Chapters Transcript Adolescent Nicotine Use Dr. Schuh discusses the importance of nicotine on adolescent health and alternative methods of nicotine delivery. Haple of objectives for today. One is to demonstrate knowledge of alternative methods of nicotine delivery, also to discuss the importance of nicotine on adolescent health, and then finally, identifying these opportunities to affect change from individual treatment to federal advocacy. So here's our outline, do a little bit of baby 101, catch everybody up on the latest and greatest, talk about some of the other new alternative nicotine delivery methods, um, talk about some nicotine addiction, some of those health effects of nicotine proper, um, touch base a little bit on the National Youth Tobacco survey, talk about some of the latest news in adolescent medicine. Still muted. Thank you, Angela. Try. No. The green lights are on. I mean, I definitely clicked the thing and then this that was taught me. OK, I think it may be like a oh somebody else does hear me thanks all right I don't know. I'm gonna go out the Lynn I'm in and hot thank you so much. cool. All right, we're just gonna keep on moving forward, um, because it seems like focuss will can hear me, um, OK, talk about, uh, individual treatment and also some of the efficacy. So, baby 101, we're gonna start um early morning quiz. OK, these two gentlemen posing real nice in their hoodies, um, but one of them has a vape. Um, give me like a real aggressive hand raise if you think it's one that has the vape. Ah, there we go. Thank you so much. OK, who thinks #2 has a baby? Wow, that's amazing. Why? Why 2? Can't see his thumb. So it's all about, it's the thumb that makes or breaks the baby. OK, I like it. All right, so, um. Are strong words. Number one it's crazy. OK, so actually, um, the way that he is, um, has the bait is actually the strings in his hoodie, right? Like, so you can like pick up that hoodie string and Yeah, all right, cool. OK, one more quiz to warm us up. Oh, I've been through twice, um, here, but anyways, some, uh, school supplies here. We've got labels 1234, and 5. If you can't see over on the side, feel free to come center. Um, but anyways, um, I'm gonna do the same thing, show of hands as we go through numbers, which ones are vapes, OK? Who thinks number 1 is a vape? Yes, good, coming out strong. OK, 2, yeah, excellent. 3. Yes, thank you. 4, can I get 4? Uh-huh, wonderful. And how about 5. Yeah, wonderful. OK, great. I love the variety of answers. So, um, 2 and 4 are vapes. They look like highlighters, they function as highlighters, and they are vapes. Is this highlighters? Yeah, I'll show you another picture of this. So basically you pop off that highlighter part, um, there's a charger on the bottom, so you just like puff on the top, um. And like these are pretty sneaky and you can like put them in your pencil pouch, you know, at school and nobody knows. All right, strong work. All right, um, simple definitions for vaping, uh, it's just inhaling and exhaling an aerosol, um, often referred to as a vapor produced by an e-cigarette or similar device. That's it. Breathe in, breathe out, aerosol, not vapor. There are 4 major components to any vape itself. There's a battery, right? You need some power, um, to heat up liquid. You need an atomizer, that's like your coil or something like that, that's going to turn your e-liquid into the aerosol that you're then going to be able to inhale. You need a cartridge to hold on to that liquid, and then a mouthpiece in which to like breathe through. This is gonna come up again, um, later on in the presentation. These are like the hot items in adolescent baby. Um, so we got the elf bar, which we'll talk about some more, but it's technically no longer called an elf bar, but it's still an elf bar and functions in reality. There's breeze, puff. Bar Fed, Mr. Fog, the Escobar, um, and Juulel. Juulel, uh, that's a fain one because like that's like where all this kind of really kicked off with adolescent nicotine use and it's coming back full circle. We'll talk about that some more as well, but this is a mix of disposable and cartridge-based vapes. These are hot with adolescents because they're small, easily hidden, right? They're kind of pretty looking, they're really simple to use. So there are some vapes that we're not talking about today, that you might see somebody who doesn't care if you know if they vape. That's like all these buttons and adjustments and power levels and blah blah blah. This is just like, you put it in your mouth, you inhale, you get that vapor, and then you're done, you can slip it back into that hoodie pocket. Um, so they're pretty simple to use. They're also often nicotine salts. So nicotine salts versus nicotine-free, like free-based nicotine. Free-based nicotine sucks. It hurts, it burns your throat. Nicotine salts are like much more mellow, um, and so you can inhale a lot more nicotine without all the awfulness. Um, they're also available on social media, because someone buys them, posts on their Snapchat, says it's like, yo, I got some vapes for sale, and anybody can get them, and they come in all kinds of flavors. Um, so these are not the most popular options, but these are also all vapes, right? We already talked about the highlighter being a vape where you pull out that top of the like highlighter marks part and are able to inhale and vape. Um, an iPhone case, it feels like a big investment for