you might have some confusion to that young person. I look older, but I don't feel older and stuff like that. But it's really this wonderful time of exploration for an adolescent. and a time of really wanting autonomy and wanting to make a lot of decisions that we should like the make, but there are some risks that we have to be careful about at the same time.

Yeah, I haven't contributed actually. I was so my earlier dissertation work and I haven't really contributed to that literature for a while, but what you're saying is is pretty accurate to what I've seen, which is really the literature would say it's not the divorce per se, it's the conflict that is happening. So if parents actually get divorced, usually if the conflict resumes, teenagers and children generally do well and particularly within about two years.

So you can have two parents who are married and living in the same home and may or may not be a good relationship but living in the same home if there's no conflict or that then generally teens will do well or as you're saying there's not necessarily a direct correlation. The problem comes in whether parents are living at home together or separator divorce is if there's conflict and then that conflict tends to result in social issues, emotional issues, a lot of social anxiety, a lot of feeling like I need to do better so that way my parents like me more. And we see that with children too. That's not just adolescence. A lot of depression and with depression can come self-medication, self-medicating around other drugs and so on. But that generally is resolved if the conflict resolves. But as you're saying, we're seeing adolescent angst regardless of parenting. What we really need though, it's not a matter of just the divorce or not divorce or the relationship between the parents. It's parenting. That's important. So parents being good monitors, being involved in their kids' lives, not this. Oh, you're 16, you have a car, you can go wherever you want, and we're not going to keep an eye on you. We still need parents to monitor, to pay attention, to find out their kids' friends, where they going after school, that discretionary time when parents are working. teenagers come home between three and five or three and six tends to be the most risky couple of hours. It's called discretionary hours where there's no parent around and we don't always know where those teenagers are hanging out. So that's more important knowing where their children are and what they're doing and that there's some adult presence, some monitoring, then whether or not they're still in a relationship.

So I would say it's not a blanket statement. I think it depends on the behavior that we're talking about, bullying, no doubt. And the example that you gave, no doubt that if you mess up, if you do something stupid, it's getting filmed and it's going to go viral. It will go on social media and then it will perpetuate and escalate amongst the peers. That we definitely know is happening. And certainly in terms of drug use and marketing, there's definitely some peer-to-peer interaction. Look how cool I am. Look at the smoke ring I did. Look at other things that I've been doing. There is no doubt. But in general, there are also some good things about it. Parent communication. They can monitor where their children are. They can put a track on the phone. I know with my own kids, sometimes it was the best way to say, you seem a little sad when face-to-face communication wasn't happening. I could use the phone to have that conversation. So yes, there is some evidence that overall phones and smartphones have increased risk behavior, but it's more the access to the behavior and then the viralness of really getting that information out, like you said, if somebody screws up, Somebody dresses wrong, if somebody kisses somebody that that could go pretty viral. I wouldn't say that smart phones and social media as a whole is the problem. I think it's situation specific and behavior specific that we're seeing and particularly around marketing, for example, that teenagers have more access now to YouTube, to marketing that they're Promoting, not only are industries promoting, for example, esegrades or cannabis promoting to young people, but teens are promoting to each other. And that we didn't see before smartphones, right? We didn't see, I took a picture, Instagram, look at me smoking or look at me dressing sexy. I look at me looking cool or anything like that. That didn't happen before. It was more just word of mouth. So that is definitely where a lot more concerned about. social media, but more my concern about social media is the outside world targeting young people. That's where I've been the biggest concern about it. Teenagers targeting each other with bullying, no doubt, big issue, but in other ways there's more support. There's more social interaction. The other time I get concerned, no, around teenagers is more the social piece of sitting around together at a table and they're not talking, they're on the phones. So what we really don't know enough is how is the not getting out and playing and instead playing on a game, not going to the park and instead communicating through phones, how is that changing their social and physical development is where I'm also very concerned.

I answer really good point. I've talked to some teens who say that they all get together and they will deliberately put the phones face down in the middle. no phones and have dinner or have a conversation. So I think you're right. I definitely think that that is been a movement and I really appreciate that and I think that's fantastic. I've also seen circumstances where two teens are trying to help each other with homework and they're texting each other, which is fine. But I've often said why don't you just pick up the phone and call the person in five minutes. You can figure out the math assignment instead of 20, 30 minutes of back and forth. It's just not as efficient unless you're literally copying and showing the picture. But is that having a change on their social or physical development or emotional development? Probably not. It's just a different world in the way that they communicate. And that's why I say I'm less worried in some ways. As long as they're still getting out and they're playing and they're being creative, I'm less worried about that kind of social interaction on phones and social media. It's a different way. We don't have a lot of evidence to say when we're the other, But if they're still doing the things that they should be doing as young people, my concern is that outside world, the concern of predatory behaviors, the concern of industry, the concern of mass media and marketing to teens, that's the part that gives me particularly worried.

Sure, absolutely. So the good news is smoking rates. Conventional cigarette smoking rates has gone down pretty dramatically in the last couple of decades with teenagers with all people in the US, which is wonderful, but teenagers to well below 10%, if not really well below 5% of teenagers. That's the good news. In terms of esigrate use, which I prefer the term esigrate use in vaping, because they're not vapes, they're aerosols. But esigrate use has gone up pretty dramatically. So esigrates came on the market in the US in 2007. And they were slowed to, for uptake amongst teenagers. They look like cigarettes when they first came on the market. They weren't very popular with teenagers. They didn't have, they had some flavors, not a lot. They didn't have a lot of nicotine. It was probably around 2011 to 2014. We started seeing an uptick, but then it was really in 2017 to 19 that we saw dramatic increase. And that was the statistics that we saw upwards of 27 to 29 percent of teens using e-cigarettes during those couple years. past 30 days. So any use in the past 30 days was an endily so be some smaller percentage of that. It was something like a 78% increase in high school student use and a 48% increase in middle school use over those couple of years. So a very dramatic increase in use since 2019 it's gone down. But I'm going to give a caveat. It's gone down in 2020 to the national numbers are showing, uh, they went to around 20% and now we're on 10%. Part of that was in 2020, we had COVID. And initiation of a cigarette use really occurs socially and going back to socialization. It's a lot of teens get in together. And it's not peer pressure if you have to try. Come on, try this. It's more like my friends are using. I met a party. I feel like using. Yeah, let's try it. During the pandemic and the shutdown, teens were not at school. They weren't with their friends. So initiation went down. Teens who were addicted and we can certainly talk about levels of nicotine and e-cigarettes, but teens who were addicted continues to use. Some try to quit, which was great, but we still saw a fair amount of use. So part of the decrease in those 20, 20 to 20, 21 have to do with just access and socialization had changed and so rates going down. Since then, even we publish a paper showing relationships between COVID and vaping, we saw Evali, Isigrat and vaping associated lung illness so that that we think was part of why we also saw further drops around 2021, but people were concerned about their lung health and teens as well and that's great. The latest data show that the rates are under 10%, the national data. I actually don't think it's true. And the reason I don't think it's true is I'm in the schools doing curriculum presentations all the time where I teach and educate teachers to use our tobacco and cannabis prevention curriculums. And we've never been busier than we are right now with schools just crying for help. We have another group of teenagers using esigrats, nicotine or cannabis or whatever. It's way more than 10%. I would say schools are telling me it's 40 to 60% of their students are using esigrats. We don't know. It's very hard to know. It's very hard to know what's in there. But 40 to 60%. That's what the schools are saying at some point in the last 30 days. It's some point in the last 30 days. They're catching just exorbitant numbers of students using right now. And so from a science perspective, is it 10%, 20%, 30? We don't know. I can just tell you that The national CDC data would say 10% and maybe it's a problem with the surveys of the questions or teens aren't being honest, perform a school's perspective, it's much higher. And then we have some national data suggesting it's more in the 20 to 30 to 40% range as well. Whatever it is, it's too many. It's too many teens who are inhaling nicotine and cannabis as well.

So there are a few reasons why they start based on the literature, scientific literature and just talking to teens. One has to do with the marketing. No doubt. If you look at the marketing, it is targeting young people. It's targeting them with First of all, the devices themselves. They are cool looking. They're easy to hide. They look like USB devices. They look like highlighters. In fact, there's a new brand-out called Highlight that is a highlighter. That's a working highlighter, but it's actually in nicotine cigarette.

Highlighter pen to study. And then. But it's actually you take the cover off. And it's actually a nicotine e-cigarette device.

