What follows is a personal “creative writing” assignment detailing my very positive experiences visiting middle and high schools to discuss vaping. The epidemic of this past fall lit a fire for me and my graduate students. I decided to share this in the SOT Communiqué largely because we have organized a 2020 SOT Annual Meeting Hot Topic Session titled “E-cigarette and Vaping Product Use-Associated Lung Injury (EVALI): Outbreak Analysis from an Epidemiological, Clinical, Forensic and Mechanistic Perspective” that will be held on Wednesday, March 18, at 1:30 pm (PT). Please enjoy the following musings about K–12 outreach as an important part of our mission as public health scientists.
“Cheese” was the first answer from the crowd. It began as a low, uncertain murmur. But it gathered steam as more voices added to this single harmonious response. Ultimately, like the drone note on a bagpipe, it became obvious to those of us onstage. “Are you saying ‘cheese’?” I asked incredulously.
Indeed, they were. The question that prompted this moment in a middle school performance studio was, “What else, besides nicotine, is addictive?” It was a session on e-cigarettes and vaping. It was part-seminar and part-Q&A and as bidirectional as we could accommodate with the time and class size. My graduate students and I presented some of the recent facts related to the vaping “EVALI” epidemic and talked about the chemistry of e-cigarettes, the addictive qualities of nicotine, and the questionable marketing tactics of an unethical industry. We asked the students a few simple thought questions like the question on addiction. “What is safe to put in your lungs?” was really the main one—which allowed some kids to show off their knowledge of the atmospheric content of oxygen (21%!). “What is in e-cigarettes?” This one drew a blank, which largely set the stage for a discussion of chemicals that no one had really ever heard of, like propylene glycol, glycerin, formaldehyde, and other not-so-“safe” substances.
The internet has a wealth of information of the hazards of vaping. Many trusted sources exist, including the American Lung Association and the American Academy of Pediatrics (websites below). On these sites, you can find lots of slide decks, videos, pamphlets, facts, and posters. The reports from the Centers for Disease Control and Prevention have been excellent for their straightforward presentation of facts related to the EVALI epidemic. We have many brilliant colleagues in the worlds of toxicology and pulmonary and environmental medicine who have been publishing with gusto over the past decade, but often the details of such studies are beside the point. Some concepts we try to make clear to kids:
- Nicotine is marketed as the cure for nicotine addiction. Heroin is not used to treat heroin addiction—we have methadone for that. So, it is already questionable that companies try to make nicotine delivery systems “cool” or “marketable.”
- “Vaping” is not a water vapor—it made up of chemicals you would probably not put in your lungs if you stopped to think about it.
- Dose makes the poison (a classic!).
- Nicotine addiction only benefits the companies that sell nicotine.
- E-cigarette “juice” contains chemicals intentionally added, along with unintentional contaminants.
- There are a million things you can put in your stomach that you probably should not put in your lungs. Like vitamin E acetate . . . or orange juice . . . or garden peas. (This is a good step to discuss “edibles” should the conversation move in that direction.)
- “Flavors” are also chemicals.
- Vitamin E acetate was added for some reason that made sense to the companies (it is a “cutting agent” and I am confident that everyone involved assumed it was benign). This turned to be quite problematic, as we now know. What chemical of convenience will be added next, without safety testing or regulation?
- E-cigarette companies have been indisputably targeting underage users in their advertising. Middle and high school students are impressively resistant to being manipulated once they know the game.
- Why are there microchips in e-cigarettes? The manufacturers have a reason, and they share this information. But they might have another reason that they do not share. Students do not like being manipulated and are fairly skeptical about how a corporation will respect data use and privacy.
The internet is a double-edged sword. In addition to the information available on the web, there is a mountain of misinformation. Also, e-cigarette devices, “juice,” and paraphernalia are easily obtained with a valid credit card and the click of the button that says, “No, really, I am 18”. I found some of the more “reputable” suppliers would not ship to New Mexico. But after an “extraordinarily challenging” web search that took about seven to eight minutes, I found a supplier. A vape pen arrived three days later and was successfully installed in my lab—we helped a high school STEM team expose their prototype propylene glycol detector. It worked, and they won their competition!
Be the voice your kids hear. While I appreciate the efforts of various groups to provide literature and materials online, I’ve found far more impact can be had in talking directly with students. Consider this a call to arms for our biomedical community. Go to your kid’s school and talk to the counselors or teachers or principals. They are struggling with this issue right now. Vaping is hard to detect—it is not the obvious aroma of cigarette smoke leaching off of a jacket. Kids are sneaking hits in bathrooms and hallways and the back of large classrooms undetected. Vaping paraphernalia may be the only thing that obeys the laws of Reaganomics, with older models of e-cigarette devices “trickling down” from older users to students with fewer resources. Without hearing a sincere, informed voice, kids are left to believe the noise around them.
Democratize. At the University of New Mexico, we have passionate young scientists, physicians, nurses, and pharmacists in training. Our College of Pharmacy has a Generation Rx club that routinely provides outreach on substance use issues. My graduate students Jessica Begay, Russell Hunter, and Tamara Young have joined me in the talks with middle and high school students. They are extremely enthusiastic, knowledgeable, and far more relatable to the students in the audience than me. In a state as big and sparsely populated as New Mexico, help is required to reach the rural and frontier communities, so outreach efforts utilizing our graduate and professional trainees is a perfect way to provide the personal touch, as well as further develop our future health care professionals as advocates and educators.
My graduate students and I all agreed that “cheese” was the “most right” answer to the question about addiction. In the back of the room a teacher held his cell phone aloft like Excalibur and unwittingly helped us make the perfect segue to digital addiction and misuse of data. The middle school students seemed to be concerned about the health effects of vaping, but the high school students have been consistently more perturbed by the idea of having their data—and privacy—invaded.
Bringing the graduate students helped bridge a gap in communication and trust. High school students responded well to these highly educated young adults. They also helped with the lay language and conveyed personal experiences that touched home for students. My students wanted to be there and their compassion for the students was evident.
Being there in person conveyed how much we care, which is something all the information on the internet will never do.
Resources:
American Lung Association:
American Academy of Pediatrics: