Vaping and Teen E-Cigarette Addiction: Will Conventional Harm Reduction Programs Work?

The prevalence and use of electronic cigarettes has increased rapidly over the past decade, particularly among youth.  The extraordinary growth of e-cigarettes has also raised significant public health concerns about the emergence of a new generation of teens with nicotine dependency.  Changes in the design and marketing of vaporizers with the introduction in 2015 of more stylish, sleekly-designed, discreet high-tech devices, known as JUUL, have proven irresistible to teens and become the latest ‘nightmare’ for today’s high school principals and teachers.

School authorities in Canada as well as the United States are coming rather late to the challenge of combating vaping and its associated health risks.  Advance promotion of e-cigarettes as a smoking cessation device may have contributed to the initial ambivalent, almost helter-skelter, response.  A May 2019 Ontario Tobacco Research Unit report confirms that schools were caught off-guard by the surge of vaping among never-smokers and responded with interventions once used to combat smoking or imported from the United States, where the craze is far more advanced among youth.

Five years after the arrival of JUUL, public concern has reached a panic stage with the spread of fear over a recent spate of lung-disease cases involving teen users of e-cigarettes. Breathing in flavoured aerosol that contains nicotine was already a worry of doctors, parents and schools.  Over the past few months, some 380 people in 36 different American states have been struck by a mysterious lung infection linked to chemicals inhaled through e-cigarettes, and seven of those affected died.  Shortly after Health Canada issued a September 6, 2019 advisory, a London, Ontario, hospital disclosed that a local high school student suffering from vaping-related illness had been placed on life support before recovering and being sent home. It could become worse in mid-December 2019 when the sale of vaping liquids containing cannabis compounds becomes legal in Canada.

Schools are on the front lines of the current teen health scare. Since entering the Canadian retail market in 2009, e-cigarettes have morphed from a smoking-cessation aid to a full-blown health concern among today’s youth. Ten years ago, Health Canada greeted e-cigarettes with an advisory warning of the dangers of the new nicotine delivery devices, expressing concern over the lack of scientific research to support claims that they were safe for adults and teens. More recently, Canadian health authorities monitoring the spread of e-cigarette use have been echoing the U.S. National Academies of Science, Engineering and Medicine research finding that ” e-cigarettes are not without biological effects on humans” and, rather than aiding in cessation, can lead to further dependency.

Vaping devices and products containing nicotine are now flooding the Canadian market and readily available in local convenience stores and gas stations. Since September 1918, JUUL, the San Francisco-based company that controls over 50 per cent of the market, has been selling its sleek devices that look like a computer flash drive and are re-chargable at a USB port. They have proven more popular that the Imperial Tobacco brand Vype, released Canada in the Spring of 2018, and Japan Tobacco‘s Logic brand released in early 2019.

First introduced by Juul Labs in mid-2015 as a smoking-cessation device, JUUL became the so-called “iPhone of e-cigarettes.” The extraordinary sales growth of the product was driven by a variety of effective, wide-ranging and engaging campaigns reaching youth through social media, particularly on You Tube, Twitter, and Instagram. Five million Canadians, mostly aged 15 to 34, had tried e-cigarettes by 2017 and 300,000 reported using it every day. One more recent study, published in the British Medical Journal, reported that the proportion of Canadian teens (aged 16 to 19) vaping rose from 8.4 per cent in 2017 to 14.8 per cent in 2018, a 74 per cent increase. 

The Ontario Tobacco Research Unit conducted an environmental scan of current harm reduction programs and quickly recognized that there were, as of the Spring of 2019, no studies of the effectiveness of such interventions. Most intervention programs were public education and school-based efforts, typically aimed at teaching children and youth about the dangers of vaping in the hope of reducing or eliminating the practice. Three of the programs reviewed were E-Cigarettes: What You Need to Know (Grades 6 -12, Scholastic), CATCH My Breath (Ages 11-18, CATCH), and School E-Cigarette Toolkit (Grades 6-12, Minnesota Department of Health).  The report also examined interventions outside of schools, including community-based initiatives, public health efforts, health-care programs, and public policy strategies such as advertising and promotion restrictions, age restrictions, labelling and health warnings, flavouring restrictions, and safety requirements.