Clearly marketed towards students. Wow. You have what's called a boba, uh, you know, uh, T's drinks.

The mimicking that drink that's actually us that the straw is actually the vaping. It hailing there. Little pieces. You have, um, Star Wars shapes. It goes on and on just the cartoon shapes that are clearly being targeted to, not just teenagers, children that we're seeing.

So I'm shocked. So kids younger than 10 are having these products pushed their way. They are. And actually, I didn't tell you in the statistics. The statistics I was citing, I should go back and clarify a couple. They are that are even more shocking. So those are the numbers have been on high school. We don't have data from elementary, but again, the other part of the addition to the science I contribute to, the interventions I do, I am getting elementary school teachers calling us for help. They are catching second and third graders. using nicotine cigarettes, I'm not kidding. And not just one or two. Quite a bit. We said we would never develop an elementary school version of a vaping prevention curriculum. That's what we call ours. You and me together vape free. We would never, we have a middle school and a high school. We were never going to do elementary. We've had so many schools. across the country, call us and say, we need something for elementary. So we actually created a curriculum. So we're having, there was a story of an eight year old, a back east who was caught and using and the teachers and police didn't know what to do. And of course, I said, it's not a police matter. Why aren't we helping this young person? So we are, we're seeing younger. Now sometimes they're starting because they're siblings, older siblings. It's been marketed to. They don't realize that it's a nicotine cigarette or cannabis is a cigarette. They just don't realize what it is. But the number of these products that are being targeted to young people is absolutely ridiculous what they look like. The pictures are endless and the problem is they're coming out with new products every few months that are targeting kids. So marketing. And the other is flavors, and flavors of marketing go hand in hand. If it looks bad, it looks like, or it smells like in taste like nicotine or tobacco, teens know that that's gross. That's why we don't have cigarette use anymore. We've socialized our country to say, if you smell tobacco, it's nothing that we want to smell. We walk away from it, you walk across the street. Whatever, we've done a really good job in tobacco control getting the word out around. Now, these products, e-cigarettes, smell and taste like sugar, like sweets, like dessert, like candy. So you've got, and the names are things like unicorn poop and sugar booger and honey do do. That's not for adults. Those names are squarely for kids. It's kids who are using chocolate. It's kids who are using these flavors that are on the market. And then the marketing around it are these, I mean they're beautiful. They're these, you don't possess a pineapple dancing around or a how strawberries, dancing or whatever it is that are very animated. They're juice box style that have come out juice box style vaping devices that are marketed looking like juice boxes. And that's not targeting you and me. That's targeting a kid.

So I've seen numbers anywhere from 5% to around 20% depending on the statistic. I actually haven't looked at the latest data on adults. But the majority of adults who are using, it's a little bit different to think about it. Adults are using generally, they're not initiating tobacco through e-cigarettes. They're generally, and I'm talking 30 and up, they generally have been smoking cigarettes, and then maybe they're trying to use e-cigarettes to quit, which is a whole new, set of literature that it's not necessarily as effective as we're hoping that it is. There isn't good literature on a population level that e-cigarettes help adults quit cigarettes. The difference with teenagers is they're initiating with esigrats. And they're not saying, ha, here's a cigarette, here's an esigret which went away, cheers. It's not that they're substituting or replacing. They're not using cigarettes. Some are now because they're switching back and forth, but they're initiating with esigrats. They're initiating because of the marketing, they're initiating because of the flavors. and the products and the ability to hide it, parents don't know what these products look like. So the landscape is very different.

Yeah, absolutely. So the other reason why they start is they like the taste and they like the rush. So I've talked to. So that's the other piece says. So a few more reasons why they start and then and then certainly answer your question around the nicotine. Teens have told me outright that they like the taste. They like the rush. They like the buzz. And we could talk about how much nicotine is in there. It's astonishing. And I can explain that. But they like the buzz. Another reason, by the way, is stress and coping. Right now, teens are so stressed out. They've been stressed out for years, but they're particularly stressed with the pandemic. And even there were a couple of years out of the lockdown, teens are still there having socialization issues, social emotional learning issues. They're still confused. They missed a couple of years, particularly high school students. They may have missed part of middle school where you're learning to socialize with other people. So they're very stressed and we know that there's a pretty strong relationship between stress not being able to cope and using any drug but including a team. So there's a lot of different reasons why young people, and certainly the peers. And again, it's not peer pressure. It's more like a lot of friends are using it. I've talked to teens who say, I didn't wasn't intending on, but I tried it. Wow, I really liked the taste. I liked the flavor. And then there's the amount of nicotine. That's in there. In 2015, when the newer products came on the market, it was a salt-based nicotine. So cigarettes and then earlier e-cigarettes have a free-based nicotine. Free-based nicotine uses ammonia and sugar to bind to the nicotine and the other chemicals. There's hundreds of chemicals in there to go through the body, lungs into the brain and give you that rush. The free-based nicotine is very caustic. If you think the lip mist tests, it's very much on the basic side of the lip mist tests there. And if you're a nicotine naive youth, which again, most teens starting with nicotine e-cigarettes have not used nicotine before, When you start, you don't want that caustic throat head feeling. That's why I would subscribe. Tins will say they don't like it, they cough, it tastes too bad. Well, to an adult who's been using cigarettes, they don't mind that they're used to it, but a teen is not. Well, I will mention Joel here because it's relevant. Joel came on the market in 2015 with a salt-based nicotine.

It's exactly right. It's exactly right. So salt-based nicotine generally uses pins or a gas said to move that litmus test needle from the caustic towards a sedic because it's an acid, but really towards neutral. So you're exactly. So when you use it, it's smooth. It's easy to use. You don't have that throat hit. You don't cough. You don't feel sick from it. So teens will say, and I've talked to teens in younger adults who tried earlier e-cigarettes and didn't like it. And then tried the salt-based style and said, Ooh, I like it. Couple with the flavors. It's also more absorbent. So there's some suggestion and similarly evidence that it's also more addictive. So when those products first came on the market before earlier e-segrets had say 0 to 36 milligrams of nicotine, suddenly we jumped up to 59 milligrams per mill, which is about generally about a 40, 41 milligrams, because it's about a 0.7 mill. Sorry, little chemistry and math that we do a lot here, but you're looking at basically it's anywhere from the nicotine that you see in either one to two packs of cigarettes. per per device, per pod per e-sigrat device.

So I've asked teens in some of the earlier publications we did now, not with the newer devices, but the older devices. And they would say that they were using a pot of week, which is about two or three cigarettes a day, to 1 to 4 pods a day.

1 to 4. Now these are highly addicted teenagers. That is 1 to 8 packs of cigarettes depending on the debates on how much nicotine is in there. But you're looking at several packs of cigarettes worth a nicotine.

In many cases.

So a lot of things that you said are really important to highlight. Absolutely. Now, not all teenagers are using for pods a day. These are extremely, very highly addicted teens. And unfortunately, teens we've seen with lung collapses and other pretty significant health issues. Typically, teens are using maybe a pod a day. The newer easter grats, by the way, have probably four times that. They're bigger volume. So you're looking at 60, 70 milligrams of nicotine. Some of them are equivalent to about 3 to 500 cigarettes worth of nicotine. Now, are they using them in a day? Probably not. We haven't done the studies on them. But it's really the first nicotine product we've had that you can use 24, 7. When I've talked to teens, you know, I wake up in the middle of the night. I may check my phone and check my email. Tees are waking up in the middle of the night to take hit and they're they're hiding them under their pillows and their nightstands whatever and they're telling me that they're just using them all the time and they could just suck on them all the time.

