Dr. Jose Torradas:
... at some point we were their age. At some point there was something, whether it was e-cigarettes or tobacco or some drug or something that we were being advised against. And take a step back, think how would we want to have wished our parents had approached it?

Speaker 2:
This podcast episode is brought to you by the Aetna Foundation, an independent, charitable, and philanthropic affiliate of CVS Health. With the mission of promoting wellness, health, and access to high-quality health care for everyone. The Aetna Foundation dedicates its work to improving health in local communities and large populations alike.

Donna Mazyck:
Welcome to School Nurse Chat. I'm your host, Donna Mazyck. Executive director of the National Association of School Nurses. And this is the second in a 10-part series exploring the health crisis of vaping and what schools can do about it. In the first episode, "Deep dive on vaping." We talk with our guests about the problem and today in this episode, "What we can do about vaping?" We'll talk about the solutions. Our guests are youth leader in vaping prevention, Allyssa Williams, Dr. Karen Wilson, a pediatrician and researcher on nicotine addiction. Dr. Jose Torradas, a physician focused on healthcare, leadership and equity, and NASN nursing education and practice specialist, Liz Clark. Liz will share with us the perspective of school nursing and vaping prevention. Hello everyone.

Dr. Jose Torradas:
Hi Donna.

Elizabeth Clark:
Hello.

Dr. Karen Wilson:
Hello.

Donna Mazyck:
So great to have you all here today. Many students are already addicted to nicotine and there are some who believe vaping can help people quit, but we know the evidence just isn't there. Dr. Wilson, what are some cessation strategies that schools or clinics can implement or refer to today?

Dr. Karen Wilson:
It's been very difficult, especially with the advent of JUUL and the other very high... The nicotine salt delivery systems that deliver a very high concentration of nicotine. This is creating addiction in teenagers to nicotine that we really didn't even experience with combusted tobacco use among teens. And so it's even more difficult for many of these kids who stop using these products. Obviously prevention would be the first place you would want to go. Much of what I'm going to talk about in terms of cessation, we do discuss on the American Academy of Pediatrics Richmond Center of Excellence website.

Dr. Karen Wilson:
There's plenty of resources there to help with cessation and teenagers. We encourage people to do in particularly for your audiences, school nurses. You have to ask the questions, you have to understand what they're using to see if they're going to be addicted. And they don't always know that they're using an e-cigarette. If you just say, "Are using e-cigarette?" They may say, "No." But what they're using is JUUL. You want to have an honest conversation with them about the dangers and if they come to you wanting to quit, there are different resources. There are Text-to-Quit programs that have actually been shown to be effective in helping kids stop using electronic cigarettes. There's one through the National Quitline. And then there's also one by The Truth Initiative. And then we also encourage you to think about recommending or prescribing pharmacotherapy for teens that are severely addicted.

Dr. Karen Wilson:
This is, we're giving them nicotine to help with the withdrawal symptoms that they're having when they're not using their vaping devices and nicotine replacement therapy can help with that. It's not FDA approved under the age of 18, but that's because the studies that have been done on the use of nicotine replacement therapy in combustive tobacco users didn't find any significant improvement in cessation. It didn't find any problems with safety in the use of these products in adolescents under the age of 18. So we do believe that this is safe and we haven't tried it before in cessation for electronic cigarettes because we haven't had to deal with the addiction levels that we're seeing now with these kids. We're even finding that there are some kids that end up going to an in-patient rehabilitation for substance use so that they can quit this nicotine addiction. It's pretty severe, but there are some things that providers can do to help kids quit.

Donna Mazyck:
Thank you, Dr. Wilson. It's great to hear that there are resources available and we'll be happy to share those resources, as you mentioned. Dr. Jose Torradas, we understand you're referred to as Dr. Jose, we'll call you Dr. Jose in this podcast. Dr. Jose, what are some ways to support a teen who's quitting?

Dr. Jose Torradas:
It's not easy. And I think that, that's an important frame of mind for anybody who is confronting the issue, whether it's the first time, which that jump from zero to one is obviously very difficult. But also for those individuals who are dealing with relapsing patients, because that's also has its own psychological toll. Giving them options and alternatives through other activities, a different group of friends, a different environment, change to routines. This and generally parents who trend a little bit more understanding firm, but understanding. I think are the keys to the highest likelihood for success. In addition to all these alternatives of how else do you occupy their time. As an ER doctor specifically, I'll see the children who come in for suicide ideations, suicidal attempts. So you see when the addiction and the withdrawal can get so severe that children are thinking about taking their own lives. So in following up with some of these children in the work that I have done, those have generally trended to be the factors that most likely indicated somebody's success when it comes to trying to truly quit e-cigarettes and other substances in general.

Donna Mazyck:
Liz Clark, what are some ways schools can support students who are quitting?

Elizabeth Clark:
Well, there are lots of things that schools can do. One is to look at their policies regarding disciplining students that are caught with the products at school. Many schools have begun to make changes in those policies and are now offering students options for suspension or expulsion. And having them participate in education activities, working closely with school nurses and school counselors in group support, and also being referred out to community providers such as pediatricians or those that need more intensive support in the community.

