Vaping, Alcohol Use & Other Risky Youth Behaviors | Dr. Bonnie Halpern-Felsher

Welcome to the Huberman Lab Podcast where we discuss science and science based tools for everyday life.

I'm Andrew Huberman and I'm a Professor.

Of Neurobiology and Ophthalmology at Stanford School of Medicine.

My guest today is Dr. Bonnie Halpern Felcher. Dr. Bonnie Halpern FELCHER is a Professor of Pediatrics and Adolescent Medicine at Stanford.

University School of Medicine.

A developmental psychologist by training, Dr. Halpern Felcher is a world expert in the risk behaviors that adolescents and young adults participate in today. We discuss nicotine use both by way.

Of smoking as well as vaping and e cigarette use.

We also discuss cannabis and some of the correlative, as well as possibly causal data linking cannabis use to psychosis in young adults. And we discuss some of the other common risky behaviors that adolescents, teens and young adults participate in, including risky driving behavior, alcohol consumption, and risky sexual behavior. We discuss the various factors that impact whether or not a young person will participate in risky behaviors, including the family and home, as well as peer group and social media. And as we discuss social media, we get into a deep discussion about how marketing is combining with peer pressure in order to drive youth toward particular risky behaviors. By the end of today's conversation, you will have learned from Dr. Halpern Felcher the latest research on risk taking behavior in adolescents, teens and young adults and what we can each and all do to ensure that they either avoid these behaviors or if they are already engaging in these behaviors, that we can mitigate some of the potential harms and potentially get them to eliminate these behaviors toward having a life of enhanced mental and physical health. Before we begin, I'd like to emphasize that this podcast is separate from my.

Teaching and research roles at Stanford.

It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast.

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Thank you so much for having me.

We're going to talk about a very important and sometimes troubling period of life. Not always troubling, but I think for everyone. Adolescents and the teen years. Youth essentially is a tricky landscape.

Yes, it is. It can be, yeah.

As our brain and bodies mature, we have more autonomy in where we take them. But that means also more exposure to the ideas, suggestions, actions, peer pressure of others. And that's sometimes where the problems arise. And who knows, probably also where the solutions come from too, from time to time. But I think as conscientious people who mind the well being of others of.

Our species, we'd all like to know.

Sort of like what are the key features that mark this stage of development? Maybe we'll just start off by talking about this through the lens of your expertise as a developmental psychologist. What is adolescence in the teen years? What's going on? What sorts of things are being worked out psychologically that we might not be aware of? And then we can talk about some of the common pitfalls and the risk taking behavior. Everything from smoking, vaping, drug use, sexual behavior, addictive behaviors as it relates to social media, bullying, risky driving. There's so much there. But maybe we could just look at this stage of youth through the lens of a developmental psychologist and share with us anything you feel is worth worth knowing.

Sure. So first of all, ages, adolescence can be anywhere from start, 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 pubertal changes, onset of menses for girls, and really the pubertal and physical and secondary sexual characteristics are coming out. We also have a lot of emotional development going on during this time. Height changes are occurring during this time, but we're getting a lot of social changes as well. As you said, peer pressures. So one misnomer 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 asynchronous development too. If a young person, for example, starts puberty at a younger age, say 10, where they're physically looking older, more mature, but emotionally and psychosocially, they still might be young versus the late matures, physical matures, who may be not having and looking like an older teen or an adult till 16, 17, 18, but they're more mature emotionally than others, then 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 let them make. But there are some risks that we have to be careful about.

At the same time, I often heard this word autonomy as it relates to this stage of puberty in the teen years. You mentioned that kids of that age still really need their parents. In the last, gosh, 20, 30 years in this country, there's been a marked increase in the frequency of divorce. Is there any direct evidence that single parent homes, or homes where, I don't know, people are remarried or just basically divorced homes are somehow creating more challenges in terms of risk taking behavior in adolescents and teens or not? Because I know plenty of people who had, you know, grew up in single parent homes, sometimes parents remarried and sometimes didn't. And I, by my mind, I can't seem to come up with any direct correlation. You know, plenty of Those kids did fine. And plenty of kids in two parent homes that I know had challenges and vice versa.

Yeah, I haven't contributed actually that was some of my earlier dissertation work and I haven't really contributed to that literature for a while. But what you're saying 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 if the conflict resolves.

If the conflict resolves right. 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 separated or divorced 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 adolescents, 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, we still need parents to monitor, to pay attention, to find out their kids friends, where are they going after school. That discretionary time when parents are working and 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 present monitoring than whether or not they're still in a relationship.

My sense is that smartphones have allowed more communication and monitoring between parents and kids, but also more interactions between kids and other kids and kids and Adults more broadly. So is there any evidence that the advent of smartphones is directly creating problems for kids that has to do with just so much more peer to peer interaction or peer to peer exposure? Like when I was growing up, we didn't have smartphones. If you did something stupid like that, meaning that kids would laugh at it might get told to a small group of people, maybe a larger group of people, but in general, it just kind of didn't go anywhere. You're like, I screwed up. And then you get teased a bit and then it would kind of dissipate. But now of course, that can propagate very, very far, very fast. Is there any evidence that that mere fact is creating issues for kids?

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 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, at the smoke ring. I did look at other things that I've been doing there. 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 tracker 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, 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 smartphones 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, e cigarettes 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 or Instagram, look at me smoking or look at me dressing sexy. Look at me looking cool or anything. Like that we, that didn't happen before. It was more just word of mouth. So that is definitely where we're a lot more concerned about social media. But more my concern about social media is the outside world targeting young people. That's where, where I've been the, 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 though, 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.

Yeah, I have family, relatives who are in their teens and it's interesting to see them interact where they're on their phones a lot of the time. But I've also noticed that there's a cohort of kids that are really trying to put their phones away and just spend time together. And that was actually directly stated to me that, oh yeah, we hang out and we make it a point not to be on our phones when we hang out. But then of course they'll text or be on the iPad with one another in the evening when they're apart. So they're sort of never apart.

Right.

But I do think there seems to be at least a sub movement of kids and teens that are trying to do more face to face interaction with devices at least put aside.

I think that's a really good point. I've talked to some teens who say that they all they 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 has been a movement and I really appreciated 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 and 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. 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 one way or 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 gets me particularly worried.

Well, we know for sure that this is the first time in human evolution that humans have essentially written with their thumbs. It's got to be a massive expansion of the brain's representation of the thumbs relative to 20, 30 years ago. But maybe now would be a good time to talk about risky behaviors or even just behaviors that are known to have some detriment to health. Smoking and vaping and E cig. Cigarettes primarily. And we should be probably distinguishing between nicotine and cannabis. Maybe let's just start with nicotine. What are the statistics on smoking, vaping and E cigarettes? Just rough statistics. I saw a talk that you did online that cited some pretty outrageous increases in or shocking increases in smoking and vaping in the last couple of years. Just staggering. So maybe if you give us the top contour of those.