Absolutely. General, all great questions there. So what we're, what we're finding when we talk to teens is that pretty rapidly they're going from, I like it to I need it. So, you know, your multi-part question, which is great. What makes them start and what makes them continue? They start because of the flavors and the marketing and they like the taste and all that. They continue because of that high level of nicotine. And we are seeing that teens are addicted. And we're seeing, we actually publish a couple of studies showing that teens who have been using esigrats in the past 30 days that the majority are showing signs of addiction. really rapidly, too, within a few weeks. It's such high levels of nicotine. And there are some people who don't believe that teens are becoming addicted to nicotine, and that the levels of nicotine are off the same as whore seeing in cigarettes. That's actually not the case. And we've seen more and more studies into the question of using it as soon as they wake up. There's a study by a colleague of mine that showed, in the last few years, the data are showing that teens, a greater percentage of teens who use e-cigarettes are doing so in the first five minutes of waking. That is a sign of addiction. So you wake up, maybe go to the bathroom, maybe not, and you take that hit. And all the national data are showing even though initiation may go down, the percentage of teens who are using daily has gone up. And I attribute that a lot to the type of nicotine, the salt-based nicotine, and to the huge amount of nicotine that's been on the market. So yes, teens are definitely feeling it. They're definitely going through withdrawal, sometimes that that feeling, shaking, the sweats, all the feelings that they need, like a concentration. The promise when you talk to teens, they think that Easter grads are helping with school. And by the way, I've not heard a teen tell me that they started because of school reasons or concentration. Maybe they're continuing for that reason. But teens have said that taking the hip makes them feel good. What they don't understand is it's that it makes them feel not bad. Right, the withdrawal is making them feel bad and they don't realize that that hit and that don't be moved rush that they now need it that they're going through withdrawal either way.

Yeah, it's a great question. So there's not one way. In terms of money, I think there's questions about money and question about access, right? And they're not necessarily the same thing. Money, they be seeing the problem is when some of the newer products came on the market, some of them that say 2020, 2021 products were about a dollar or two per pot. Compare that with the back of cigarettes, which is 10 to 15 dollars depending on the state you live in. So they are cheap. They're easy to get. Now, newer ones at older ones are a few dollars more, but they're not that expensive. They start off their expenses when they first come on the market, but they haven't been. The other is the sharing and we used to hear about pod parties where somebody buys the device which is more expensive buys the device and then you bring your own not beer bring your own pod which is a feet dollars then you pop it in and then you share it around. We've also heard stories of a few teenagers buying them and then selling for a few cents or a few dollars a puff. So meet me in the bathroom for 50 cents or a dollar, you can have a couple of puffs. So I think teens are getting very, very creative. We've also seen unfortunately parents buying e-cigarettes for their teens. Well, at least they're not smoking cigarettes. That's not the right comparison. So I think they're very creative. They're getting in many, many different ways. I've heard students say I'm not using my lunch money to buy lunch. I'm going to use it to buy dates. There's no one way. There's not. And unfortunately, access is easier than it should. By the way, one thing I think is incredibly important for people to understand is across the U.S. in 2019, December 2019, the legal age to be allowed to purchase or to sell nicotine products across the U.S. has become 21. So many people think it's so 18. So you're going to evap shop or tobacco shop and if the shop owner doesn't realize it's 21, they'll sell it to somebody who's 18. And even if they know it's 21, they're still selling it because there's not enforcement right now going on. So we really do need our the public, we need all the parents listening, we need educators, police officers to really enforce the and regulate this age restriction because teens are getting them from vape shops really easily. They're getting out of line really easily. They're buying them for each other, somebody's going on buying 10 and then reselling them if the person looks older. There's not a lot of carding going on or fake cards, ID cards is pretty easy still to get. So unfortunately, we have a product that is appealing to teens in a very unregulated market right now. The FDA is not regulating it. Local shops are not regulating it. That it's just, it is the wild west out there.

So that's it.

Yeah, so first of all, start with the brain and nicotine. Uh, absolutely. These high levels of nicotine are really any nicotine is harmful to the developing brain and our brains continue to develop in total around 25, 24 and 26 depending, but two around 25. So In that process of your brain developing or if you're brain changing, if you introduce nicotine, you're changing your brain, you're changing the brain chemistry, and you're so much more likely to become addicted as an adolescent and a young adult. The tobacco industry knows this. I mean, that's why they target teens. We've known this with cigarettes. If we target a teen, then we're going to have them for life. So significantly more likely to become addicted because it actually requires your brain and there's plenty of evidence for that. The other pieces that were worried about is, you know, you're right, nicotine in terms of cancer, although I will tell you, having talked to someone colleges, they would say the vast amount of nicotine still worries them in terms of cancer. We just haven't had enough for search on e-cigarettes to really know. Now, you're right, e-cigarettes do not have tar, but e-cigarettes have aldehytes. And aldehytes have been linked to cancer, so there's still some concern there. Early and a total evidence or probably some of my colleagues out there would say, no, no, there's pretty good evidence around cancer. We just don't have enough body of research. But again, it took 50 years to figure out cancer and cigarettes. We've not had the amount of e-cigarette use or that we saw with cigarettes for that long, for that many people to really know it's still pretty new.

That can't be good. Logs, bloodstream, everything.

Right. Right. And so that's why there's a lot of concern there. And when I talk to teens, and in our curriculum, we often say, because when you just say, and you gave a beautiful explanation of the aldehyde's, but for a teenager, what I generally say is, if you ever dissected a head biology in a dissected frog, yes, how did it smell? It was gross. Well, that's what you're putting into your body when you're vaping. Because that's exactly the point and that kind of helps them understand a little bit more. But there's a lot of concern around the aldehydes. There's lead. There's cadmium. There's propylene glycol and glycerin. There's a lot of other chemicals. So no, we may not have the thousands of chemicals that we have in cigarettes, but we certainly have hundreds of chemicals in an esigrat that's very concerning. So there are a lot of studies now really showing pretty significant effects of e-cigarette use on heart and lungs a lot. Not only all the chemicals we've mentioned, but also the flavorants. There's cinnamon out the hide and other out the hide. There's vanilla and there's what is it? The buttery flavor that's in there is also a lot of concern. So that you're inhaling these flavors, and I often explain, you can take flavors, you can take butter, and heat it to several hundred degrees, and eat it. If you don't burn your tongue, but you then take it and really inhale the resulting aerosol, and then we're seeing the lesions on the lungs. We're seeing young people who have been using e-cigarettes, having lung collapses, pneumonia, asthma, amongst people who have not had seizures. One of the teens I know who was using four pods a day was having seizures. So.

Yeah, and I should say 40 to 60 is what schools are telling me. And that might just be using what's in a while. We don't really know.

No, it is actually much harder and teens will say that. And adults, I know, I actually have a known adult who said that when he went from smoking cigarettes to e-cigarettes, it actually was harder for him to exercise and to write his right and exercise and to write the things on the e-cigarette compared to the cigarettes that the impact on the lungs is so strong. It's your right. It is probably hurting athletics right now. We're actually, there are some curriculums on athletes and vaping and we're building one as well because there's a lot of concern. When you tell a teen, I'm worried about lung cancer in 20 years. I don't care about 20 years from now, but you would tell a teen. It's hard to run. They're more likely to listen to you.

Right. Absolutely. So first of all, the just saying no, not effective. Just having saying just saying no around any behavior to a teenager, whether it's tobacco cannabis cigarettes and sex does not work. It doesn't work. And for many reasons, first of all, teaser curious. And when you say, just say, no, why? Well, because it's bad for you. Well, wait a second, exactly what you're saying. Just telling me that it's bad for me. If you tell me I'm going to get lung cancer or I'm going to have lung disease or anything. And I tried the e-cigarette and I didn't have lung problems. And instead, I actually liked it. Then we look bad. We look like we're lying to teenagers. And instead, we were talking about earlier, the feeling, the rush, the flavor, the taste, the perceived and real benefits outweigh the concerns over the risks as a teenager. So when we say to a teen, just say, no, don't. And they say, well, why? Well, your brain or your heart or your lungs or it's bad for you. They don't believe us and we absolutely lose credibility. So we talked to teens and this is based on decision making research that I've been doing for 25 years. We have to help teens weigh the benefits and the risks. Now, I don't mean that we say, hey, it's good for you or you're going to like it, certainly not. But if we only come from a risk model and adjust say no model, that never works for teens, we need to help them understand the balance. And teens know that there are good things about using some drugs, real or perceived, and we can't lie to them on that. So that gets to then how do we have those messages? And you're right. If we only harp on and our research would show this too, the long-term health risks, your brain on drugs, those kinds of things, that's so far in the future or the trait. You know, you're gonna have a trait if you smoke, but they're showing the 80-year-old and no 16-year-old even looks at somebody at that age or cares about somebody, that's so that other person, that that's the problem. So we need to talk about the social aspects that teens really care about. You, you make it wrinkles, other we don't know that, so much with these cigarettes, but, but the athletics, the things that are important to teens. No, the campaigns that you're talking about are really effective as well, particularly the mass campaign, which level that we see social media campaign, which is, do you realize that the industry, e-cigarettes tobacco, nicotine, cigarette, whatever you want to call it? is targeting you as a teenager on purpose. They want you as a smoker. I used to go to middle school students and say before Eastern grads, when cigarettes were of concern. And I love saying to young people 400,000 adults are dying each year from a cigarette from cigarette use. You're a replacement smoker. And it was great because teens say, well, they're really angry. It's a way that this 12 year old boy was so cute. I don't want to be a replacement smoker, Dr. Bonnie is a big deal to him. And I don't want to give money to the industry and it's great channel that energy and get young people mad. That's what really worked. Showing that the seven dwarfs we call it the seven CEOs of the big tobacco companies at the time said nicotine is not addictive nicotine is not addictive. There are cigarettes are not addictive and that clearly they were lying to teens. You show that to a teen and explain how nicotine is addictive and they knew it, but they're trying to get you works really well. And simply with marketing, we have a whole lesson on marketing. Do you think that that candy was for me as an middle-aged adult? It's for you. And that gets them mad because they don't want to be duped. They don't want to be targeted. That is a much better message. Now, we still have to tell them about the health risks. We absolutely do. They still need the knowledge. They still need to understand what they're doing as unhealthy. But we can't do it in a lecturing way, and we can't do it in a way that makes them feel stupid. We can't tell them their brains are developing until 25 and therefore their DOM are lessons on talking about brain or more like, it's really cool that you're developing. It's why you can do dance. That's why you can sing better. You can learn language. There's so much that you could do. That's really cool that I can't do right now. But because of that, that's why you're so much more likely to become addicted and The industry knew that. That's why they're targeting you. Those are the messages that work a lot better for teens.