like, I don't know, just to be able to vape, and I don't think like nobody has antennas on their iPhone cases anymore, so like I don't think it's that hidden, but. Incorporated vaporware is a big brand that also includes like, basically this is a camel back for vapes. So the same thing, it goes through, right, the, the hook. So as you're hiking and you're like sucking wind from all the smoking you're doing, like you can hit your vape again, uh, and then this is a smartwatch, smartwatch that tells you the time, whatever, doesn't connect to your phone, but then you like pop out that face. Inhale and put it back in. I know it's amazing stuff. Um, OK, and then, um, recent, um, research out there about like why are your adolescents baby, like what's the point for them, um, and so in the study of 8 through 12th graders, um. They surveyed like people who have vaped in the past month, and then like, why are you vaping? So, 56% said that they vape to relax, right? So like, that's something that we can maybe help with. Um, 42% said that they're just like experimenting, curious about like what it's all about. Uh, just under 40% are bored, so it's what they do to fill their time. Um, 38% say that it tastes good, that's where those flavors come in, and then like. This is not, this is not actually sequential. There's a whole lot in between, but 13% looks cool, right? And that's what I always think about, like why do you smoke because it looks cool, right? But it's actually not like the most prominent, uh, reason for people to be vaping. The other question that I always have is like, how much nicotine is in a vape? So, you'll get different numbers here, but in general, the amount of nicotine that your body gets through smoking one cigarette is about 1 mg. Um, we're gonna do some math today too. Um, there's 2 cigarettes in a pack, which means, you know, you like cross out your cigarettes and then you like, do your stuff, and um that means that basically you're gonna get 20 mg of nicotine per pack of cigarettes that you smoke. But a vape is weird cause it's like different volumes and different concentrations and all kinds of things. So, different labels that you might see on a vape is like percentage. So like, here's some e-liquid bar juice, blueberry flavor, that's 2% Nick salt, so that's something that you might see. You also might just see like a total number of milligrams, which is not actually total, it's still a like percentage of, but it's just labeled differently, so this is gonna be 20 mg, it's the same as 2%. All of this is 20 mg per milliliter, right? So if you have a gallon of liquid, and it's labeled 20 mg, it's not 20 mg for that gallon of e-liquid, it's 20 mg per milliliter of that liquid. So L bar that we hit on a little bit, that is no longer called LB because they're illegal, um, has 20 has is the 2% or the 20 mg, which is 20 mg per uh 20 mg of nicotine per milliliter. Or 10 mL of um liquid in an elf bar, math, and that means that there's 200 mg of nicotine per elf bar. Which da da da da is equivalent to 10 packs of cigarettes. Um, so that's like a lot of nicotine in like a little nice handy thing that you can like quickly slip into your pocket. All right, so the other thing that's like nicotine is going to be the most common thing that people are vaping, but like you absolutely can vape cannabis, right? There's like THC and CBD options, and I, I have yet to meet someone who actually does this, but it exists. You can like fake melatonin. It's like sold as like. I don't know, a quicker way to fall asleep, I don't know, but like you can get it, and even this is in cosmic berry, right? So like you're gonna fall asleep quickly, hit your other baby pen with melatonin in it, um, to, uh, I don't know, get a good night's rest. There's another alternative nicotine delivery, uh, that's coming up high, and that is, um, the nicotine pouches. Yeah, so this is, um, as you can see, like the drift on the left, but they're like, there's no smoke here, there's no vapor, there's no tobacco leaf, which is like, I don't know, the nicotine's derived from tobacco leaf, so it's not the tobacco leaf itself. You still get the other pieces to it. You don't have to spit. There's no battery that's going to run out. Um, and in January of this year of 2025, right, the whole thing is FDA is. Managing nicotine stuff now, so 2025, FDA said, OK, zen, only zen right now can absolutely sell um their pocket in two strengths, 3 mg and 6 mg, and most interesting to me is that there's like flavors that are approved. Um, so there's Zen chill, cinnamon, citrus, coffee, cool mint, menthol. Peppermint smooth, spearmint, wintergreen, all these different options for flavors of nicotine pouches. Well, you're not allowed to have flavors when it comes to a vape, but you can with a nicotine pouch. Drift Envelo, um, not yet FDA approved, still like in the process of either getting denied or approved. So because like we're like, I don't know what to do here. Yeah, you just keep selling it. So like technically they can still be sold even though they're not approved. One thing I'm really curious about, right, is like there's such a big push for vaping to like get rid of flavors, to get rid of like these things that are easily accessed by adolescents, and that's because they don't want teenagers to get addicted to nicotine. But like now they're approving flavors in nicotine pouches. Nicotine pouches aren't used as much, but