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 U.S. 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 E cigarette use, which I prefer the term e cigarette use than vaping because they're. They're not vapes, they're aerosols. But E cigarette use has gone up pretty dramatically. So E cigarettes came on the market in the US in 2007 and they were slowed to for uptick 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. 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 2017-19 that we saw a dramatic increase. And that was the statistics there. We saw upwards of 27 to 29% of teens using E cigarettes during those couple years. Daily use past 30 days. So any use in the past 30 days was. And daily use will 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 they went to around 20% and now around 10%. Part of that was in 2020 we had Covid and initiation of e cigarette use really occurs socially. And going back to socialization, it's a lot of teens getting together and it's not peer pressure of you have to try, come on, try this. It's more like my friends are using. I'm at a party, I feel like using. Yeah, I'll try it. Well, 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 in e cigarettes, but teens who were addicted continues to use. Some tried to quit, which was great, but we still saw a fair amount of use. So part of the decrease in those 2020-2021 have to do with just access and socialization had changed and so rates went down since then. Even we publish a paper showing relationships between Covid and vaping. We saw evali e cigarette 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 in 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 te 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 an out another group of teenagers using e cigarettes, 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 e.

Cigarettes with for nicotine we don't know or cannabis.

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.

At 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 or the questions or teens aren't being offered. Honest. But from 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.

Wow, a lot to unpack there. First of all, nicotine. I did an episode of the podcast about nicotine, and a little bit of that got confused in the way it landed. So I'll just quickly state. Nicotine, known cognitive enhancer, also known to dramatically increase blood pressure and vasoconstriction. Not healthy for the body. Just to be clear, it's not healthy for the body. So when people hear that it's a cognitive enhancer, increases focus and alertness. That's true in the short term. Highly addictive. Highly, highly addictive. And habit forming, since sometimes those are separated, maybe we delve into that distinction. But by my observation, very few people can use nicotine. Occasionally, people who try it seem to like it, at least in the short run, and keep using it. So presumably kids are using, I should say youth are using nicotine, either by vape or e cigarette, and they quote, unquote, like the way it makes them feel. Who knows, maybe it allows them to focus on their studies better, I don't know. But it is known to improve certain forms of cognition, but only transiently. And it's highly addictive and it's bad for their health, for anyone's health. So that puts us in kind of a tricky situation when evaluating in the statistics that you just laid out, because one wonders, you know, are they taking it and then continuing to take it because of peer pressure, because of lack of peer pressure to not do it, because it helps them with their schoolwork, because they're naturally a little bit depressed and it provides a kind of antidepressant signal? I mean, what. What do we know about why they're actually starting and why they're continuing and why they are reluctant to quit? Maybe we just parse those. So why does a teenager try nicotine?

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 a nicotine e cigarette.

So highlighter pen to study.

Highlighter pen to study.

And then.

But it's actually. You take the COVID off and it's actually a nicotine e cigarette device.

Clearly marketed towards students.

Clearly marketed towards students.

Wow.

You have. What's it called? Boba? You know, teas, drinks.

Oh yeah, the tea with the.

Yeah, yeah. Mimicking that drink. That's actually, that the straw is actually the vaping inhaling there little pieces. You have Star wars shapes. You know, it goes on and on. Just the cartoon shapes that are clearly being targeted to not just teenagers, children that we're seeing.

Children like young children.

Children like young children.

So wait, 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 there to that are even more shocking. So those are the numbers for middle and high school. We don't have data from elementary. But again the other part of. In 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 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 being marketed to. They don't realize that it's a nicotine e cigarette or cannabis e 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, the other is flavors. And flavors of marketing go hand in hand. If it looks bad, looks like or and smells like and tastes like nicotine or tobacco, teens know that that's gross. That's why we don't have cigarette use anymore. Teens, 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 that 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 Honeydew Doo. 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 know, pizzazz of pineapple dancing around or, you know, strawberries dancing or whatever it is that are very animated. There are juice box style that. That have come out, juice box style vaping devices that are marketed looking like juice boxes. Again, that's. That's not targeting you and me. That's targeting a kid.

Interesting and scary. To hear all this, I'd like to.

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In the US vape or use E cigarettes? Just by way of comparison?

So I've seen numbers anywhere from 5% to around 20%, depending on the statistic. I actually haven't looked at at the latest data on 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 nother 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 e cigarettes and they're not saying, huh, here's a cigarette, here's an E cigarette. Which one do I choose? 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 E cigarettes. 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.

So you were telling us why teens and adolescents start vaping. The marketing is clearly oriented toward them. There are a number of reinforcing factors that, at least to my mind as you're describing all this, make it sound like this stuff is supposed to be playful, that it's not a drug, that sort of thing. It reminds me a little Bit of sugary cereals. When I was a kid, you'd buy the cereal because you wanted the taste, but you also wanted the colorful box. You had the cartoons that it related to on TV and there's usually a toy inside that you wanted some surprise that you could then collect across boxes. So there was a lot of levels of incentification. Why do they keep smoking or vaping? Are they addicted to nicotine?

Yeah, absolutely. So, so the other reason why they start is they like the taste and they like the rush. So I've talked too. So that's the other pieces. 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. They, they. Another reason, by the way, is stress and coping. Right now, teens are so stressed out. They've, they've been stressed out for years, but they're particularly stressed with the pandemic. And even though we're a couple years out of the lockdown and teens are still, they're having socialization issues, social emotional learning issues, they're still confused. They missed a couple of years, particularly high school students 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 nicotine. 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. Talk to teens who say, I wasn't intending on, but I tried it. Wow, I really like the taste, I like 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 base. 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 freebase nicotine is very caustic. If you think the litmus test, it's very much on the basic side of the litmus test 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 hit feeling. That's how it's described. Teens will say they don't like it, they cough. It tasted 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 Juul here because it's relevant. Juul came on the market in 2015 with a salt based nicotine which essentially.

For those who aren't familiar with caustic and litmus tests and things like that, the salt based nicotine as I understand is quote unquote smoother.

Correct.

It causes less sort of coughing, static contraction of the muscles in the mouth and throat, you know, and so it's basically more palpable, more of a kind of gradual on ramp, which is exactly what a company wants. If you want somebody to start using something, you don't want to hit them square in the face.

That's exactly right. That's exactly right. So salt based nicotine generally uses benzoic acid to move that litmus test needle from the caustic towards acidic because it's a, it's an acid, but really towards neutral. So. 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, I've talked to teens and young adults who tried earlier E cigarettes and didn't like it and then tried the salt based style and said, ooh, I like it. Coupled with the flavors, it's also more absorbent. So there's some suggestion and some early evidence that it's also more addictive. So when those products first came on the market before earlier E cigarettes had say 0 to 36 milligrams of nicotine, suddenly we jumped up to 59 milligrams per milliliter, which is about, generally about a 40, 41 milligram because it's about a 0.7 mil. 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 cigarette device.