First of all, you're right. I'm in teach. See levels we're seeing today's joint is about 10 joints when I was a teen. So the dramatic increases in the potency right now that we're seeing around teach see, and then you get something like gabbing, which is about 80% THC versus 20 to 30% of the more mainstream products. that we have in the market. When I say mainstream, I mean like joints or e-secrets. So the policy has gone up dramatically into this of concern. So depending on the study, you're going to see anywhere from 10 to 20 percent of teens saying that they're using some form of cannabis either smoked or in the form of a joint or a blunt. And for those who don't know a blunt, a lot of people don't realize is a combination of both tobacco and cannabis. It's a cigar leaf or some people buy a cigar and pull out the tobacco and put in the cannabis. Or they'll just get the cigar leaf and roll the cannabis flower. Then you're getting both the kind of the double whammy and the chaser, the high of both of nicotine and THC. So we're seeing a fair number of, it's interesting, even though teens are not smoking cigarettes, they're still using joints, which is interesting. But very quickly, increasing his e-cigarettes with cannabis said there. You can buy a cannabis style e-cigarettes and that's been around for a long time with volcano vaporizers and specific cannabis vaporizers. That's not new, but it's become much, much more popular. But now we're also seeing teens buy and nicotine e-cigarette. Inhale half of it, and then add the cannabis wax or oil to it, and then basically get the combination. I had one young, young teenager, 12, 13, 14 year old young man who said, yeah, I got a cherry nicotine vape, and I inhaled half of it, probably the use of it, but I used half of it, and then I added in some cannabis oil, and now I had a cherry flavored cannabis nicotine device. So we're seeing that more and more and even though you're not technically supposed to in the manufacturers of nicotine cigarettes, they don't open them and add stuff. a simple YouTube video or teach you how to do it. And then, fortunately, the videos are not using gloves and bedzork acid is coming in your skin and things like that.

It supposedly does, yeah, yeah.

correct. Correct. And it only takes about seven to 10 seconds to go through the whole system and into the brain, too. So it's a very fast process. So yes, so teenagers are definitely vaping or using cannabis e-cigarettes. And the problem is, you know, for one teasle think it's healthier than just like nicotine e-cigarettes, I think it's healthier than combustible. I mean, yes, you're not burning yet, but you're still inhaling and you're still inhaling. There seems to be the propelling glycolic glycerin, the flavorance, all the aldehyides, even if it's just just a and cannabis, esegrat. So there's a lot of concern there. And then addiction is still huge. It's a huge issue when you talk about cannabis. The same reasons that we talked about when nicotine, the brain development and so on. Psychosis, just a lot to think about here, psychosis. There's actually some scientists now who are really strongly saying it's not associated with causal. That if you are predetermined to have a mental health issue, psychosis, schizophrenia, then starting to use or using cannabis can actually trigger and cause you to become psychotic. I don't totally understand the mechanism yet. I don't think we totally do yet, but that there seems to be more than just, and might happen. And it seems to be right in that older adolescent young adult time frame that it is happening. So around the same time that the brain's developing and we're heard we're airing the rest of our brain that that changes happening from a neuronal connection perspective.

You know, it's a good question. I honestly don't really know the answer to that of what percentage, the few cases I know of and in talking to the psychiatrist would say that it's causal and it may be permanent. No, it could be, it could be managed. It doesn't mean that somebody is going to be having psychotic episodes all the time. It means certainly can be managed. And certainly we would say, please don't continue to use would be very important. But whether it's completely reversible or something that I'm not sure of somebody more versed in this. What you do in your research and what I know is, you know, changes to the neural circuitry is not changeable. You know, when we heard our brain cells, that is not something that we could recover from, so that is very much concerning.

It's really difficult, and maybe I'll talk about nicotine first, and the same would be true for cannabis, but a little bit less extent, both are addictive. And interestingly, not a lot of people realize that cannabis is addictive, and about 1 in 6 teens or people who are using, particularly under the age of 25, do become addicted.

They don't realize it's addictive.

No, no. You know, I often say people say, well, why do you start studying tobacco? I mean, there is no safe level of tobacco use period. Yes, we have very few 30 year olds who suddenly pick up a cigarette and become addicted. You know, at that point, you, you're development of your brain. Now, kid, if you use regularly, you're still going to hurt your lungs and heart and stuff like that, absolutely, the brain changes may not be there in the same way. But most people don't pick up the cigarette or any cigarette for the very first time in their 30s or 40s and on. So absolutely, it's addictive and it is probably the most difficult to quit drug that's out there. Whereas alcohol, we don't see. I mean, yes, we have alcoholism. I'm not downplaying that as a huge issue. in this country. It's a huge issue on this planet, but you're not going to have people in two weeks, three weeks, suddenly say, I'm addicted to alcohol. You are going to with nicotine in you are with cannabis and to some extent as well. So yes, nicotine is incredibly addictive and we have so many teens who are addicted to nicotine through e-cigarettes and really struggling to get off of it. I give a talk recently to a group of parents And they said, this is all great information, Bonnie, but how do I help my kid? And I just thought, awful, because there's not a lot that we have. So taking a few different things. First of all, we don't have, there are some programs. There are inpatient programs, absolutely, showing some, some. Inpatient programs. There are actually some inpatient programs.

And they take weeks. And then you're taking a young person out of their natural environment, out of their school, out of their friends, stigmatizing, which hopefully we're not stigmatizing drug use anyway. But you know, you take a young person at 12, 14, 16. You put them in another place. That's very difficult to on them. And if part of why they're using in the first place is stress, you're just enhancing that. Outpatient programs, We have some things, but the problem is we don't have the best recommendations because we don't have great research. So for example, nifty replacement, there'll be the patch. First of all, it's not authorized for use by the FDA. It's not put approved by the FDA for anybody under 18. And yet we have a lot of teenagers who are addicted. We just don't have the right studies and they haven't gone to the FDA for that approval. Now, a lot of doctors are using nicotine patches and prescribing them for somebody under 18. It's considered off-label, but you still can do it. And most people would recommend it. The problem is, and I don't mean problem with using them. I have no problem with, and I've often suggested to, and I don't treat. I want to make sure that I'm not misquoted there. Either I don't directly treat and see patients myself. but based on the evidence and the American Academy of Pediatrics recommendations, we should be using a patch with those under 18. But then the question is how much? If a nicotine patch is about 21 milligrams of nicotine and a teenager's using 40 milligrams of today, do you give two patches? And I've had some doctors say, wow, that's a lot of nicotine. I say, well, they're using a lot of nicotine. What I've heard some, my adolescent medicine colleagues have suggested is one patch and then supplement with gums and suckers and law centers. Not as a starting. I don't mean like what we're seeing with some pouches out there like in as a starter. I don't mean that. I mean as a former treatment.