like, what about when they start getting used as much, right? Are we going to like backtrack against these flavors? I don't know. We'll see. All right, help the action. I lied, nicotine addiction. OK, nicotine addiction, simply adaptation to nicotine over time, and those psychoactive actions of nicotine are related to its release of dopamine, that's drug-induced reward. The other amazing thing about nicotine addiction is that like almost 90% of adult smokers started smoking by the time that they were 18, right? So that's all of us graduating high school, um, that like, you have a pretty good chance if you can get through high school without smoking, like, you know, you just kind of might not smoke for the rest of your life. That's also then why it's really important for adolescent medicine and just taking care of adolescents in general. And by the time you all graduated from med school, maybe, I don't know, aged around 26, right? That's like where 100% of people who are adult smokers would have started by then. Um, so if you can get through med school without smoking, golden. And absolutely I'm worried about the health effects of nicotine itself, but we also know that when people are addicted to nicotine, when people are using e-cigarettes, they're 3.5 times more likely to use a traditional cigarette, and that's horrible, right? Like lighting a plant on fire and inhaling it into your lungs, like that's where a lot of that damage happens. It's not just the nicotine, it's all the other combustible things. Um, so nicotine addiction, adolescents, they are definitely more prone to addiction. Um, even with intermittent exposure, the adolescent brain is just more susceptible, right? So it just doesn't take as much as often to get them addicted. We also know that social media, I know this is an old Twitter thing, it should be an X, um, but like social media plays a big role, right into the social environmental influences of nicotine use by adolescents. And we also know that the younger you start smoking or using nicotine, the more rapidly you transition to more frequent like daily or multiple times a day use. All right, health effects of nicotine proper, not lighting tobacco leaves on fire. So, nicotine um uh induces changes in drug-seeking behavior. We know that there are long-term changes in the brain's reward system um from nicotine use and. And this is because vaping is not quite as old as traditional cigarette smoking, but for adolescents that smoke traditional cigarettes, there's a higher rate of comorbid substance abuse, alcohol, cannabis, stimulants, petty light. There's also uh impacts on attention and cognition. So you know that adolescent smokers, again on traditional cigarettes, so not specifically, um, just the vaping, um, have been found to have chronic impairments in the accuracy of working memory. They show decreased prefrontal cortex activation during attention tasks, and it's a two-way street with mood, OK? So, um, people, adolescents with mental health disorders are more likely to smoke, and people who smoke are more likely to have anxiety. So it's a little bit of back and forth, um, both ways there. And then that's like, you know, reasonably low dosing of nicotine. There's also always that concern of acute toxicity, um, from nicotine exposure in those high doses, right? It's hard to like acutely intoxicate yourself on a traditional cigarette, but a concentrated e-liquid is much easier. So, um, this study just came out, um, in August that evaluated, uh. single um single substance nicotine ingestions among kids under the age of 6, which is where like most of these, um, acute toxicities happen. Uh, then that were reported to the National Poison Data System from 2010 to 2023, so there are over 100,000 nicotine ingestions in this age group, um. Mostly under the age of 2, like 3 quarters of them, mostly boys, not surprised, but only 55%, um, and mostly occurred at home, 98% occurred at home. Um, and so the thing that I think is really interesting is looking at this data over time, those blue circles, that's the liquids, right, that's the e-liquids, and so this is like coinciding with just like that boom in popularity of vaping in general, and then a slow downward trend. Like I remember, I don't know. Med school, I think, like going to the state capitol to talk about childproofing um e-liquid, right, making it harder to just like open up as a 2 year old. So that's starting to go down, and then even more interesting, as I alluded to a little bit with those nicotine pouches, those are those like X's towards the bottom right, right, we're starting to see like a really big increase in nicotine um ingestions and acute toxicity from those pouches themselves. And then there are other stuff, other stuff in vapes other than just the nicotine. So there are volatile organic compounds, um, some of those are known carcinogens. There's also those ultrafine particles that get down really deep into the rechyma of the lungs and cause inflammation, which is bad. Um, there's other cancer causing chemicals, so this is like almost every single, I mean there's some. Explains otherwise, but in general, all the nicotine in all these products come from tobacco leaves, right? They like extract it out, but they don't just steal the nicotine out of those leaves, they're getting a lot of other things too that are also bad. So we know that there are also tobacco-specific nitrosamines from that nicotine