Most of the actual school-based interventions were embedded in existing tobacco control programs and sought to counter the marketing messages of companies claiming it is a safe, smoking cessation activity. The Ontario Tobacco Research Unit recognized the scattered approach being taken and recommended considering interventions that proved successful at reducing rates of regular cigarette smoking among youth. They also identified the need for a more coordinated and planned anti-vaping strategy.

Vaping has overtaken smoking as the favoured health-risk behaviour of high school students.  Some 15.8 per cent of Ontario Grade 9 students vaped in 2017, and only 6.2 per cent smoked cigarettes. As many as one out of every three high schoolers may now be regular users of vaporizers with nicotine-laced fluids. The recent health scares may have jolted users and curbed the growth in usage, but it remains the biggest, mostly unaddressed health issue in our high schools.

Why have health agencies and school authorities been so slow off-the-mark in combating the spread of vaping among adolescents? What more can be done to regulate and curtail the marketing of e-cigarettes among the youth market segment?  Where are the research initiatives aimed at identifying the real health risks for teens of vaping nicotine and cannabis products?  Should vaping cessation programs simply mimic smoking control strategies and programs?  What can be done to develop more effective student-centered vaping cessation programs? 

 

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Marijuana Legalization and Teens: Are High Schools the New First Line of Defense?

Teachers are talking and raising alarm bells about the impact of marijuana legalization on students and our high schools – and the real daily challenges that lie ahead. This is a head’s up – we should all be listening to those on the front lines of education.

Seven American states and the District of Columbia have followed the early adopter, Colorado, in legalizing the recreational use of cannabis and the movement is spreading to other states. Four of the seven states legalized its use in November 2016, and the Canadian government has established its implementation date later this year.

Looking across Canada, province after province has been announcing its implementation policy, focusing almost exclusively on the control and regulation of the previously illegal substance, provoking fierce debates over who will reap most of the the exise tax windfall and  whether cannabis will be sold in government stores or delegated to heavily regulated private vendors. All of the provincial policy pronouncements claim that the policy will be designed to protect “public health and safety” and safeguard “children and youth”  from the “harmful effects.”

Marijuana legalization policy across Canada is a top-down federal initiative driven largely by changing public attitudes and conditioned by the current realities of widespread use of marijuana, purchased though illicit means. Setting the age of restriction, guided by the proposed federal policy framework, has turned out to be an exercise in reaching a “compromise” rather than heeding the advice of leading medical experts and the Canadian Medical Association (CMA). The CMA proposed age 25 and then accepted age 21 as more “realistic.” It’s going to be 18 year-of-age in Alberta and Quebec, and 19 years-of-age in most other provinces. Getting it “out of high schools” was a critical factor in bumping it up to age 19 in most provinces.

Every Canadian province is complying with the federal legislation, but — in our federal system – it’s “customized” for each jurisdiction. The Canadian Western provinces, Alberta, British Columbia, and Saskatchewan have opted for regulating private retail stores, while Ontario and the Maritime provinces (Nova Scotia, New Brunswick, and P.E.I.), are expanding their liquor control commissions to accommodate retail sales of cannabis.

My home province, Nova Scotia, tends to find the “middle ground” in public policy and has done so once again. That’s why Nova Scotia provides perhaps the best point of entry into the Canadian situation.

On top of chronic absenteeism, ‘accept all excuses’ policies, and bureaucratic paperwork, most of Nova Scotia’s high school teachers will soon, as of September 2018, be battling a spike in marijuana use and greater peer pressure to smoke pot on the mistaken assumption that it is “harmless” at any age.

In the scramble to meet the federal July 1, 2018 implementation date, provincial authorities, in Nova Scotia and elsewhere, are grossly underestimating the potential harm to student health, safety, and life outcomes. That much is clear after carefully examining the best background research, the October 6 to 31 survey consultation, and the December 7 policy pronouncement.