And how long does a pod typically last? A, let's say like a 15 or 16 year old kid who's, you know, taking a hit off the vape pen. I don't know, what, five times a day.

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 pod a week, which is about two or three cigarettes a day, to one to four pods a day.

One to four pods a day.

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

Okay, so just to backtrack a little bit, because we got a little bit technical, which is great, but I want to make sure everyone's on board. The amount of nicotine in one of these pods that goes into the vape pen or E cig is significantly greater than the amount of nicotine in one pack of cigarettes. In many cases.

In many cases.

And there are many youth. So adolescents and teens, you said before, between ages of 10 and 21, roughly 10 to 18, 10 to 21, that are going through as many as four pods per day, which has to be at least the equivalent of four packs of cigarettes, but could be as much as eight packs of cigarettes per day.

Correct.

In terms of nicotine concentration.

Correct.

Now, I guess to be fair, they are not smoking in the traditional sense, so that presumably there's some tars and other contaminants that are not going into their system. But we know that there are a lot of chemicals in these pods besides just nicotine. And I think that's where a big source of the debate and interest is now is how dangerous are those other chemicals? Is really an interesting question.

So a lot of things that you said are really important to highlight. Absolutely. Now, not all teenagers are using four pods a day. These are extremely 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 E cigarettes, 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 three to 500 cigarettes worth of nicotine. Now, are they using them in a day? Probably not. We haven't done the studies on that, but it's really the first nicotine product we've had that you can use 24, 7. When I've talked to teens, I wake up in the middle of the night. I may check my phone and check my email. Teens are waking up in the middle of the night to take a hit and 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.

Are they using when you say all the time? That's interesting. Forgive me for interrupting.

No, no, no.

Are they using it specifically to wake up, to study, to or just to maintain baseline? I mean that's the problem with any addictive substance or habit forming substance is that what starts off as a rush becomes less of a rush and then when one doesn't use they feel below baseline. I've done a lot of discussions about dopamine and baseline versus, you know, non baseline peaks in dopamine and some of that is smoothed out for general discussion. Dopamine does many things besides set up reward systems and incentives in the brain, but it's at least one of the things it does. So are kids starting off taking nicotine and then and feeling like whoa, that makes them feel really elevated in terms of mood, focus and alertness and then finding that without it they're just depressed? Is that the general thing? I'm not trying to lead the witness here. I just want to know what's going on internally.

Absolutely. No, no, no. All great questions there. So what we're finding when we talk to teens is that pretty rapidly they are 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. 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 published a couple of studies showing that teens who have been using E cigarettes in the past 30 days, that the majority are showing signs of addiction pretty 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 nicotine addicted to nicotine and that the levels of nicotine are not the same as what we're seeing in cigarettes. That's actually not the case. And we've seen more and more studies and to 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 awaking. That is a Sign of addiction. So you wake up, maybe go to the bathroom, maybe not, and you take that hit. And so 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 symptoms. That, that feeling, shaking, the, the sweats, all the feelings that they need, lack of concentration. The problem is when you talk to teens, they, they think that e cigarettes are helping with school. And, 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 hit 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 dopamine rush that they now need it, that they're going through withdrawal. Either way.

I'm wondering where they're getting the money to pay for all this nicotine. When I was a kid, I worked. I like mowed lawns. I had a newspaper out for a little while, but mostly started working when I think I was about 14 or so. Coffee shop, skateboard shop, bus tables, did that kind of thing. So I made money and I was able to use that money on the things that were important, music, skateboarding and bus passes and stuff that, that's what it was back then, food, et cetera. Where are 12 year olds getting the money to buy four or even one vape cartridge pod, as you called it, per day? I mean, someone's got to pay for this stuff. I mean, unless they're stealing it. And I can't imagine that they're all stealing it. Where are they getting it? How are they getting it?

Yeah, it's a great question. So there's not one way in terms of money. I think there's questions around money and questions about access. Right. And they're not necessarily the same thing. Money babysitting. The problem is when some of the newer products came on the market, some of them, the, the say 20, 20, 2021 products were about a dollar or two per pod. Compare that with a pack of cigarettes, which is 10 to $15 depending on the state you live in. So they are cheap, they're easy to get. Now newer ones and older ones are a few dollars More, but they're not that expensive. They started off very expensive when they first came on the market, but they haven't been. The other is their 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 few 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 into 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 vapes. 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 US in 2019, December 2019, the legal age to be allowed to purchase or to sell nicotine products across the US has become 21. So many people think it's still 18. So you go into a vape shop or a 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 the public, we need all the parents listening. We need educators, police officers to really enforce and regulate this age restriction because teens are getting them from vape shops really easily. They're getting online really easily. They're buying them for each other. Somebody's going and 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 that. It's just it is the wild west out there.

So setting aside the issue of whether or not vaping is, quote, unquote, better for us than smoking cigarettes, because that argument is a complicated one, to say the least. What do we know about the health hazards of vaping per se? Does it increase lung disease? Does it increase cancer rates? I mean, my understanding is that nicotine, the chemical, is not what causes cancer in cigarettes. It's the tars and other things that are consumed or brought into the lungs and therefore bloodstream when one smokes. That's not to say nicotine is safe. I have to be careful here. Sometimes clips get cut and people run wild. And I'm not saying nicotine is safe, but. But what are the problems with vaping nicotine, even, let's just say one or two hits per day, especially in kids. Are there known challenges for brain development? Are there known challenges for cognitive development? Are there known challenges for lung function? I mean, nicotine is a vasoconstrictor and it raises blood pressure. So that's basically stress on the the system, chronic stress. But, you know, what do we know about what vaping and E cigarettes are doing to malign health?

Yeah. So first of all, start with the brain and nicotine. Absolutely. These high levels of nicotine, or really any nicotine, is harmful to the developing brain. And our brains continue to develop until we're around 25, 24, 26, depending on, but to around 25. So in that process of your brain developing, of your 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 know 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 rewires your brain. And there's plenty of evidence for that. The other pieces that we're worried about is now you're right, nicotine in terms of cancer. Although I will tell you, having talked to some oncologists, they would say the vast amount of nicotine still worries them in terms of cancer. We just haven't had enough research on e cigarettes to really know now. You're right, E cigarettes do not have tar, but E cigarettes have aldehydes, and aldehydes have been linked to cancer. So there's still some concern there. There's some early anecdotal evidence, and 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 in 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.

I just might want to just interject the aldehydes like paraformaldehyde, formaldehyde. These are the same chemicals that we use in laboratories to fix, as it's called, tissues, to make those tissues firm so that then they can be cut and analyzed under the microscope. Aldehydes cross link proteins basically change the configuration of proteins and turn what would otherwise be a pliable tissue into kind of a hard, rubbery think of like a dense eraser, like consistency. And in other words, not the configuration most conducive for those cells to live and thrive. Actually quite the opposite. Which is why that's for sake of doing anatomy on, well, any body part. You use paraformaldehyde, glutaraldehyde and formaldehyde to cross link proteins. It basically kills tissue by cross linking proteins, taking a nice pliable configuration that's amenable to life and twisting or shearing the proteins more or less relative, cross linking them and making them nice and rigid. So if that's happening in the living child, that can't be good.