combustion. So yeah, it's not lighting a cigarette on fire, but you're still getting some of those harmful effects. And then evidence is still evolving, in general, we know that vaping is not good for your health, um. There's evidence that e-cigarettes cause Endothelial dysfunction, oxidative stress, and that chemicals and e-cigarettes cause DNA damage and mutogenesis. Which are not good things. All right, National Youth Tobacco survey, anybody here uh familiar with the National Youth Tobacco Survey? No, OK, cool, wonderful. Great, good that I have this next slide then. All right, so the National Youth Tobacco Survey was designed to provide national data on indicators key to the design, implementation, evaluation of comprehensive tobacco prevention and control programs, and serves as that baseline and comparing for progress toward meeting Healthy people 2030 goals for reducing tobacco use among youth. So this goes out every single year. Then flashback to dark times. This is the national youth tobacco survey from 2019, and like vaping and tobacco use was rampant. So this figure is from the 2019 data, tobacco product use among high school students, and this is people who have like current use, right? So that's within the past 30 days that they've used a nicotine product, and e-cigarettes, this is the peak, over 1 in 4, right? Um, high school student was using an e-cigarette, um, and almost 1 in 3 was using any kind of tobacco product. Very fortunately, now we're transitioning to looking at high schoolers, just e-cigarette use, but more able to like look at that data over time, right? We see 2019 was that peak at that 27.5%. Most recent data in 2024 is down to 7.8%, which is amazing, but that's still a lot of like adolescents who are using nicotine. So, again, a little bit of transition here to, this is more comprehensive, looking at the 2024 data, current tobacco product use among US middle school and high school students, right? So we're gonna loop in those middle school students with this data here. Couple of things to pull. Um, 2024, we have 2.25 billion youth, 8.1%, who've reported currently of any tobacco product. Um, that's down from 2.8 million in 2023, that's awesome. Um, there's 1.6 million youth, that's the 5.9% with e-cigarettes, who reported that current use of e-cigarettes, and that's down from 2.13 million in 2023. So all good things. Um, on the downward trend, one thing that's still not great is like huge racial and ethnic disparities in tobacco use, right? So on the like the highest proportion of use is that non-Hispanic American, Indian or Alaska Native, and this is any tobacco product used in the past 3 days, right, 16%. Which is crazy, especially when we compare it to the very bottom there, non-Hispanic, Asian, it's only 3.3%, right? So that's like, I mean, that's freaking huge differences, um, that are going to be important to like pay attention to and target as we're trying to improve some of the adolescent health. Couple other highlights from the National Youth Tobacco survey. Um, one, we, we saw these, we'll look at these again, but the most popular brands, none of, uh, well, Juul, we'll get to that. Almost none of these are legally sold in the United States, um, and yet they are used everywhere. Al Barbreeze, Mr. Fogg used. Of the people who reported current e-cigarette use, right, so in the past 30 days, 1 in 4 are using them every single day, which is like the fiction and not good, and most of them are using flavored e-cigarettes again, which are not legally allowed to be sold in the United States, and yet here they are, almost 90% of these current users are using flavored e-cigarettes. Fruit is, you know, just the most popular flavor. So, flashback to vaping 101, these are some of those vapes that we looked at. This elf bar, which still has the name elf bar on it, strawberry pina colada. Breeze is blueberry mint. Um, anybody know what OMG flavor is? Orange, mango, guava. I know, like, it's genius marketing, right? To adolescents of like OMG, right? And then you just like force in the flavors into that to make it work. Um, all right, and then the Mr. Fog is a great blue raspberry, lemon ice. Bar, blue raspberry and lemon, it's all over the place. The most common device used among um these adolescents is a disposable, right? They're relatively cheap. You're gonna throw them away anyway. So like, let's say you get caught and it gets tossed, right, your investment was small, you can go get another one. All right, latest news on what's going on with adolescent nicotine use. So, a little bit out of the zoo, um, so there's a new study from researchers at Mizzou and Yale School of Public Health that found state restrictions on flavored e-cigarettes led to a decrease in vaping. Woo. But also led to an increase in traditional cigarette smoking among those young adults compared to states without such restrictions. So like, I don't know, this is every complex system that exists, right? There's always those unintended consequences, um, but I think this is like a really important thing to be thinking about and balancing that like, is it just a single hammer of like, get rid of them all, right? Or is there some other nuance that needs to be taken into consideration? Um, we're gonna go south to Georgia, DeKalb County. Um, just last month they budgeted $1.6 million for their school district, um, to put vape detectors that are going to detect like fake aerosol and nicotine, but