Elizabeth Clark:
So behavioral support as well for those addictions. So the schools are really working to educate families and parents in regarding understanding what is going on with these youth and the products that are available and how to identify them and support their children. So those are actively involved in many, many areas to support this epidemic that's going on.

Donna Mazyck:
I heard the same word that Dr. Jose used, you use the word understanding. That somehow this sense of this is a restorative issue in terms of helping students to quit. Allyssa, what do you think school policies on vaping?

Allyssa Williams:
I'd agree with Liz about how taking the alternative to discipline and making it more educational. Right before the pandemic happened, I was working with our school board and our schools to really turn the whole discipline thing into more education because as a youth, when you want someone to do something in a more positive light, to make a positive change, the more they feel like it's a punishment, the less likely they are to do it. So giving them those resources to really go ahead and make the change themselves to go ahead and quit and to get educated. It's important that it's less a punishment and more of a, "Let's make this a lesson learned."

Speaker 2:
For more information on the National Hispanic Health Foundation's Stop Vaping Campaign visit nhmafoundation.org/stop-vaping-campaign

Donna Mazyck:
Parents agonize about how to talk to their children and their adolescents about vaping, so they'll listen. Parents are worried that they're starting the conversation too late, and we're wondering what are some resources out there and when should parents be talking about vaping? So we'll start with Dr. Wilson.

Dr. Karen Wilson:
And I share this all the time. Parents really are so confused about what to talk about. They originally were looking at this and I think not thinking that electronic cigarettes were that serious. They were initially marketed as being harmless, water vapor. And so I think it caught us all by surprise and definitely parents by surprise how dangerous this is and how addictive these are. And so I think that the important thing is to start talking about it young. We need to be getting the message out to eight and 9-year-olds that you shouldn't be inhaling things into your lungs that aren't medicine or air. In that there may be chemicals in there that these companies are trying to trick you into inhaling so that you're going to want to use more of these and that they can be dangerous.

Dr. Karen Wilson:
And these are all messages that you can start to have with your teenagers and even pre-teenagers before they get to middle school. We start to see electronic cigarette use among middle school students, it starts very young. I think that having an open relationship and we've talked a lot about understanding and trust. And I think if parents can have an open relationship with their children so that they can be honest. If you find out that your teenager is using electronic cigarette product, it's not something where you should be necessarily yelling at them and punishing them. It's understanding why they're doing it. And then trying to figure out the best way to help them quit. Some of that may be helping them to put it away, helping them to manage their stress better or helping them to get to their pediatrician so that they can get help with quitting. But I do think that starting that conversation early and continuing it through young adolescents, through adolescence is really critical to helping kids never start.

Donna Mazyck:
Dr. Jose, do you have anything to add to that?

Dr. Jose Torradas:
What I would advise parents or anybody who's about to initiate a conversation like this is, as an adult what I've learned is that we were all youth at one time. So at some point we were their age, at some point there was something, whether it was e-cigarettes or tobacco or some drug or something that we were being advised against. And take a step back, think how would we want to have wished our parents had approached it because it's normal to feel that the first reaction should just be like an explosion or a very firm reaction. We are in stressful times, financially, psychologically. The pandemic has certainly changed every single person in some way or another, but there's definitely value in that understanding perspective, taking a step back, being more open. I think that being open and discussing a conversation more head on knowing that there are resources to support whatever conversation you're going to be going into. Like Alyssa, Liz and Dr. Wilson have mentioned earlier in this podcast and previously, there's definitely help out there, but a careful tact, I think, can really go a far way.

Donna Mazyck:
Words of wisdom, thank you. Liz, how do you respond to resources out there and when parents should be talking about vaping?

Elizabeth Clark:
I really would like to empower parents. I don't believe many parents think that their youth listen to them, especially if you have a teenager in your home, but they really do. And I believe in comprehensive health education and having conversations with your children early on, all the way up through. And so as a school nurse, I think it's important that we share resources with parents that have been tested and approved and vetted. And there are lots and lots of resources that Dr. Wilson mentioned earlier with the Truth Institute and others. And NASN is actually working on a toolkit for school nurses. That'll be coming out later this year.

Elizabeth Clark:
And there'll be information in there also to share with parents and also looking at the age of the child, the developmental levels. School nurses have also seen 4th and 5th graders doing some experimenting with vaping, either looking at older siblings or having access to those devices. And so it is never too young and parents are important and what they say to their children and their children do, listen to them. And it is hugely important that they understand that. And they just start that conversation by saying, "Hey, I care for you. I'm worried about you. What's going on?" and start there.

Donna Mazyck:
And Allyssa, any thoughts you have about parents and when they should be talking to their children about vaping?