Correct. Correct. And now But then they also don't have the hand to mouth piece that we see that is difficult. So in this case, I mean, non-niqueting gum, just chewing regular gum. I've heard teenagers say that there would draw last three to four minutes. So they have a one teenagers said, I have a playlist on my phone that's each song is three to four minutes. And when I start to feel the withdrawal, I pop the music in my ears. And I go do something, and I listen to the song, and by then that uncomfortable feeling is over. I've heard teens say that they'll run, that there's many different things that they'll do to add a toothpick, not a nicotine toothpick, but it's just a toothpick. Other ways to really get their mind off of that feeling is really important. But we also have to know, with adults and cigarettes, it can take seven to 11 tries. So it can't expect, and totally off of a cigarette, can't expect a teenager to quit overnight.

Most people fail.

Absolutely right. One of the things that we do in our program to help teens quit is we talk about social withdrawal and it was actually one of our we have a wonderful group of 40 youth who work with us we call our youth action board our yeah or reach lab lab our labs say that we need to talk about social withdrawal not just physical because of exactly where you're talking about they may not be able to go to that party at a Saturday night where they know their friends are vaping because it'll, and we know the brain cues up that they'll see or smell or or witness somebody using any cigarette and those cues will happen and they'll want to use it. So they actually have to isolate themselves from their friend group was using so it's very difficult. So really setting up your social mail you really setting up your friends who are not using, really trying to talk and have your family around you. And I really tell parents, it's not the time to get pissed off with your kids for using. It's the time to really help them. Let's be in this together. And often I say the reason why they're using is that they're fault. Let's go back to the beginning of our conversation about marketing and that they're being targeted. And teens didn't even know what was hitting them, what was going on. So let's not be mad at them. Let's be sympathetic and help. So they need the combination of nicotine replacement. They need to change the milieu. They need to have healthy stacks and water and exercise and all kinds of things around them. And they may also need cognitive behavioral therapy or some of the therapy to really get them. It's not going to be a one-stop. We need to work with them. And that's the same with cannabis, by the way. This is just any drugs. And just feel so bad. It is such a problem right now. When we built our curriculums, same thing I said I was doing middle and high school, and never thought I'd do elementary. And we have an elementary curriculum. I thought I was only going to do prevention. We now have an intervention in moving towards cessation. That's how many young people are just struggling right now.

you do and and what you're saying is is so correct and so relevant and why I feel so bad for teens right now and and and the social media right you put put that in there as well and it's all over the place right now with them they're bombarded by all of the different factors that you talked about and it was interesting we were talking about earlier around the social aspects too I was thinking there was a point where it was so cool particularly around you all so cool to jewel that I had teens come up to me and say Dr. Bonnie, do you have a fake e-cigarette? And I said, a fake e-cigarette? Well, yeah, all my friends are using, and I don't want to, but I want to fake it. And I just felt so bad. And I said, well, I'm not going to get you a fake e-cigarette, but I will help you with refuse or skills and teach you how to say no. But in this case, not just saying no, but teach you how to feel good about saying no to certain things that you don't want to be doing. And during that time, it was very difficult for teens to come up and say, I either want to quit or I don't want to be a user. I just don't want to start because that was not cool. I think we changed in the last couple of years, thankfully. I think there are more teens who are not using who are open to it or who are open to quitting a lot of teens want to quit right now. So thankfully we're in a new era where the yes, the pressures to use are absolutely there. But they're starting to be a tide change where we're getting more teens who are getting on the so-called banwagon to either quit or not use. I think the social supports are being there. A lot more than we've ever seen before, we have more youth groups who are getting on board of either trying to help quit or trying to make sure that it's okay not to use. It's still hard and what you're talking about. So it's our job as adults and healthcare providers and community partners and educators to really talk to young people to set up those social groups and say, it's okay not to use. It's okay to come on over to this group and Yeah, maybe you're not going to be with that same social group on Saturday night. Let's start a new social group for you. I'm not saying it's easy. This is not easy for young people and it's not easy. Parents are struggling too. They're struggling to know how to talk to their teenagers. But this is what we have to work towards and setting up the social networks of it's called not to use. One of the other things by the way that we talk about is the environment. When we talk to teens about not using and why it, why it's bad for them, heart lungs, et cetera, and all the things, and being duped and be marketed to, and the money, the environment piece has also been interesting. You know, teens right now may not care about their hearts, their lungs, 20 years from now, but they care about the environment. And there are environmental aspects to these, the plastics, the pods don't disappear. The benzoc acid does not evaporate and we've got second hand vapor, second hand smoke, second hand and third hand. So what I mean by that is if I were to use any cigarette near you, you would actually get a lot of the volatile organic chemicals, a lot of the nicotine is in the air actually some days to just COVID might even be on those droplets. There's a lot of issues there and then third hand is it just doesn't dissipate that vapor air salts on vapor that airs all then settles into carpets and and clothes and so on. And this is toxic to pets, to children, things like that. So when we talk to teens about that, that's another way to get young people to be willing to either quit or to rally around not using as the environment. If I wash dishes for too long, my younger is out of the house, but when she comes over, I get yelled across the room, I'm turn the water off, the environment, we have to say water. That's what they care about so much that if we could at least get that into young people's hands, say, you know what? You may not care about yourself, but what about your friends and what about the environment? I think we can also shift some of the generation right now.

Right. Right.

When we were talking about cigarettes, when I first started my career up until probably 2014, I would say, yes, you're absolutely correct. And it was generally the teens who would say, I'm bored. And I didn't know what to do with myself. And that's why I picked up cigarettes, or I'm not an athlete, or this was my social outlet. I haven't seen that as a result as much with E-sigrette. Now, as a result of E-sigrette, yes, but not as a cause of using because it's so ubiquitous. E-sigrettes, we're seeing everywhere. It doesn't matter if you're how old you are, male, female used to be more males using because some of the earlier devices were where tech and guys were using it and some of the females didn't want to put them in their purse because it would leak. We now are seeing more of an equal rate if not a little bit more female using. It's not your so-called batter good kids. It's not anything. It's not the young people who are struggling with school. It's everywhere right now. It independent of location, race, ethnicity, things like that. So I don't see so much where you're talking about in terms of our predictor, in terms of a result, absolutely. I mean, then we're seeing teens who become more isolated, who are not engaged as much or more bored because they're sitting home in their vaping. But I also see a lot of young people sitting around together vaping. So I do think that that landscape has changed. Is it going to change back? I don't know, is hopefully we change the culture again. But it's interesting thought. I mean, as soon as you said that, I was thinking, yeah, I mean, they're certainly not out as much as they used to be in terms of, you know, we're talking about this at the beginning. We're not seeing them out in parks as much. We're not seeing them playing pick up sports games as much as we used to. But I don't think that's because of Eastern great years. I think that's because of social media and just the whole trade. And honestly, parents being afraid of letting their kids out for some predatory behavior in other ways.

Absolutely the phone connects everywhere and that's something we try to teach teens as well. But I think that that's been something that parents are worried about, you know, I have to sue you. Almost the pendulum almost swung too much of now I have to keep my kid in because I don't want to let them out of the house that I don't want to let them alone driving and alone at the park and things like that. But I think that we've reduced, you were talking earlier about autonomy. We've reduced teens just autonomy and they have to get into a little bit of trouble. They have to J-walk. They have to do, I mean, and the encouraging. But there's some natural amount of getting together and hanging out and being crazy at the park and playing games and things like that. And I think That has stopped or slowed down a lot. I see it with some people in my own community. I don't see as much just hanging out in the front yard and shooting the breeze and instead they're inside and they're on their phones and stuff like that. So could that be part of why we're seeing more Easter grant use? Possibly. I just don't happen. I haven't seen the studies on it.