also THC in all their bathrooms. I then like went down that rabbit hole, and it sounds like they're really easy to disable with like a piece of plastic wrap. You just put it over the top of. But then then when you're done, you can take a bow, right? But like there's a lot of like money and and like interest and like efforts to reduce this, this vaping. Um, in Saint Louis proper, Saint Louis Public Radio, just from this year in January, found that teen e-cigarette use was increasing, um, so. Missouri Department of Health and Senior Services does a Missouri student survey. Their 2024 survey found that 13% of teens that were surveyed in Saint Louis used e-cigarettes in the past 30 days, and that was up about 2% from 2022. Um, ABC News is getting in on this action. Um, so they, Rachel Welker, Welker, is that her last name? OK, cool. Anyways, so she's like doing all these stories, right, and like going to warehouses where all of these babes have been seized, they're being illegally sold in all these kind of like babe shops and gas stations. Um, and this is both like elf elf bars, no longer elf bars, um, but it's also like the highlighter, right? So all these different ways to like. Figure out sneaky ways to inhale nicotine, uh, and there is nationwide prohibition on flavored cartridges in particular, um, that was imposed by the FDA in 2020, but these flavored products, including the QT by my house, um, still are really available in all kinds of convenience stores, but like specific vape shops, but also just like gas stations are selling these. Um, the FDA, which we'll get into a little bit more too, is a lot of bark. And they don't have as much money, sent out 800 warning letters to retailers for selling these products, but then that's. And that's it, right? If you're just like dealing out baits and making all kinds of money, like, you know, I'll take a warning letter, um. And then the thing that I like was just like, what? when this came out is that Juul, right? Like the thing that started like with the vaping crisis in adolescence is now legally sold, which like that just like blew my mind. Now, it's like it's restricted for sure, but FDA said that they can continue selling e-cigarettes as the FDA says that vaping benefits outweigh risks. This is the only stuff that they can sell what you're seeing here. One is their device, but then also either 3% or 5% when it comes to strength, and only in menthol and Virginia tobacco. That's it. But it's now legal. It's like to me, when I gave this talk in residency, I brought Juuls to it, so people could try it, but it was like with flavor, like I I brought flavors, um, I can't do that anymore. Oh, yes, please, uh, what, what, what, uh, benefits did they, uh, include of vaping in the reasoning? Yeah, I see to look really cool doing it. No, so really it's like a great, so the, the, my understanding is that the flavors come in when it comes to. Um, adolescents, right, preventing adolescent use, so that's why there's no liquors. However, they're also looking at all the adults who smoke traditional cigarettes, and they're like, lesser evil. Yeah, I'd rather you evade these gross things than smoke a cigarette. Yeah, great question. I was not part of that family though. Um, OK, you don't need to read this list, but this is it. This is the only thing in the United States that is legal to be sold in stores. The four devices that are now legal are the Logic Pro, Enjoy, this Views vibe, and the Jewel. All of those flavors that you don't need to read, they're all tobacco-y, right? Or menthol-y. Golden tobacco, Virginia tobacco, something something tobacco, um, but that's it. That's the entire list. And yet, uh. This can still be the things that you see in stores, right? Bright colors, lots of flavors, including at my local QuikTrip, um, because really there are just like too many loopholes. So Ef bar no longer exists by name, OK? So if you get a shipment in for Ef bar, that is now getting flagged as it comes to be imported. So the producers just literally took off the name Elf bar. And they're just like, this is a vape, and then it goes right on through, OK, um, so there are weak diplomatic ties, um, with China, and that's where a lot of these vapes come from, so we're not able to stem that flow. There's also a large financial incentive to continue to sell illegal vapes because the enforcement is low. So if you want to make money, vaping's your game, OK, um. And the FDA has addressed this, uh, of like, how come we're not able to stop all this stuff? So, the FDA says we approve or deny new nicotine delivery methods from a public health perspective, hence the jewel being legal, right? We prioritize flavored products, meaning we don't want them, and also products with no application pending. So if you're a flavored product. They're gonna try to enforce that and say, nope. And if you're just trying to sell without having gone through proper channels through the FDA looking for that approval, they're also gonna say nope, and that's where the warning letters and the fines are gonna come in. However, this is like a direct quote from their package here, we are unable to take action against every illegally marketed tobacco product. They just don't have the resources to like stop this from happening. The other thing that's amazing is that now that nicotine is getting increasingly regulated from the vape perspective, those scientists in the lab are like, how