Allyssa Williams:
Earlier, Dr. Wilson mentioned my favorite resource for youth, which is the Text-to-Quit. I feel, in this day and age with social media, technology... I was born in the early 2000s, so technology is what I know, it's what I grew up with. And I know that it has made it very easy for me to be disconnected from my parents, from teachers. And to sometimes have that thought, "Well, they can't relate to me, no one's really listening. No one notices me." But having resources like Text-to-Quit where it's really technology based and it really reaches out to youth in a way that youth want to be reached. Which is through their phones, through their devices.

Allyssa Williams:
It makes it a lot easier for you to understand that there are people who are noticing that this is a resource that they need. And here's a way that they can use it that doesn't make them go out of their way or try something that they're going to be completely uncomfortable with. And ask for conversation, I think parents should have the conversation as soon as they can, as soon as they're comfortable doing it with their youth. Even if their kid doesn't vape or they don't think that it's a path that their child might take.

Allyssa Williams:
I still think taking the initiative to just have the conversation. Let their their youth know, "I notice that this is a epidemic going around and maybe we should sit and talk about it." As for those who like go through their stress and they're feeling overwhelmed, just having conversation really is just really important. Especially as a youth, I think that's what really got me through high school was my parents consistently talking me to me. Making sure that things weren't getting too much, that I didn't feel overwhelmed with anything that was going on. Especially now that we're going through a pandemic and we have so much going on. It's important to just have those conversations whenever you can. No matter the age, I agree having them before they go to middle school would be best because students are starting very, very young and just taking the initiative.

Donna Mazyck:
Thank you very much. Dr. Wilson, we've heard that there are students waking up at night to vape just because of their addiction. On the other hand, we hear parents asking, "How do I know if my kid is addicted?" How do we support parents?

Dr. Karen Wilson:
There's a variety of ways that kids can be using electronic cigarettes. And I think that the signs of addiction that we tend to ask people to look for are, "Is your child leaving the table unusually to go to the bathroom while you're eating? Do you hear them waking up in the middle of the night? Are they sneaking out to try and buy products?" And things like that.  I mean, those are all... And certainly the other signs of addiction: Is their behavior changing, are their grades falling -- things like that. That's pretty significant addiction, but those are definitely warning signs.

Dr. Karen Wilson:
I think going back to keeping that open relationship with your child so that you can talk to them and that they feel comfortable and confiding you, if they've gotten themselves into a place where they're unable to stop their nicotine use.

Dr. Karen Wilson:
So I think that supporting parents as pediatricians. From my perspective as a pediatrician, it's when we're in the practice.  We're saying, "We're here for you, here are some resources." The Richmond Center website has resources for parents in addition to resources for clinicians and policymakers. And so making sure that they have the skills that they need and the support that they need from the people around them. I think that school nurses can be an incredible support to parents and they certainly are on the ground with what's being used in the schools. And can be a resource there. I think it's also important to recognize that not every kid who is addicted is using the equivalent of four packs of cigarettes a day. You can still be addicted -- and this is definitely true for adolescents -- and be a light, intermittent user as well. And so I think having your open a relationship to be able to discuss that use with your kids is important.

Donna Mazyck:
Thank you so much. And Alyssa, we'll end with you. What does this epidemic look like from the youth standpoint? And how are you helping their peers avoid vaping or quitting?

Allyssa Williams:
So from a youth standpoint, it basically looks like vaping as an epidemic, as a whole has really taken over the youth. It's kind of the only conversation people really have, the only thing you really see when it comes to like social media. But I think on a more positive standpoint, it is less terrible as it was when it was first starting. I feel more youth are educated now, more youth are getting their resources. More parents are getting involved.

Allyssa Williams:
Schools are getting involved. And I feel like as a youth ambassador and advocate, I've done my job very well. I feel the youth finally understand what's really going on. And they're also taking that initiative, that next step to making sure that the tobacco epidemic ends with us, the next generation will be tobacco free. To help my peers avoid or quit vaping, I kind of just pay attention to their needs. Maybe some people just need a friend or they just need someone to talk to, or they need help with homework or something. Something that can take that stress off their hands, make them feel less overwhelmed with whatever's going on in their lives. Or just be there for somebody, give them the resources, give them the time to do it their own way, to quit their way. And just go that extra mile and be a friend, be a classmate, be a sister, a sibling, something like that.

Donna Mazyck:
Well, we appreciate that perspective. Tobacco epidemic ends with us, that's a word of hope from a youth ambassador in nicotine and vaping prevention. I want to thank all of our guests for being with us today. Thank you, Allyssa Williams, Dr. Karen Wilson, Dr. Jose Torradas and Elizabeth Clark. Thank you for sharing your wisdom. Thank you for helping us understand that we can make a difference to this problem of vaping. We can provide support and empowerment to parents and helping them to know that, keep that open relationship, talk to your children and make a difference in being even a school with policies that are restorative. We appreciate all that you've brought to us on the topic of vaping. Thank you.

All:
Thank you.

Speaker 2:
To view the American Academy of Pediatrics parent information on vaping, visit healthychildren.org/vaping