That can't be good.

That can't be good.

Floods, bloodstream, everything.

And all the aldehydes are carcinogens, Correct. We know they cause cancer.

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 aldehydes. But for a teenager, what I generally say is if you ever dissected a head biology and you dissect a 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, that's exactly the point and that kind of helps them understand it 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. So there's a lot of other chemicals. So no, we may not have the thousands of chemicals that we have cigarettes, but we certainly have hundreds of chemicals in an E cigarette. 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, aldehyde, another aldehyde. There's vanillin. There's. What is it? The. The buttery flavor that's in there is also a lot of concern so that you're inhaling these flavors. And I have often explained you can take flavors. You can take butter and heat it to several hundred degrees and eat it. 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.

Makes sense, because nicotine is a stimulant.

Yes.

It can cause runaway excitability in the brain if too much is taken. If 40 to 60% of kids are using E cigarettes and it's destructive to the lungs and it sounds like the brain as well. Where are all the young athletes? Are they the remaining. Are they the remaining fraction?

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

But even kids just like I had to do PE class when I was in high school.

Yeah.

Yeah. We had to run a few laps. I can't imagine doing that if you're. If your lungs don't function properly.

No, it is actually much harder. And teens will say that. And adults. I know. I actually know an adult who said that when he went from smoking cigarettes to e cigarettes, it actually was harder for him to exercise than to ride his bike and. And. And exercise and do other things on the E cigarette compared to the cigarettes that the. The impact on the lungs so strong. So you're right. It is probably hurting athletics right now, where 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, you know, 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 harder to run. They're more likely to listen to you.

I'd like to take a brief break.

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We haven't talked too much about peer pressure or just social pressure. I remember when I was a kid, it was in the just say no to drugs era and I remember seeing the television commercials with the eggs, like two really beautiful raw eggs and say this is your brain. And then it was just your brain on drugs and it was frying. Nancy Reagan was the big was everywhere in that time. Just say no. Just say no. In any case, there must be a lot of data indicating what messages kids respond to. I was told, and I don't know if this is true, but, but I was told by a researcher that the anti smoking campaign that was effective in kids was not one that convinced them that smoking was bad for their health, but was one that convinced them that it was their purchasing and use of cigarettes that was making other people rich and then kind of demonizing those people that was effective. Kind of like show the commercials of of these guys kind of cackling behind closed doors making fun of the people that were, in their words, not bright enough to know that they were being taken advantage of. And then that set a kind of a psychological warfare between teens and these people that they perceived as taking advantage of them for money and that that was effective in getting them to smoke less as opposed to telling them, hey listen, smoking is really bad for your health, right?

Absolutely. So first of all, the just say no. Not effective. Say just having saying Just say no around any behavior to a teenager, whether it's tobacco, cannabis, cigarettes and sex, does not work. It does not 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 what 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 when we talk 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 risk. 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 just 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. The trach, you're gonna have a trach 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 may get wrinkles, although we don't know that so much with E cigarettes. But the athletics, the things that are important to teens. Now 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 E cigarettes 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 teen said, we get really angry and say, wait, this 12 year old boy was so cute. Wait, I don't want to be a replacement smoker. Dr. Bonnie, it was 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's not addictive. Nicotine is not addictive. Our 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 same thing with marketing. We have a whole lesson on marketing. Do you think that, that that candy was for me as a 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 is 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 till 25 and therefore they're dumb. Our lessons on talking about brain are 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.

Sounds like the key is to never undervalue the spirit of defiance in youth and perhaps to wager it against these clearly destructive behaviors. To be honest, I'm shocked that there's so much vape use and E cigarette use. I mean these numbers are staggering. Maybe we could weave in A discussion about cannabis. Sure, I did an episode about cannabis. The landscape around cannabis has changed so much since I was a kid. It was highly illegal, at least where I grew up. Now I think it's been decriminalized. Certain places still illegal elsewhere. I don't want anyone getting in trouble as a consequence of not understanding what, you know, the laws in their area and outright legal.

Pretty easy to get in a lot of the country.

And it's not clear that at least with individual use that it's being punished nearly as frequently as it used to be. So the 10 word summary of the cannabis thing is that the ratio of THC to CBD is important. It is true that a lot of cannabis has much, much higher levels of THC now than in the past. Although I'm told that high THC level cannabis always existed. But it seems to be the concentration of THC that is of, let's just say, concern as it relates to the potential development of psychosis if there's a predisposition in terms of how addictive the cannabis is and so on and so forth. Which is not to say that CBD is totally innocuous, but it seems to be like the THC concentration is the kind of the thing to mainly focus on. So what do we know about cannabis? And here we're going to assume cannabis with a reasonable to high level of THC in it. So not pure cbd. What do we know about vaping and e cig use of cannabis specifically? Is it true that youth that are taking nicotine by way of vape or e cigarette then transition into using cannabis? Is it sort of a gateway into cannabis use? And how prevalent is cannabis use in kids age 10 to 21?

First of all, you're right. I mean, THC 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 THC and then you get something like dabbing, which is about 80% thin 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 cigarettes. So the potency has gone up dramatically and it is of concern. So depending on the study, you're going to see anywhere from 10 to 20% 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 the, for those who don't know, a blunt, a lot of people don't realize is a Combination of both tobacco and cannabis. So it's, 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, 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 is E cigarettes with cannabis in there. You could 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 a nicotine E cigarette, inhale half of it and then add the, the cannabis wax or oil to it and then basically get the combination. I had one young, young teenager, probably 12, 13, 14 year old young man who said, yeah, I, I got a cherry nicotine vape and I inhaled half of it. She probably used the word inhale, but I use 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 E cigarettes will say don't open them and add stuff. A simple YouTube video will teach you how to do it. And unfortunately the videos are not using gloves and benzoic acid is covering your skin and things like that.

But which is bad for which is bad? Does it go transdermally? Does it go through the skin?

Supposedly it does, yeah. Yeah.

But if the benzoic acid is going transdermally, presumably when one inhales off one of these pods, they're also bringing benzoic acid into the lungs.

Correct.

And hopefully people realize this from our episodes on breathing. But if not, I'll just make it clear now that when you breathe in a substance, you know, a airborne substance into your lungs because of the interface between the vasculature, the blood supply and the lungs. I mean, basically things pass from the lungs into the blood supply very, very readily. And then if those things are able, they'll cross the blood brain barrier.