The Nova Scotia government, guided by the steady hand of Minister Mark Furey, has done a reasonably good job in responding, under tight timelines, to the immediate challenge of establishing a strict control and distribution regime, albeit dependent upon the traditional public sector apparatus and the NSLC stores.

The essential problem is that control and regulation is only half of the challenge – and it sends out implicit signals that, after the failure of the ‘war on drugs,’ softened public attitudes will now dictate policy, irrespective of the health harms inflicted on children and youth.

One in five young people between 15 and 24 years of age, according to a recent national study, report daily or almost daily use of cannabis. They also see marijuana as “much safer than alcohol and tobacco” and “not as dangerous as drunk driving.” Few either know about or seem concerned over the clear linkage between heavy use and early onset psychosis.

Three major education policy concerns are not being addressed, all of which are identified in the current research on the harmful effects of marijuana on children and youth up until age 25.  With the legalization of marijuana, evidence-based policy needs to recognize that:

• Heavy marijuana use can, and does, damage age 13 to 18 brain development: A 2016 Canadian Centre on Substance Abuse study confirmed the direct link to loss of concentration and memory, jumbled thinking, and paranoid psychosis.
• Marijuana users perform more poorly in quantitative subjects requiring precision, like mathematics and senior science: Clear evidence was presented in 2017 by Dutch researchers Olivier Marie and Ulf Zolitz that ‘liberalizing’ rules also led to decreased academic success among Maastricht University students, and particularly for struggling students.
• Legalization of marijuana increases the number of teen users: Early initiators increase their use significantly and overall reported use rises by about 10 per cent to one out of three teens, including previously low-risk students (New York University 2014, Oregon Research Institute 2017).

Medical researchers and practitioners have warned us that legalization carries great dangers, particularly for vulnerable and at-risk youth between 15 and 24 years of age.

One of the leaders in the medical field, Dr. Phil Tiboo, initiator of Nova Scotia’s Weed Myths campaign targeting teens has seen the evidence, first hand, of what heavy use can do at the Halifax QE II Infirmary Early Psychosis clinic. We will pay a price for not heeding the warnings of Dr. Tiboo about popular and rather blasé notions that marijuana is “harmless” to teens and “recreational use” is somehow “fun” and “healthy.”

One glaring example of the mixed messages was the November 2017 CBC Nova Scotia televised debate, entitled “Joint Venture,” a media production that actually made matters worse. It was all framed as a “cool” public policy about to propel us into the “green frontier. Watching and listening to the four panelists must have been terribly upsetting for doctors and high school teachers. Ill-informed comments went unchallenged, and no one spoke for educators who have daily encounters with students “high” on drugs.

High school principals and staff are facing a real test with the legalization of marijuana.  The old line of defense that using marijuana is illegal will have disappeared. Recreational marijuana will be more socially acceptable. The cannabis industry will be openly marketing its products. High school students who drive to school will likely get caught under new laws prohibiting motor vehicle use while impaired by drugs or alcohol. Fewer students will be abstainers when it is perfectly legal to smoke pot when you reach university, college, or the workplace.

We have utterly failed, so far, in getting through to the current generation of teens, so a much more robust approach is in order.  “Be firm at the beginning” is the most common sage advice given to beginning teachers. Clamping down on teen marijuana use during and after school hours will require clarity and firm resolve in the year ahead – and the support of engaged and responsible parents.

Legalization of recreational marijuana is bound to complicate matters for Canadian high schools everywhere. Busting the “Weed Myths” should not be left to doctors and health practitioners. When it comes to meeting this serious challenge, let’s get behind those on the front lines.

What’s really driving the move to legalize the recreational use of marijuana?  Where does that leave education authorities, school principals and high school teachers?  What works, if anything, in deterring teens in the absence of a law prohibiting open public use? Is it possible that teaching in high schools is about to get far more challenging? 

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