Yeah, it's a good point. I mean, some of it has to do with just the methods of a research to know, you know, it's interesting. I haven't seen more recent data in terms of differences by sex of a engagement and risk behavior. I mean, a lot of what I've seen is balanced out. I think it's maybe different kinds of risk behaviors that people do. But we're still seeing it. We're still seeing teens drinking. We're still seeing teens going to parties and getting drunk. We're still seeing teens out in the beach and getting drunk. I think the big difference now is whether it's from others against now. I think it's destructive driving. Is that what it's called? I think it's now. I think it's destructive driving. I think that's the thing who's drunk driving and racing and driving under the influence of cannabis or anything else which can be harmful, but at least in a lot of the teens and young adults I've talked to at least we've gotten that word out to teens. So they're still drinking and they're still doing stupid stuff when they drink, but they're not getting behind the wheel as much, much less, and this idea of designated driver, sober driver, um, or Uber, Uber's or left, or any ride chair, let's just say any ride chair has certainly been a game changer in in the landscape of teenagers and younger adults right now. And in fact, I've heard not just a designated driver, but a designated partner or a sober, a sober sitter. So this idea that you go to a party and there may be drinking going on, but you make sure that there's one person who's sober, not just for driving, but to make sure you're not going home with somebody you don't want to go home with, to make sure that you're not leaving, drunk and falling down stairs, to make sure that you're not falling out of that window. So that message we've gotten across really well, which I'm thrilled about. Are we still seeing drunk driving in accidents? I certainly have amongst some people I know. Certainly we are, but I think that the message over all has gone out. There's some people I've talked to said, we just don't get behind the wheel period. What's also interesting is more and more teens are not driving. They're delaying driving more and more, whether that's because of Uber lift. I mean, it's as apparent It's less expensive to pay for a right share than a pay for insurance for somebody under 25, or to pay for a car. So certainly that might be it. But, but that is there. Do another stupid stuff. I mean, addition to drugs, jumping, skateboarding. Certainly we're still seeing that.

Yeah, yeah, we're definitely still seeing risk behavior amongst teenagers. And part of it has to do with impulsivity. We know that teens up into around part of the development, right, of cognitive and social, psychosocial and social development. It's up until around 16, 17, there's still very impulsive. We know with the brain development, right, the back of the brain develops faster and first. And that's our amygdala, our emotional center, our motor coordination versus the front of the brain, which is our executive functioning, our planning for the future, our really slowing down and being able to think of the risks and benefits and make those decisions a little slower and a little bit better, more like we would as adults. So we certainly see impulsive decision, you know, hey, let's go, TP that house or let's go right on that car or let's go do things that probably hopefully wouldn't get them killed or injured but may get them busted in other ways. We're still seeing that. I think there have been more programs to help teens sort of rehearse in situations so they're not in more life skills training so they're not making some of those impulsive decisions. But teens well teens are going to be teens which by the way is why we don't put things in front of them like you know sugarburger and unicorn kind of marketing that's going to get teens attractive because that is buying into that knee jerk impulsive it looks cool everyone's doing a kind of thing that they can't resist I don't mean that they can't but just buys right into teens are going to be teens and that's what they're going to do

Me too. Me too. You drive.

Yeah, stabilizing and going down, and certainly rates of risky sexual behaviors also gone down. So we are getting the message across around condom use around STI testing around birth control, things like that, which is also really good. But rates overall have gone down.

I think it's down. Actually, I haven't looked at the latest numbers. I think it's down. Certainly, I don't think has gone up. But I actually wouldn't need to look back at those numbers. It's been a little while since I've looked at them.

So it totally depends on the behavior that we're talking about.

So interestingly, E-Sigarette nicotine E-Sigarette use has not been his high in a lot of other countries. It depends on the country. But for example, the UK or Europe, we haven't seen the rates as high in the last few years. Part of it was that a lot of other states have a nicotine standard. So that means a minimum amount or maximum amount. Excuse me, of nicotine that you're allowed to have. So for example, the UK, I think it's around 1.7%. In the U.S., we have no nicotine standard, which is another major issue with regulation. We don't have, as I was saying, 5%, 10%, nicotine levels. There is no regulation about how much nicotine that you could have. So in certain countries, if it's right around the addictive level or a little bit below it, we're going to see fewer teens becoming addictive. It's still bad at any amount, but we're going to see fewer people becoming addictive. The other is the marketing was not as big in other countries, and really was the marketing was e-cigarettes if you're trying to stop smoking cigarettes, not marketed to teens. That has changed a little last year or two. So in countries I've talked to, for example, the UK I've been interviewed by them many times the last few years, it They would say, we don't have the same problem. And now they're saying, boy, we are seeing a pretty significant increase in the number of teens who are using. Part of it is a different landscape of the kind of e-cigarette that's out there, the kind of marketing that's out there, whatever it is. We are now seeing, is it as high as we have in the US? I don't think so, but it's certainly increasing. same thing in other countries where they actually didn't allow certain needs of threats to be on the market, have now come in and be on the market and infiltrated. And even in this country, certain needs of threats are illegal and they're coming in, illegally through illicit trading is happening and crossing the borders. So, so easy grid, we're still seeing cannabis depends on this on the country, whether it's legal or not. Even in the US, I should say, even states that have legalized cannabis, you have to be 21, but we're still seeing underage cannabis use, of course, just like we're seeing underage drinking and underage nicotine use. In other states where it's just really difficult to get, we're not seeing cannabis as much, but we still are seeing it.

So this is a case where I've seen this one other time. We're actually the popular presses ahead of the scientific press and probably there ahead of the science and teaching us scientists that we better hurry up and figure this out. So the popular press has been talking about in a lot and arguing that it's a very popular product and that we're seeing Now, this is true. We're seeing a very sharp increase in the market share of ZIN compared to other nicotine products. So we're seeing it on the rise. What I mean by science as in caught up is we don't have a lot of surveillance data to show whether or not teens are actually using ZIN. We have some data. We actually published a study a couple of years ago showing around 20 to 25% of people in general adolescents and adults and about 11 to 15% of teens are using a pouch. Presumably ZIN, we didn't ask. We now are looking at our data around ZIN use. but we don't have wide scale studies. We do have studies of pouches more generally like the CDC show that about, I think it was a couple of percent, one and a half percent, and that it went up a little bit. So I think I can't remember. It was something like I think it went from one point one percent to about 1.5 percent of teens seem to be admitting using pouches. So not a huge increase, but A few hundred thousand teens are using across the country as opposed to two and a half million plus using e-cigarettes. But with all those qualifications aside, yes, we are seeing an increase in use amongst teenagers. What's most concerning is that it seems like it's teenagers who are not using it in addition to e-cigarettes, but new initiates. So they're now just like I'm concerned about teens initiating tobacco or nicotine through e-cigarettes. Now it seems like summer initiating through Zen.

It may be an r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r-r- And I don't know what else is in there. We are really lacking the research there. But my concern is we've seen this with smokeless tobacco for years is oral cancer. And you're putting this in the mouth and at the mucosal line and are we going to start being concerned about oral cancer, which we've already been concerned about with other pouches.

The question is what else is in there? Is it just nicotine or is there aldehydes and other chemicals that are cut with it? So that's why we don't know enough about it. My big concern is exactly where we're saying, are we going to start seeing teens using nicotine and them? Nicotine pouches and moving on. But the brain piece, it doesn't matter what else is in there. We are still concerned about the brain development. And if you're using a 3 milligram or 6 milligram pouch and we know that a lot of teens are using multiple pouches are studied showed this as well. multiple pouches throughout the day and actually some social media is showing teens putting in several pouches at the same time. Then you might be getting again as much as a pack of cigarettes of nicotine and that's very concerning. So the whole piece we talked about before about brain development and are we studying or changing or really rewiring the brain when nicotine doesn't matter what form it's in. It is not going in. It is not good for teenagers.

I think it's 15 to 20 pouches per can

And do the math. Do the math. What's that? 60 upwards of 60 milligrams. That's, that's, and I'm thinking back to you. The impacts of cigarettes. You got your, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you're, you pack cigarette years, right? How many packs of cigarettes and how many years? And that language kind of reduced for a while because adults and people weren't using cigarettes as much. And so we weren't worrying about this concept of packs. I'm worried about it again. We're getting so much nicotine now. Now, yes, not in the form of combusted, not in the form of burning, maybe it's in the form of e-cigarettes or pouches, but it's still a huge amount of nicotine that we're seeing that young, very young brains are using.

And then you go back to the eight-year-olds we were talking about earlier. And we have no studies, right? On what does a drug like nicotine do to not a teen brain, but a child brain? And clearly, it's not good. But what exactly is happening? We don't have those studies, but it's incredibly scary to think about what's happening with young people and getting addicted so young and they continue in that addiction of a lifetime of addiction that they might have.