Correct, correct. And it only takes about 7 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, for one, teens will think it's healthier than just like nicotine e cigarettes. They think it's healthier than combustible. I mean, yes, you're not burning it, but you're still inhaling and you still are inhaling. There seems to be the propylene glycol, the glycerin, the flavorants, all the aldehydes, even if it's just, just a cannabis e cigarette. So there's a lot of concern there. And then addiction is still huge. It's a huge issue when you're talking about, about cannabis. The same reasons that we talked about with nicotine, the brain development and so on. Psychosis. Just a lot, a lot to think about here. Psychosis. There's actually some scientists now who are really strongly saying it's not associated as 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 it 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 hardwiring the rest of our brain that that change is happening from a neuronal connection perspective.

My understanding, Sorry to interrupt, but my understanding is that indeed the use of high THC cannabis in youth, in particular male youth, predisposes and you're saying might even be causal toward the development of psychotic symptoms.

Correct.

In late teens, early 20s.

Correct.

And that some of those cases are ones in which the psychosis is irreversible.

Correct.

Is it sometimes the case that somebody exhibits psychotic symptoms as the consequence of using THC and the psychotic symptoms resolve, or is it some sort of circuit switch that is then permanent?

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 in talking to the psychiatrist would say that it's causal and it may be permanent. Now, it could be, it could be managed. It doesn't mean that somebody is going to be having psychotic episodes all the time. I mean, 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 is something that I'm not sure of. Somebody more versed in this, but we, you know, what you do in. In your research. And what I know is, you know, changes to the, to the neural circuitry is not, you know, when we hurt our brain cells, that is not something that we could recover from. So that is very much concerning.

Yeah. As an. As adults, there are very few new neurons added to the brain. There is significant plasticity and recovery of function in some cases, both by virtue of traumatic brain injury. Certainly people can get over certain behavioral patterns, and that no doubt involves plasticity, but it's. It takes work. And when it comes to addiction, there's evidence that some of the reward circuitry can adjust. But again, it takes adherence to specific things in order to make that happen. I'm very concerned about this potentially causal relationship, but certainly correlation between high THC containing cannabis and psychosis, mostly because we already have a serious problem with psychosis on the planet. A lot of people don't realize that approximately 1% of the world's population has schizophrenia. And by the way, I have to be careful with the language nowadays. Has schizophrenia or is schizophrenic or all that language gets murky. But meet the diagnostic criteria for schizophrenia, I think, is a safe way to put it. So if one is then adding to that number of people exhibiting and suffering from psychotic symptoms that prevent them from having functional work lives, et cetera, that's an issue. How difficult is it for these adolescents and teens to quit vaping and e cigarettes and cannabis? I mean, can they quit just by deciding, are there programs, Are they all going into, you know, recovery programs? Are there recovery programs in schools? I mean, how successful are they in stopping?

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. I mean, both are addictive. And interestingly, not a lot of people realize that cannabis is addictive. About one in six teens or people who are using, particularly under the age of 25, do become addicted.

So they don't realize that it's addictive.

They don't realize it's addictive.

The argument I often heard was it's not as bad as alcohol, which is a kind of a lame argument. I understand why people default to that, but I mean, getting hit by a car might not be as bad as getting hit by a train, But I don't. I wouldn't even look at that analogy as accurate. There's just different levels of destructive. Different types of destructive. Yeah, these. Not as bad as blank. Doesn't really seem to work.

No, no. And you know, I often Say, people say, well, why'd 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, your development of your brain now can, if you use Regoliq, are you 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 a cigarette or an e cigarette for the very first time in their 30s or 40s and on. So absolutely it's addictive and, 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. It's 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 and you are with cannabis to some extent as well. So yes, nicotine is incredibly addictive and we have so many teens who are addictive, addicted to nicotine through E cigarettes and really struggling to get off of it. I gave 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 felt 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 inpatient programs. There are actually some inpatient programs, but.

Those are going to be expensive or require that people have insurance that will cover that.

Absolutely. 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, astigmatizing, 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 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, nicotine replacement therapy, the patch, first of all, it's not authorized for use by the FDA. It's not been 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, 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 patches about 21 milligrams of nicotine and a teenager's using 40 milligrams in a day, 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 lozenges. Not as a starting. I don't mean like what we're seeing with, with some pouches out there like Zinn as a starter. I don't mean that. I mean as a, a form of.

Treatment, as a way to wean them off. So reducing the dosage over time.

Correct, correct. And, and now. But then they also don't have the, the hand to mouth piece that we see that is difficult. So gum in this case, I mean non nicotine gum, just chewing regular gum. I've heard teenagers say that they're, that their withdrawal lasts three to four minutes. So they have a. One teenager 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. Chewing on a toothpick. Not a nicotine toothpick, but 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 we can't expect until they're fully off of a cigarette. Can't expect a teenager to quit overnight.

Especially with the social pressure. And again, sorry to interrupt, but I think that the 7 to 11 tries did an episode on nicotine and I talked about smoking a bit. And most people fail. Most people fail, they relapse. It's very, very difficult to quit smoking. People that do it and stick to it are real heroes of the process. It's not easy, but that's with a heavy incentive, you know, immediate health issues, sometimes it's financial, etc. With kids it feels like all the pressures are pushing in the opposite direction because it's socially rewarded. They get that, you know, elevation of mood and focus and there's just oh so much driving them to, you know, continue using.

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 or YAB our reach lab. YAB. Our YABs say that we need to talk about social withdrawal, not just physical because of exactly what you're talking about. They may not be able to go to that party on 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 witness somebody using an e cigarette and those cues will happen and they'll want to use it. So they actually have to isolate themselves from their friend group who is using. So it's very difficult. So really setting up your social milieu, 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 be in this together. And often I say the reason why they're using is that their fault. Let's go back to the beginning of our conversation about marketing and 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 their milieu. They need to have healthy snacks and water and exercise and all kinds of things around them. And they may also need cognitive behavioral therapy or some other 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 intervention and moving towards cessation. That's how many young people are just struggling right now.

When I was in high school, there seemed to be a phenomenon of, you know, certain behaviors allowed kids to have some social clout by virtue of. I guess they used to call it holding. Like, if someone had weed or if somebody. Yeah, if they had weed, then it sort of gave them a position in the social structure. Oftentimes the kids that, you know, I mean, I was friendly and knew most people in my high school class, you know, and a few of them were kind of like, less socially engaged than others. But then at some point midway through high school, one of them was like, start showing up with weed at parties or something, and suddenly, like, they had, like, a social clout. It was kind of interesting to see how, you know, having paraphernalia, having nicotine or cannabis or whatever it is is sort of, I think, has long been a kind of like an instant sort of route to inserting oneself into a social structure which is obviously unhealthy. I'm not. I'm not promoting this.

Yeah.

And then it is social, right. That there's a. There's sort of an instant substrate for communication. When I was growing up, I. I.

Worked at a skateboard shop.