do I make something that's nicotine but not nicotine? Introducing metine, the patented non-nicotine compound that provides adult users with a strong sense of satisfaction that is largely indistinguishable from traditional vape products. OK, you have 5 seconds quick. What's the difference between nicotine and 6 methyl nicotine? Yeah, exactly, there's carbon thing, right, like on the bottom left, but otherwise it's like the exact same. And so this is sold in flavors, right? And then, OK, so this is the thing that really cracks me up about this. So, they're saying like, no, no, no, we're not, we're not nicotine, but it feels like nicotine, right? And they're like, no, no, we're, we're definitely not nicotine. But it might be addictive, just like nicotine, and no, no, no, we're not nicotine, right? But you should only really use this if you're a current adult smoker of cigarettes. And also we're still not nicotine, just so everyone remembers, but like don't use it if you're under 21, yes. Will that show up that like will that be missed on a jerk screen or like do they, can they be detected in the same way as nicotine? It's like the same but not, uh, yeah, it's a great question. I feel like that's another component, yeah, um, any questions they might not be able to. Oh, thanks. Question was, thank you so much, um, will metine be able to be detected on a drug screen just like nicotine would be, and I have no idea, but I can look it up. But yeah, I have no idea. It's also relatively new. All right, now we'll talk about some individual treatment. So, two big components to individual treatment for nicotine use. One is behavioral, um, and the other is pharmacologic. So behavioral, there's a whole lot of A's to like loop into this, so it's really just making sure that you're asking about nicotine, um, if they're vaping, if they're smoking, what they're using. Um, also then to advise some of that's the education piece, right? Don't, don't recommend vaping for smoking cessation, it's not harmless water vapor. There was a time when people didn't really quite realize that there was nicotine in what they were vaping as well, um, and then just like encouraging some of the thinking about some of those impacts to health, their wallets, sports performance, getting in trouble with their parents. And then I think mm probably one of the biggest things is like assessing that motivation, right? Like, do they wanna stop? What do they like about vaping? Because if they really like that, it helps them relax, maybe there are other things you can do to help them relax, like a therapist or an SSRI, right? If that's what they need, um, as like maybe a healthier modality than continued vaping and nicotine addiction. Um, assist with, um, connections to treatment and therapy, whether that's treatment that you're doing yourself or some other provider that you're familiar with. Um, and then a range, so arranging follow-up, so nicotine and stopping it is really just awful, right? Nicotine withdrawal is the worst, so you need that close follow up to make sure that you're continuing to support those efforts because it's gonna be miserable. Um, locally, um, the Saint Luke's has a tobacco, has tobacco cessation counselors. Mercy has the program. Washu has a program at the Living Well Center for smoking cessation. Um, there are also, uh, text lines and phone lines, so if you're dealing with. Cravings or you want to quit, there's other ways that you can get those resources. There's also a quick start app, which is what the picture is here, that both tracks how long you've gone without using, um, gives you some distraction and motivation as well as all the resources. And then we'll talk about pharmacological feedback. First line is nicotine replacement therapy in adolescences. Second line bupropion and and vereniclin for Chantix. I'm not gonna talk about pure bupropion or Renolin, we'll focus on some of that nicotine replacement. So, nicotine replacement is two big pieces. One piece is, what's your daily, easy breezy, continuous dose that's gonna minimize some of those cravings that you're getting? And then the other is the like, when I have a craving, how am I gonna treat that, manage that without hitting a vape? That easy breezy is the pad, right? That's your like all day steady dose. That comes in 7, 14, and 21 mg patches, and. The goal is to do an 88 to 10 week taper, kind of depending on where you start. Wherever you're gonna start, we'll talk about how to pick where you're gonna start. You're gonna start with 6 weeks. So you're doing a patch every single day for 6 weeks, that's your march. And then um at the end of those 6 weeks, you would step down to the next lowest dose and do that for 2 weeks. The gum or lozenge or like inhaler or nasal spray that we won't talk about, we'll talk about gum and lozenge, comes in 2 and 4 mg pieces. And is a longer taper, right? So like you're gonna be off of your daily dose of nicotine before you're off of like you're craving a quick hit dose from your gum or your lozenge. And that's then gonna be that 12-week taper, where you do um one piece every 1 to 2 hours for 6 weeks, one piece every 2 to 4 hours for 3 weeks, one piece every 4 to 8 hours for 3 weeks before then ideally you're coming off. The thing that I remember learning from adolescent medicine training is that like you don't just chew the gum, like it's not just like big league chewing, you're just like jumping on