The most important is, and I've said this for years, have a conversation. And some people think that having a conversation about name your name your risk behavior drugs a very sort out called tobacco other drugs having conversation about sex having conversation about risky driving get young people curious that is not at all the case there's nothing we can talk to a young person about that they don't already know We're kidding ourselves to say, oh, we can't mention drugs to a 16 year old because we're going to get them curious. They've noted about drugs since they were eight years old. And I often say to parents, start that conversation young. When your kids are really young for five, maybe the conversation is having a cookie or having some grapes. And make, or going to bed now, we're going to bed in five minutes. I used to say that with my own kids. You want to go to bed now, we're in five minutes. So they felt like they were making the decision. I didn't really care which decision they were making. It was not a fight. We need to start having conversations around decision making and healthy decision making and not have a confrontation, but a conversation. very young. Now, I'm not saying that we talk about drugs or sex when they're very young, although to be honest, I did. I talked about cigarettes and and and puberty development with my kids when they were very young, but it, but just starting that conversation so that when you move into more sensitive topics for difficult topics as a child ages and becomes an older child and into an adolescence, it's not shocking that you're having this conversations. And this is whether you're a parent, an educator, or whatever. So just talking, a conversation. and not scheduling it, by the way, not on Saturday at three o'clock. We're going to sit down and talk about sex, or three o'clock, we're going to talk about drugs. That does not work. You need to, I would joke that was like the Queen of Organic Conversation. You know, I'd see something on TV. Oh, you know, oh, let's have a conversation about that, just making it a natural part. And you were asking about differences in cultures and countries, we don't normalize those conversations, other countries do, and we need to be doing that.

Correct. We don't. So that's one thing. The other is we're kidding ourselves if we just talk about the just saying hours we're saying before. Of course we want no use. Of course we want teens to wait. I mean, I haven't say we hope and expect that most people, if not all, will grow up into a healthy sexual relationship, whatever that might look like. Even a healthy alcohol relationship, a glass of wine, or half a glass of wine, and I would dinner. Again, no safe use of a lot of the other drugs, including nicotine, certainly fentanyl, but illicit fentanyl. I want to make clear, not all fentanyl, but illicit fentanyl. But to just simply say, no, and don't do, and it's bad for you, is setting up again that failure of your conversation because, okay, well, you're telling me it's bad, but I liked it, or my friend liked it, and it's not so bad. So you've lost credibility. The most important part of her production is not to do it. Absolutely, of course. Not to use, not to have risky sex. Maybe not to have sex at all until you're older. Not to use tobacco, not to use any drugs. But how do we do that with a young person who you go into a classroom and 10%, 20% of already started using or having sex or whatever the conversation is? You shut them down. Well, they don't understand me, so why should I listen to them? They're not talking to me. And so that no use conversation doesn't work. There's a continuum or spectrum of use. Everything from no use to once a while to regularly use all the way up to addicted to use. We're talking about drugs. So to go in and assume that nobody's ever used or nobody wants to use, you're setting yourself up for failure. That's the expectation that's the hope, but what we really also need to talk about is, best if you don't use, but if you do, if you are using, let's help you cut back or quit. And if you are continuing to use, let's keep you safe. Let's make sure that you're not gonna die. And when I'm talking about here is, you know, When most parents, if their kids are going to go to a party, why should say most parents? But a conversation often is, hey, I hope you're not drinking, but if you are, pick up the phone and I will come get you. That's harm reduction. And parents, oh, I didn't think about that. Well, that's putting safety first. That is a harm reduction message. or saying, you know, you're pretty young to start having sex, but here's a condom just in case. Why do schools have condoms in? Because they know that as much as we say, it's best to delay teens are going to. That's harm reduction. Let's at least reduce risk of STI's pregnancy and so on.

All the research are pretty much all the research that I've read and hopefully will contribute to shows that those messages, the harm reduction messages, or what I would say comprehensive, really the harm reduction. Unfortunately, harm reduction has gotten a bad rap partly because of cigarettes versus AC cigarettes and this reduction or harm continuum with tobacco. So maybe we don't say harm reduction. We say comprehensive conversations, comprehensive education from no use all the way up to what do we do if you are using and all the research is really saying that those messages are way more effective than not using it all than that. If we tell teens don't use, and we see this a lot in sexual behavior, we say, do not have sex, period, sign a contract that you're not going to have sex. And then they're in a situation. And we don't arm them with the understanding of how to negotiate, how to have a healthy relationship, how to have a conversation. What do they do if they're thinking that they might want to have sex? What do they do in that situation? We then find that we're having teens who then don't know how to protect themselves. and either have sex that was unwanted or sex that was unprotected and teens want to understand. They want the truth. They want the knowledge. I went to a school and asked whether if I came and talked about cannabis when they come and they said, absolutely, I want to understand it. And there's this great quote that I recently learned, that said, if you don't, basically the concept is, if you don't teach teens, they're going to seek out information. So the quote is, having teens learn about sex from porn is like having them learn physics from a transformer, from the transformers, or having them learn how to drive from fast and furious. We need to give teens the information, because they're going to find it.

counterbalances, real science based information that's not overblowing the risks, that's not scaring them. And then that helps them understand it's best to say no, but if you do fentanyl, let's make sure you're not using a loan. I mean, I was saying I don't want somebody using a drug that hasn't been tested and they got off the internet period because I know kids who have died.

Yeah, it was more in the 20s and 30s. It's now really getting into the teens and younger adults. You're absolutely right. And some of the teens I know of who and young adults who have died were not your drug users. You know, we talked about not stigmatizing. And that's the other thing. If we don't talk, then we're stigmatizing. We need to have those conversations. But a lot of those teens were not used. And they needed a pill because they were in pain or they needed something. And they were not told. And this is again, that harm reduction in that conversation. They were not told. Don't buy something off of the internet. If you do test it. And it tests it with a fentanyl strip, for example, and make sure that you're not using a loan. because if you're using alone, we can't then give you an arcane. We can't do something. I carry an arcane with me all the time. Do you really? I do.

It's a particular thing. Thankfully, it hasn't happened, but if it does, and you can't hurt somebody from using it if that's something's happening. Just everyone carry an arcane. I think everybody should have Narcan. I do. I think every school should have Narcan. I think every library should have Narcan. I think every bar should have Narcan. I absolutely believe it. Now, test trips is an interesting debate that I've had. Totally believe in this concept of comprehensive, if you don't want to say wrong, or would actually comprehensive drug education, comprehensive sex education. And what I mean by that is both the spectrum of use or behavior, as well as all kinds of drug sex rock and roll that we talk about the whole thing. But if that non-test trips has been an interesting dilemma within myself, and I'll explain why. I've been working with some groups to try to test whether we could study whether if we put both Narcan and fentanyl test trips in schools, which means you get them. So, your, my fantasy, bowl of condoms, bowl of Narcan, bowl of fentanyl test trips, and you have it out for teens.

It is a very bold statement.

So I've grappled with that. And with condoms, we know that that's not the case. It's not going to create teens starting to have sex. Just going back to what we said a few minutes ago, you're not going to incentivize or create people engaging in any risk behavior by having the conversation. But my grappling with the Narcan and with the fentanyl test trips has been there. Well, you tell me it's about idea to use a drug, but I'll just test it, make sure it's okay. We'll have a couple of problems with that. Even though I still believe it, I still believe in having those there because right now we have an overdose epidemic with fentanyl and other drugs. So I'll be honest with you. I grapple. If I were in a school and I saw a teenager taking a fentanyl test strap, which probably means that they're going to use it for themselves, is the first thing I want to do, shake the kid and say, are you crazy? Don't. That means that you're thinking about using drugs. Of course, that's my inclination as a parent, as a scientist, as a developmental psychologist, as a human being. You want to say, what are you doing? So, yes, I would grapple. At the same time, if I know that there's a chance that a teen's gonna go to a party or pick up a drug and not know, do I, would I rather that they're safe? Yes. The problem with fentanyl test trips, though, is that they're not perfect. If you are testing the right side of the pill, but it's the left side that has fentanyl, you still could die. And so I don't want to give the impression that there's one stop is going to fix anything right now. It is not. And that is the issue with the comprehensive drug education or harm reduction conversations. I'm not saying that it's perfect. I'm not saying that it's going to stop young people from engaging or young people from getting hurt or, you know, unfortunately dying. But if you have a group of youth who are going to use, I would still rather arm them with that information, so they don't find themselves in trouble. That is the biggest part that scares me.

So, the most of what I've seen is either by itself, and all, using, or that it's mixed into pain pills a lot. Wow, if you want to take pain pills, I mean, they're in pain, they're stressed.

correct or prosak their anxious.