And on my break, I would go behind the shop. There's a little alley there. We'd skateboard. There's this little bump. But occasionally, employees would share a cigarette, or you'd ask someone for a cigarette. This was kind of a way of bridging social gaps. So, again, I feel like it's so hard to be a teenager. There's so much going on internally and externally, and everything you're talking about in terms of the negative health effects, the paraphernalia, the marketing, the taste, the addictive qualities of it, et cetera, just start to pile on. All these challenges to staying away from it. But a big one seems to be the kind of instant social cred that one gets when they participate in something that other people are participating in. Because, for instance, like a sport, if there's a pickup basketball game, you. You have to play reasonably well to get into the game. Otherwise it's not going to be easy, or you have to be very bold. So unless you're engaged in a sport, you're in theater, you're doing other things. It's sort of an Instant route. Okay, I think I've made my point. Is there anything about that that by way of understanding can help create replacement behaviors? I mean, it's going to be hard to take a kid who's, you know, entire life is hanging out with their friends and vaping cannabis or nicotine after school and hanging around and playing on their phone and saying, hey, listen, you're gonna quit vaping nicotine, you're gonna feel worse, your friends are all gonna be doing it and you'll still be their friend, but you're not really part of it. It's almost like you have to create a culture of quitting before this can really go the other direction.

You do. And what you're saying is, is so correct and so relevant and why I feel so bad for teens right now and the social media, right, you put. 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 Joel. It was so cool to Jule 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 refusal skills and teach you how to say no. But in this case, not just say no, but teach you how to feel good about, about saying no to certain things that you don't want to be doing. And during that time there was, 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. Because that was not cool. I think we changed in the last couple 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 this, yes, the pressures to use are absolutely there, but there's starting to be a tide change where we're getting more teens who are getting on the so called bandwagon 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 those social networks of it's cool 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 benzoic acid does not evaporate. And we've got secondhand vapor, secondhand smoke, secondhand, and third hand. So what I mean by that is, if I were to use an E 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 studies suggest 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 aerosol, it's not a vapor. That aerosol then settles into carpets 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 the environment. If I wash dishes for too long, my younger was out of the house, but when she comes over, I get yelled across, mom, turn the water off. The environment. We have to save 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.

Interesting. Yeah. I think replacement behaviors, concern for the environment, seem like good incentives. I'm hearing all this. I feel really lucky that I was always obsessed with something growing up, whether or not it was like birds in fish tanks or skateboarding or prior to that, soccer or, you know, I mean, certainly there were drugs and alcohol around, but there were always activities that kept us busy. And I guess I wonder whether or not the advent of social media has created less interest in activities, you know.

After school activities, I guess they used to call them.

But I mean, even if it's video games, if it's playing a sport, if it's theater, if it's art, if it's music, presumably kids are still doing all that stuff. But is it the case that the kids that are vaping, let's say, nicotine, maybe cannabis as well, are less likely to be engaged in other activities? I mean, is this thing becoming just kind of a cliff, closed loop of reward? I mean, that's, to me, the real danger of any substance that increases the dopamine system activation without a lot of effort. Right. Because as you and I know, the whole of dopamine circuitry as it relates to reward is all about effort, reward, reinforcement, effort, reward, reinforcement. But the effort piece is key, and drugs basically bypass the effort piece, and then you get the reward reinforcement, and then eventually the rewarding and reinforcing levels of return on that drug, nicotine, cannabis, et cetera, diminishes, and then you're just caught in a behavioral loop.

Right, Right, absolutely.

So are kids doing less stuff? Are they studying less as a consequence of this? Are they playing fewer sports? Are they less engaged in youth theater and music and youth groups and things like that?

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, or I'm not an athlete or. Or this was my social outlet. I haven't seen that as a result, as much with E cigarette now. As a result of E cigarettes, yes, but not as a cause of using, because it's so ubiquitous. E cigarettes 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 more tech and guys were using it and some of the females didn't want to put them in their purses because it would leak. We now are seeing more of an equal rate, if not a little bit more female using. It's, it's not your so called bad or good kids. It's not anything. It's not the young people who are struggling with school. It's everywhere right now, independent of location, race, ethnicity, things like that. So I don't see so much what you're talking about in terms of a predictor, in terms of, Of a result. Absolutely. I mean then we're seeing teens who become more isolated, who are, are not engaged as much, who are more bored because they're sitting home and they're 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 an 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. And we were talking about this at the beginning. We're not seeing them out in parks as much. We're not seen them playing pickup sports games as much as we used to. But I don't think that's because of E cigarette use. I think that's because of social media and just the whole change. And honestly, parents being afraid of letting their kids out for some predatory behavior and in other ways.

You mean if kids are let out of the house, they're more at risk to predatory behavior. But of course they're also at risk. But just by use of the phone. Because the phone connects everywhere.

Absolutely, the phone connects everywhere. And that's something we try to teach, teach teens as well. But I think that that's been something that parents are worried about. You know, I have to 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 and 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, they have to get into a little bit of trouble, they have to jaywalk. They have to do. I mean I'm not encouraging but you know, but there's some natural amount of getting together and hanging out and being crazy at the park and playing 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 E cigarette use? Possibly. I just don't, haven't, I haven't seen the studies on it but you know, but, but there's some natural amount of getting together and hanging out and being crazy at the park and playing and playing games and things like that. And I think that had, you know.

Perhaps that's a good segue into risky behaviors. When I was a kid, I mean.

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.

The dumb stuff that we did meaning dumb because it was dangerous to ourselves. I mean, I am not suggesting people do this. Kids, please don't do this, just don't. But just the dumb stuff of, you know, jumping off roofs or between roofs. I'm not going to give any other, any anecdotes, just it's amazing that we all survived and some didn't, but 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 E cigarette use? Possibly. I just don't have, I haven't seen the studies on it.

Yeah, perhaps that's a good segue into risky behaviors. When I was a kid, I mean that was largely the consequence of drugs, alcohol, mental health issues of kids I knew. But car accidents. Actually I grew up in the, in the Mothers against Drunk Driving era and there was a real discouragement around drunk driving. I was fortunate that at least the dumb stuff that we did, meaning dumb because it was dangerous to ourselves. I mean, I am not suggesting people do this. Kids, please don't do this, just don't. But just the dumb stuff of, you know, jumping off roofs or between roofs, I'm not going to give any other. In high school, most of my friends didn't drink or didn't drink much. But you still heard about fatalities in kids happen. Even one is too many. Obviously. What's going on now in terms of risk taking behavior, driving fast, driving drunk, doing what used to be just described as dumb stuff. Any anecdotes? It's amazing that we all survived and some didn't. But that was largely the consequence of drugs, alcohol, mental health issues of kids I knew. But car accidents Actually, I grew up in the mothers against Drunk Driving era that unfortunately sometimes is fatal or results in paralysis. People jumping off bridges into water without testing the water depth. We've all heard the stories and sadly they're true. Stories of people becoming paralyzed, that kind of thing. Dumb stuff, dangerous stuff, teens do more of it. And there was real discouragement around drunk driving. I was fortunate that at least in high school, most of my friends didn't drink or didn't drink much. But you still heard about fatalities in kids happen. Even one is too many. Obviously. What's going on now in terms of risk taking behavior? Still true that males are doing more of that physical danger stuff than females, or is that not true? That's what we used to hear. But then of course, there's been this big push, importantly, really, to balance out the amount of research on both sexes.