it, right? Like, the thing that you have to do is you have to chew chew chew chew, feel a little tingle, and you park it in your lip, like. And then that is what delivers the nicotine into your system, breaks that craving, and then as soon as that starts to die down a little bit, you chew, chew, chew, chew, chew again, and you park it again in your lip. It's not just like, if you just swallow the nicotine that you're producing from that gum, it's not gonna do you any good. So you have to park it in your lip. A lot of times you're just like, like a cough drop, you just move it side to side. So, uh, side effects of nicotine patches can be unpleasant, and it's important that you get the generally correct dose. So wearing a sticker every single day can cause some of that skin irritation, um, uh, lots of nicotine can cause upset stomach, dizziness, diarrhea, which is nobody's favorite, headaches, vomiting, itching, burning, or tingling when the patch is applied. The other piece is that sometimes when people wear the patch overnight, they get really vivid, unpleasant dreams that are like disturbing, not the content, just like disturbing to your sleep. Um, and so if that becomes a problem too, then like they can just take it off before bed and not wear it at night. So, how do you transition from a random vape that some kid's telling you about um to nicotine replacement therapy? Just as before, we do math, OK? That's the way to do this. So, let's say you have a 16 year old female who really wants to cut back on vaping. She obtains the not elf bar from a friend of a friend on Snapchat every couple of weeks. She's starting to get in trouble with her parents, noticed that she gets cravings during school when she can't vape, and it's just like, I need help. So, This was our old map. Um, that led us to 200 mg of nicotine per elf bar. For her history, she told us that she usually eat one a bar every 2 weeks. Can't swallow L bars, you can't swallow 2s, and we get that she's using 100 mg of nicotine per week or about 14 mg of nicotine per day. So this is where I would then start that nicotine replacement therapy. So, back to our nicotine replacement therapy options, our patches and our gums and lozenges. First thing I would do is give her a patch, a 14 mg patch daily for 6 weeks, followed by a 7 mg patch daily for 2 weeks. For breakthrough cravings, give her a 2 mg gum that she's gonna use every 1 to 2 hours for 6 weeks, followed by, again, that same 2 mg piece, the dose doesn't change, just less frequent, every 2 to 4 hours for 3 weeks, and then finally, 2 mg every 4 to 8 hours for another 3 weeks. And follow-up is really important, usually that next week, um, because if you don't have the dose right, they're gonna be miserable one way or the other, and it's important to adjust to make sure that it's tolerable. The modified Baker's sperm tolerance questionnaire um is a measurement of like level. Of addiction. So when you're thinking about a little bit of like, do I use the 2 mg gum, do I use the 4 mg gum, some of it's also gonna be like, how intense are those cravings? Like, are they waking up in the middle of the night or first thing in the morning and like using their baby? Or are they like having to sneak out of school because their addiction is so strong that they're, that they have to baby, um. John Galgani on teams that do patches require a prescription, um, yes, they do, uh, for. Under 18, they do, um, but they can't be prescribed, they just have to be prescribed under 18. So follow up that week later, make sure that things are going OK with your nicotine replacement therapy plan. Um, the other, that questionnaire also puts them into like strong addiction, medium addiction, low addiction, which can also then help you decide what kind of um gum or lozenge dose that you think they might need. So if they're like really have some strong addiction and cravings, then you can consider doing like the 4 mg piece. Nicotine withdrawal, as we alluded to, is very unpleasant. So common symptoms are like just feeling angry and irritable, um, anxious or jumpy, sad or depressed, can have a lot of trouble concentrating, which is gonna be a big deal if you have an adolescent who's in school and trying to like do a really good job. Um, they might have trouble sleeping, and increased appetite. But really the most common symptom is the desire to use more nicotine, um, and so preventing that's really important for like helping to keep somebody off of nicotine. OK, we're gonna do one more back. So, now you have a 16 year old male who vapes puff bar OMG, orange mango guava, exclusively. His Father brought him in for a well child check, has concerns about his vaping. Patient experiences cravings right when he wakes up, keeps his puff bar OMG by his bed, so he can vape right when he wakes up, um, and he uses one of these bars about every 3 days, and he really wants to quit. So, you can either like Google concentration of nicotine or how much liquid is in there, which is what I had to do a little bit here, but on this puff bar itself, it says 5%, so you know. That, that puff bar um is 50 mg of nicotine per milliliter. Quick Google told me that there's 1.3 mL of e-liquid in each puff bar. Cancel out some stuff, and you get 65 mg of nicotine per puff bar. On his history, you know that he's using one puff bar every 3 days about, which, again, cancel things out, means that he's using 21.6 mg of nicotine per day about. So, for