Some are, some aren't. I mean there's been so many different circumstances. Cannabis and vaping have been interesting debates and we actually had this just the other day. Some of the studies suggest and that and and suggested biologically we can't necessarily combine cannabis or nicotine and fentanyl and have the same reaction on the body and some suggesting that the studies haven't been there. And it's still so new, but I will tell you that the talking to teens and some some studies suggesting that yes teens are combining or at least getting. And a lot of times it's not knowingly, it's cut, the fentanyl is cutty or the drug Manufacturers and sellers are cutting a drug with fentanyl. And so they're not even teens are knowing it. But that's some, I was talking to a person the other day who said that he has definitely heard of and seen some teens with fentanyl overdoses from cannabis or from vaping. So there's so much studies that are still needed right now and to understand the biological mechanism. As was the access to these drugs that we don't know, but I'm nervous. So we teach about drug testing. We teach about not going to something else. It used to be a skittled drug parties. You'd go with people would take drugs and all different things and put them in the middle of a bowl in the middle of the room and just you take whatever. Wow. Oh yeah. When was that? No. This is not long ago. Maybe five ten years ago. I was hearing about this.

I didn't either, but I didn't go anywhere.

And so yeah, in self-medication is everywhere. That wasn't, that wasn't common.

I think it was, I mean, I remember as a middle school student and walking into the bathroom and somebody had taken, I think it was kind of rude then and had passed out. It was certainly around different drugs, but not the same that we're seeing now. And we definitely saw cocaine overdoses when I was younger.

I will tell you, I'm optimistic in seeing a change in the landscape of education. Now, some people say education doesn't work, that we need policies, we need both. I mean, we have federal policies and regulations that are slipping through the cracks, FDA with regulation of visa grads with cannabis, legalization, but not being enforced. We have age restrictions not being enforced. So we certainly need education, and I'm seeing more and more people, for example, the concept of harm reduction or comprehensive education, comprehensive sex, I had not everybody's of course up for it, but we're open to it, but I'm seeing more of a shift towards understanding the need. I'm definitely seeing more teens, as we were talking about earlier, more teens being willing to say, no, that's not something I'm going to do. More teens joining youth groups, more teens speaking out about concerns and trying to be healthier and make healthier decisions for themselves. So I'm optimistic in the human capital and the social capital. I'm not optimistic when it comes to the pharmacology or the drug capital, so to speak. More and more drugs, infiltrating, infiltrating our youth. I mean, you could vape, dot, dot, dot anything nowadays and that makes me very nervous. I do think vaping, and I am using vaping instead of e-cigarettes there to be more lay conversations there, or what the culture is saying, vaping is just more normalized than if ever had it, just like smoking was normalized. Vaping and now vaping anything is very scary to me and very much normalized, so that worries me again, the fentanyl, the hallucinogens. It's way more and more so that the drugs themselves and the new devices scares me, the social and the human capital gives me optimism.

Totally agree. Totally agree. And I often say to parents or educators, if you're listening to this podcast or any, it's actually saying, hey, I learned something. Can we have a conversation about what I learned? And not confront, again, it's a conversation on a confrontation. It's let's normalize drug discussions, let's normalize behavior discussions, not normalize the use or the behavior itself. Talk to your teams. You're absolutely right. Talk to your teams. This is what I just learned. What do you know? Can we find out some information together? Go on our reach lab websites, go on other websites, go learn information out there, learn together, and not lecture, but have a conversation. You may not know right away. Team may not tell you right away. Yes, I'm using or yes, I'm having sex or yes, I'm drinking alcohol or yes, I'm doing something that is just an risky behavior. But that's not necessarily a goal as adults to find out today whether or not somebody is doing something. It's okay to let it be a little bit more organic. It's okay to start that conversation and see that's your building trust. It is parent-to-parent, but I would say I'm not going to bust you. I certainly am not going to be happy, but let's have a conversation so that way we can build the trust and I can help you either not use get help, stop using or be safer in using, or help you prevent from using at all. So having that conversation that organic And talking to teens where they're at, as a developmentalist, that's what we do. Meet people where they're at, meet youth where they're at, whether that's using already, not using, don't come at them with your preconceived notions as an adult, because it will not work. It will backfire. We need to use the strengths young people are strong, young people are smart. We need to use their strengths, take their lead, and then use our adult wisdom and experiences to then turn that into the proper conversation.

We've done studies where we've asked teens about their goals and I want to be a dancer. We had one teen tell us or I want to be a doctor or I want to be whatever it is. Asking teens about their goals, about their aspirations and then connecting their current behavior and their current risks and keeping themselves healthy and how that plays into their goals. That tends to work a lot and we've seen that in our studies, teens set boundaries. I don't want to get pregnant because I want to be a dancer. Things like that. So really linking what they're doing now to their ultimate goals is one way to really help them think that through.

So I mentioned some of them around our youth group and about the youth movement now against drugs and other things. I think, and it comes the optimism, I'm the biggest teen advocate out there. It's why I study adolescence and I do the prevention and advocacy work that I do. Teenagers are fundamentally fantastic. They're creative. They're passionate. Teens care about the environment. Kids really tease really care about social justice. Teens do care about our future and our planet. That is wonderful. Well, more than do adults right now. So I think we should be capitalizing on that. Teens are incredibly creative. We need to be working with teens and young adults in everything that we do because they are a future. And I know me that as a cliche. I really mean that. So having the conversation, let them be part of that conversation, help them. find out what they think we should do to solve some of their problems. They're the ones to talk to. So I am very optimistic about teenagers. We have 40 teenagers who and young adults who work with us all the time on our work because we trust them. So I think some people are afraid of teens. I embrace them. I think they're fantastic.

Sure, what we know that during the adolescence that nicotine changes the brain wiring, and what do I mean by that? We're actually born with the nicotine receptors. We're born with the ability to become addicted to nicotine, same thing with the cannabis you were talking about before. So if we don't during the adolescent time when we're pruning away and getting rid of the connections, the neurons that we don't need, what happens is during their process, anything that we don't use that we don't reinforce goes away. Well, if we introduce nicotine into our brain, it's solidifies it. Keeps that the receptor there and also makes it to where our receptor is really kind of, I think of it as like keys and locks and the key and suddenly you've got that receptor and it says, oh, you're putting nicotine in there. keep that in there or cups. It's developing those cups I often think about. And filling those cups with nicotine and those cups are your receptors that we're already there. You then take away that nicotine and your cups say, I need more. So you're rewiring your brain. You're wiring your brain to be more likely to become addicted. And now you're addicted and you need to keep feeding those cups with nicotine or you're going to go through a withdrawal. And so that is what happened during an adolescent and young adult that we don't see in adults. That's why we really want to keep young people away from nicotine as long as possible.

Yeah, I don't know as much actually in the developing brain. I'm sure there is. I don't know where there is, but there's clear evidence about viewing pornography around just not having good healthy sexual relationships because porn is not normal. It is not a normal relationship between two people. what your adore is really making it so that way you you're you're not necessarily developing a health relationship with your partner because you're assuming some gold standard out there that may or may not be able to be achieved so and it also is also a problem with body shaming and the body types that most people don't have and can't achieve and that's that's another problem out there with with with with pornography

So, absolutely. There are plenty of studies that show the bidirectional relationship between anxiety, depression, mental health and substance use. Your right, a lot of teens are self-medicating by using various substances to reduce their anxiety, reduce their stress. And also just social lubrication, right, of going into a party and pre-gaming or going into a party and using drugs to make themselves less stiff, less stressed during that situation. But more work we're talking about is that they're self-medicating because they're feeling sad or uncomfortable. And this is, they think helping them again. It's not helping. It's making them feel less bad by continuing to use. But we also do know that drugs also lead to suicidal ideations, suicidal attempts, psychosis, and other mental health issues. We also know that drugs lead to reduced academic achievement, even though there's some potential cognitive reinforcement that's going on, there's also some issues with lack of concentration. The other piece, by the way, that we talked about a lot, but it's the co-use that we're seeing a lot of teens, not just using multiple products, but using them together. So a lot of teens who are chasing cannabis in tobacco, because they didn't enhance us the high or they're using cannabis without alcohol and other mixing of drugs, which is enhancing the high, but not a good way in very scary for young people. And a lot of times young people don't even realize, like with blunt switches, truly is our same before using nicotine and cannabis together that you're actually becoming addicted to both products really simultaneously and that we're seeing young people who are having mental health issues in depression we're likely to use both products so definitely linkages there amongst mental health issues and multiple products as well so polypharmacology yeah

Thank you very much.