Yeah, it's a good point. I mean, some of it has to do with just the methods of our research.

Driving fast, driving drunk doing what used to be just described as dumb stuff that unfortunately sometimes is fatal or, you know.

No, you know, it's interesting I haven't seen more recent data in terms of differences by sex results in paralysis.

People jumping off bridges into water without testing the water depth. You know, we've all heard the stories and sadly they're true. Stories of people becoming parents, facts of.

Risk engagement or 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 on the beach and getting drunk. I think the big difference now is whether it's from mothers against now I.

Think paralyzed, that kind of thing. Dumb stuff, dangerous stuff, teens do more of it. Is it still true that males are doing more of that physical danger stuff than females, or is that not true? That's what we used to hear. But then of course there's been this big push importantly, really, to balance out the amount of research on both sexes.

It's destructive driving.

Is that what it's called?

I think it's now Mothers Against Destructive Driving.

I think that's what that includes drunk.

Driving and racing and racing and driving under the. The influence of cannabis or anything else which can be harmful. But at least in, 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. Yeah, it's a good point. I mean, some of it has to do with just the methods of our research to know. You know, it's interesting I haven't seen more recent data in terms of differences by sex, of risk engagement or risk behavior. I mean, a lot of what I've seen is balanced out. I think it's maybe different kinds of when they drink, but they're not getting behind the wheel as much. Much less behaviors that. That people do. But we're still seeing it. We're still seeing teens and this idea of a designated driver or sober driver. Uber or Uber. Uber's really change.

I guess we should.

Or Lyft or any ride share. Let's just say any ride share has certainly been a game changer. Drinking. We're still seeing teens going to parties and getting drun drunk. We're still seeing teens out on the beach and getting drunk. I think the big difference now is whether it's from mothers against now. I think it's destructive driving.

Is that what it's called?

I think it's now mothers destructive driving.

I think that's what that includes drunk driving and racing in.

In the landscape of teenagers and young adults right now. And in fact, I've heard. And racing and. And driving under the influence of cannabis or anything else which. Not just 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 can be harmful. But at least in. 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. Going home with somebody you don't want to go home with to make sure that you're not leaving drunk and falling down when they drink, but they're not getting behind the wheel as much. Much less stairs to make sure that you're not falling out of that window. And this idea of a designated driver or sober driver.

Uber.

So that message we've gotten across really well, which I'm thrilled about. Are we still seeing drunk driving in accidents? I certainly. Or Uber. Uber's really change.

I guess we should.

Or Lyft or any rideshare. Let's just say any ride share has certainly been a game changer among some people I know. Certainly we are but I think that the message overall has gone out danger in the landscape of teenagers and young adults right now. And in fact I've heard some people I've talked to said we just, just, 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 not just a designated driver but a designated partner or a. Because of Uber Lift. I mean it's, it's. As a parent, it's less expensive to pay for a ride share than to pay for insurance for somebody under 25 or to pay for a car. So certainly that might be at 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. But, but that is there doing other stupid stuff. I mean in addition to going home with somebody you don't want to go home with. To make sure that you're not leaving drunk and falling down rugs jumping, skateboarding. Certainly we're still seeing that stairs to make sure that you're not falling out of that window.

Well, skateboarding is a good sport. You gotta don't exceed your skill level.

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 among some people I know certainly we are. But I think that the message overall has gotten out there.

But jumping between buildings, not smart. Unless you're super skilled and know what you're doing. I mean, you know, there are the parkour kids and the skateboard kids and the BMX because we, we don't want to take away what the incredible things that they can do. But, but there's risk there.

Right?

Right.

There are some people I've talked to said we just, just don't get behind the wheel, period.

What's also I was referring to people who lack the skill to, to complete the, to complete the maneuver.

Right.

And, and getting badly hurt or, or in some cases not getting badly hurt, but you just kind of shake your head and wonder why you.

Interesting is more and more teens are not driving, they're delaying driving more and more.

Whether that's why you ever engaged in that kind of stuff just so risky.

It's because of Uber Lyft. I mean it's, it's. As a parent, it's less expensive to pay. Yeah, yeah. We're definitely still Seeing risk behavior amongst teenagers and part of it has to do with impulsive for a ride share than to pay for insurance for somebody under 25 or to pay for a car. So certainly that might be it. But. But that is there doing other stupid stuff. I mean in addition to drivity. We know that teens up until around part of the development right. Of cognitive and social psychosocial and social development is up until around 16, 17. They're 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. Rugs jumping, skateboarding. Certainly we're still seeing that.

Well, skateboarding is a good sport. You gotta don't exceed your skill level. But jumping between buildings. Not smart unless you're super skilled and know what you're doing. I mean you know there are the parkour kids and the skateboard kids and the BMX kids. We don't want to which is our.

Executive functioning, our take away what the.

Incredible things that they can do. But. But there's risk there.

Right?

Right. I was referring to people who lack the skill to complete the. To complete the maneuver and. And getting badly hurt or. Or in some cases not getting badly hurt. But you just kind of shake your.

Head and wonder why you planning for the future are 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. 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.

While you ever engaged in that kind of stuff just so risky.

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. 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 until around part of the development moment right. Of cognitive and social. I think there have been more programs to help teens sort of rehearse in. In situations so they're not the more life skills training so they're not making some of those impulsive decisions. But teens will psychosocial and social development is up until around 16, 17 they're still very impulsive. We know with the brain development right. The back of the brain develops faster and first and that's our teens are going to be teens which by the way is why we don't put things in front of them like, you know, sugar booger and unicorn kind of marketing that's going to get teens attract amygdala, our emotional center, our motor coordination versus the front of the brain, which is our executive functioning, our planning for the future are 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 victim because that is buying into that knee jerk impulsive. It looks cool. Everyone's doing a kind of thing that they can 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.

What about sexual behavior? You mentioned that kids are driving less or getting their driver's license less frequently.

Which by the way, 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 wait.

With respect to teen busted in other.

Ways, we're still seeing that wanting to.

Drive less, that just like baffles my mind. I mean, one of the reasons I like skateboarding as a sport is you could do it anywhere. It was also transportation. And I like the social milieu. I loved the social milieu of it and. But getting my driver's license was like one of the most.

I think there have been more programs to help teens sort of rehearse in. In situations. So they're not. They're more life skills training. So they're not making some of those impulsive decisions. But teens will. Teens are going to be teens, which by the way, is why we don't put things in front of them like, you know, sugar booger and unicorn kind of marketing that's going to get teens attracted.

Most important events in my life.

Me too. Me too.

I could drive to Yosemite in the summer. I could do all sorts of things with that. I'm so surprised that kids wouldn't want to do that. Such autonomy there. So much fun.

Oh, I agree.

But I've also heard that rates of sexual behavior are going down. Is that true?

Because that is buying into that knee jerk, impulsive. It looks cool. Everyone's doing a kind of thing that they can 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.

What about sexual behavior? You mentioned that kids are driving less or getting.

Yeah, stabilizing and going down. And certainly rates of risky sexual behavior has 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 their.

Driver'S license less frequently. Which, by the way, with respect to teens wanting to drive less, that just like baffles my mind. I mean, one of the reasons I like skateboarding as a sport is you could do it anywhere. There's also transportation. Is teen pregnancy down?

I think it's down, actually. I haven't looked at the latest numbers. I think it's down, certainly.

And I like the social milieu. I loved the social milieu of it.

Lee, I don't think has gone up, but I actually would need to look back at those numbers. It's been a little while since I've looked at them.

And is what we're talking about today mostly within the United States and the United States alone, or does it carry over to other countries as well?

So it.

And. But getting my driver's license was like one of the most important events of my life.

Me too. Me too. Totally depends on the behavior that we're talking about.

Yosemite in the summer. I could do all sorts of things with that. I'm so surprised that kids wouldn't want to do that. Such autonomy there. So much fun. Let's say vaping or e cig. Use of cannabis or nicotine.

So interestingly, e cigarette nicotine. E cigarette use has not been as high in a lot of other countries. It depends on the country. But for example, the UK or Europe. Oh, I. I agree.

But I've also heard that rates of. Of sexual behavior are going down. Is that true?

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. Yeah, stabilizing and going down. And certainly rates of risky sexual behavior has also gone down. So we are getting the map message across around condom use, around STI testing, around. Excuse me, of nicotine that you're allowed to have. So, for example, the UK, I think it's around 1.7%, birth control, things like that, which is also really good. But rates overall have gone down. In the US we have no nicotine standard, which is another major issue with regulation. We don't have. We have, as I was saying, 5%, 10% nicotine nicotine levels. There is no regulation about how much nicotine that you could have. So in certain countries, if it's.

Is teen pregnancy 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 would need to look back at those numbers. It's been a little while since I've looked at them.

And is what we're talking about today mostly within the United States and the United States alone, or is it counting.

Right around the addictive level or a little bit below it? We're going to see fewer teens becoming.

Addicted over to other countries as well.

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

Let's say vaping or E cigarettes, use of cannabis or nicotine.

So interestingly, E cigarette. Nicotine. E cigarette use has not been as not marketed to teens. That has changed in the last year or two. So in countries I've talked to, for example, the UK I've been interviewed by them many times in the last few years and they would say we don't have the same problem. And now they're saying, boy, we are seeing tie in a lot of other countries. It depends on. On the country, but for example, the UK or Europe, 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 in 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 allotting have. So, for example, the UK I think it's around 1.7% now seeing. Is it as high as we have in the U.S. i don't think so, but it's certainly increasing. Same thing in other countries where they actually didn't allow certain E cigarettes to be on the market, have now come in and been on the market and infiltrated. In the US we have no nicotine standard, which is another major issue with regulation. And even in this country, certain E cigarettes are illegal and they're coming in illegal. We don't have. We 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 a deadly through illicit trading is happening and crossing the borders. So. So E cigarette, we're still seeing cannabis depends on this, on the country, right? Whether it's legal or not. Now, even in the US I should say even states that have legalized cannabis, you have to. It's still bad at any amount, but we're going to see, you have to be 21. But we're still seeing underage cannabis use, of course, just like we're seeing underage, fewer people becoming addicted. 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 in the last year or two. So in countries I was drinking and underage and it continues. I've talked to, for example, the uk I've been interviewed by them and other states where it's just really difficult to get. We're not seeing cannabis as much, but we still are seeing it.

We didn't talk about things like Zyn pouches which are becoming more popular with adults as well. So no vaping, no e cig, no smoking nicotine.

But a little times in the last few years that 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 which is different than dipping tobacco or snuffing tobacco, as far as I know, Zyn pouches and things similar deliver.

Now, seeing is it as high as we have in the U.S. i don't think so.

But it's nicotine into the bloodstream which then crosses the blood brain barrier, goes into the brain, has this effect of creating certainly increasing.

Same thing in other countries where they actually didn't allow certain E cigarettes to be on the market, have now come in and been on the market and infiltrated. And even in this country, certain E cigarettes are illegal and they're coming in illegal.

Focus and alertness kind of a little high, but doesn't carry the same carcinogenic risk. But presumably there are other risks through.

Illicit trading is happening and crossing the borders.

So which include of course the addictive and habit forming nature of it, the blood pressure increase, the vasoconstriction which is related to the blood pressure, et cetera. But what do we know about Zyn pouch use?

Is it on the so E cigarette we're still seeing cannabis depends on the country, right? Whether it's legal or not now the rise.

Or is it that there's something so compelling about vaping and e cigs that.

You know, 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 people in particular.

Kids want the, the physical act of, of vaping.

So this is a case where I've seen this one other time where actually the popular press is ahead of the scientific press and probably ahead of the science and teaching us scientists that we better hurry up and figure this out. Drinking and under age 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. How is, how is that so the popular press has been talking about Zyn 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.

We didn't talk about things like Zyn pouches which are becoming more popular with adults as well. So no vaping, no e cig, no smoking nicotine, but a little increase in.

The market share of Zyn compared to other nicotine products. So we're seeing it on the rise. What I mean by science hasn't caught up is we don't have a lot.

Of pouch which is different than dipping tobacco or snuffing tobacco surveillance data to.

Show whether or not teens are actually using Zyn. We have some data. We actually published a study a couple years ago showing around 20 to 25% of people.

As far as I know, Zyn pouches and things similar deliver nicotine into the bloodstream which then crosses the blood brain barrier, goes into the brain, has this effect of creating focus and alertness, kind of a little high, but doesn't carry.

People in general adolescents and adults. And about 11 to 15% of teens are using a pouch.

Presumably the same carcinogenic risk, but presumably there are other risks.

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 showed that about.

Which include of course the addictive and habit forming nature of it, the blood pressure increase, the vasoconstriction which is really relate to the blood pressure, et cetera. But what do we know about Zyn pouch use? Is it on the rise or is. Or is it that there's something so compelling about vaping and e cigs that.

You know I think it was a couple of percent, one and a half.

Percent people in particular kids want the physical act of vaping and that it.

Went up a little bit. So I think I can't. It was something like. I think it went from 1 1.1% to about 1.5% of teens seem to be admitting using pouches. So not a huge increase but a few. So this is a case where I've seen this one other time where actually the popular press is ahead of the scientific press and probably ahead of the science and teaching us scientists that we better hurry up and figure this out.

How's it. How is that?

So the popular press has been talking about Zen a lot. Andrew Thomas teens are using across the country as opposed to 2 and a half million plus using E cigarettes and arguing that it's a very popular product and that we're seeing now this is true. We're seeing a very sharp rats but with all those qualifications aside, yes we are seeing an increase in Zin 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.