that treatment, back to the nicotine replacement, looking at patches, because you know now that you need the 25 of 1 mg of nicotine per day, then I'll give you a 21 mg patch, and this is where that um taper kind of increases, right? So it's 21 for 6 weeks, 14 for 2 weeks, and then down to 7 for 2 weeks. So you're always going through the end of 7 when you're doing this replacement. He told me that he wakes up and vapes immediately because he has strong cravings, so then I would consider using the 4 mg um gum or lozenge. Again, the dose doesn't change during this taper, it's just the time in between doses, so every 1 to 2 hours for 6 weeks, every 2 to 4 hours for 3 weeks, and then every 4 to 8 hours for 3 weeks, and it's always super important to follow up. So, um, thinking about, yes, so if the dose is kind of like between the 21, 14, above 2, how do you, um, address that if the dose is in between 14 and 21 or like above 21, it's not so easy like the math I made it for myself, is that what you're trying to say? Yeah, I do, uh, that's a great question. So, uh, it's a little bit of a judgment call based on symptoms, um, I think. Uh, I would probably lean towards going a little bit on the higher side, just to prevent some of the cravings, um, and, but then, then the follow up though, right? So like then you can adjust, but I would tend to go on the higher side. Um, can you take more than one patch? That's a great question. I don't know that I've had to. I don't think that there's inherently a problem with it, it would just be more expensive, um. I don't know. That's really, I don't think I've run into that where I've had to like go even higher, but if the cravings are there, I haven't seen something that says you couldn't do a higher dose. That's a good question. How expensive are those patches? Good question. Oh yeah, yeah, thanks, yeah, great question. The question was how expensive are the patches. I don't know actually, um, I haven't gotten that feedback yet. Uh, it looks like a 21 mg patch from Walgreens is, uh, $30 for 1414 patches for $30 is 21 mg. OK. Is that with uh, is that like a good RX thing or just in general by the counter? OK, $40. OK, great, so they're on sale right now if anybody wants to stock up, um, or they're climbing. Yeah, no, great question about price. OK, advocacy. So there, uh, the Public Health Law Center at Mitchell Hamlin School of Law tracks this stuff, um, state by state, not necessarily federally, um, but it's a really great resource for just like looking at our state and what current law is around vaping and e-cigarettes. Some of this is preempted by federal law like the age 21 for tobacco use. Um, Missouri law doesn't currently reflect that. Um, we follow the 21, but our current written law is 18, so right, we can't do baby products for people under the age of 18, can't use vending machines, um, uh, to sell vapes in places where people under 18 can get them, um, and anybody who has a babe under 18, it's not allowed. There's also smoke-free restrictions or any e-cigarette use, right? So this was a big push for traditional cigarette smoking, um, and then that kind of carried through to the vaping scene as well, uh, such that you can't vape in the places where you also can't smoke, basically. And then there are some also really great resources that you can get on, like if this is something you're super interested in, want to have a templated letter to be able to send your representatives, uh, these organizations do that, right? And we'll keep you up to date on the latest and greatest and ask you to raise your voice, um, and send letters and emails to your representatives to speak up on vaping and. In, uh, adolescents and young adults, so countered, yeah, I was just kind of curious with the restriction of vaping in places where you can't smoke tobacco, does it have like the same or risk of like secondhand or thirdhand offense? Great. So does vaping have the same risks of secondhand, thirdhand smoke as like traditional cigarettes? Log in the Casey's um, I'm gonna say without a definite answer, probably not the same level of risk. The same is that like the FDA deems that like vaping is less harmful for public health than traditional cigarette smoking. Uh, I'm not saying it's a good thing to get that secondhand smoke or secondhand aerosol from vaping, but probably similar, I would assume similarly, uh, not as bad, um. Compared to traditional cigarettes. But I think there are pets. And that's why like you can't be in front of like kids in foster care or even in the same car, things like that to avoid that exposure. Um, so some of those federal organizations that keep their finger on the pulse here are like Counter Tobacco, um, is a great one. The Truth Initiative does a lot of good work. American Academy of Pediatrics is pretty ferocious when it comes to, uh, limiting access to vaping products for youth, the Campaign for Tobacco-Free Kids, and if you want like. A really reasonable packaged presentation because you gotta give this talk tomorrow. Uh, the Stanford Tobacco Prevention toolkit has it like all laid out for you. One, they're tracking this on like a policy level and doing a lot of research, but they also make it easy for you to teach, including like what to say per slide. Uh, that's a really great resource for people who are interested here too. Created by Presenters Aaron M. Schuh, MD, MPH Pediatrics, Adolescent Medicine View full profile
