Vaping and E-Cigarettes in Schools with Emily Stockings

6:11AM Jul 4, 2023

Speakers:

Cameron Malcher

Emily Stockings

Keywords:

vapes

nicotine

e cigarettes

people

young

cigarettes

products

schools

australia

work

smoking

harms

students

talk

lungs

increasing

mentioned

contaminant

evidence

feeling

Joining me now is Dr. Emily stockings from the Matildas. Center at the University of Sydney. Emily, welcome to the show.

Thank you, Ken, for having me.

So we're here to talk about something that's a real rising issue in schools, and certainly something that's starting to get a lot more attention in the media and public discussion, and that is vaping, and E cigarettes and their prevalence among young people. Before we talk about some of the work you've been doing to support schools and parents in this area, can we start by just unpacking the what is the current situation in Australia, you know, how, how widespread is use of E cigarettes and vaping among teenagers?

Yeah, that's a good place to start, because it can feel like it's everywhere. And it's something that because we don't really know much about them, people and parents and teachers are rightly concerned. So in Australia, we don't yet have a very comprehensive assessment, a regular assessment of e cigarette use among young people. So that's the first thing to understand. So what we're doing at the moment is trying to piece it the you know, the picture together with the evidence we do have, at the moment, putting all of those pieces together in terms of young people who have ever used e cigarettes. So when I say young people, I'm talking between the ages of 14 to 24, about 30% of young people have ever tried them. So that could include they've had a path and they've gone that's not for me, and they've never used it again, right up to the people who use them every day. So about around a third is where we're sitting. And that is increasing over time. In terms of, and this is I'm sort of pulling everything together, there's some studies that are a little bit higher, something a little bit lower, but on average, that's sort of where we're sitting. In terms of the young people who use quite regularly, it's more around the four to 5%. Mark. So these are young people who are using at least weekly and continually over time. And it sounds like a small percentage. But the thing to note is that that has increased from basically zero in a very short amount of time. So since around 2013. So that's that's the concern, how rapidly the use has gone up.

And I suppose most people's benchmark comparison would be smoking, obviously, is it a sort of new replacement for that habit? How do those figures compare to the number of young people smoking traditional cigarettes, tobacco cigarettes?

Yeah, that's such an interesting point. Because there is this major concern that you know, e cigarettes are going to be a gateway, you know, they try their cigarettes, they get addicted to nicotine, or just addicted to the process of having something that produces a smoke and then they transition to smoking. From the the most recent evidence, smoking rates among young people are around 1212 and a half 13% Mark. And this is ever smokers, so it is lower. So fewer young people are smoking and fewer young people are starting smoking compared to a cigarette. So in the most recent surveys, so we've been tracking in Australia, but also in the UK, and in the US. And in New Zealand, they've got really good ongoing studies been tracking what comes first, you know, are young people using cigarettes first, and then they're transitioning to E cigarettes. And that previously was the case that most people who were vaping were already smokers. So they were already in that risk category. However, in the last wave in 2021 2022, in the UK, and in New Zealand, for the first time ever, the number of people who were using E cigarettes first was higher. So we're seeing a transition away from smoking, which is great, that's what we want. But we are seeing more young people using E cigarettes, whether it's instead of it remains to be seen. There is however a concerning trend that some of your listeners may have seen recently released through government data that among a younger group of people, rates of smoking have actually jumped from previous estimates. So that's just something to keep an eye on as well. But overall in terms of regular use, e cigarettes and more common uptake of of combustible regular cigarettes is reducing. But the interaction between the two we're still not quite sure if one is causing the other or one is replacing the other. So we're just kind of keeping an eye on that and tracking it. Hmm.

I mean, it's interesting, you talk about when we talk about the difference between E cigarettes and vaping I mean, you know, in my mind, I was only sort of peripherally aware of E cigarettes when they first became a thing and I always had this mental image of, you know, somewhat clunky devices that people would fill up with fluid and, and they were they were quite sizable and I was quite surprised the first time I caught a student using a disposable vaping device that was only slight We bigger than a pen lead. And I think it had like a handful of uses. So what sort of range of items and devices like what does vaping encapsulate, in terms of the things kids might be getting access to?

Yep, definitely great question. E cigarettes and vaping. It's the same thing. So in scientific literature, and among, you know, people who were talking about governmental responses, we just tend to say e cigarettes, it's just the more kind of neutral phase phrase rather. And vaping is just the act of using a cigarette. So it is essentially the same thing. They first came onto the market in China and around 2006, maybe a little bit earlier, designed, as the story goes by a pharmacist in China who wanted his patients to quit smoking. So developed a device that allowed the delivery of nicotine without all of the burning the combustion. So picture a campfire, that's essentially what's happening on a smaller scale inside a cigarette. So he produced these products, and they were they were clunky, they had a tank, which is basically just sort of like a, a cartridge that you could refill with fluids. So you got there was the potential for a spillage if you're filling it up with nicotine liquid we can talk about, we can talk about that. And it was attached to a battery, the battery then was attached to a coil or a wick. The weak is then encased in it various a soft type fabric material, or similar that is doused in this liquid. When the coil heats up, that liquid that's attached to that that, quote unquote fabric vaporizes, gets very hot around two to 300 degrees Celsius, and then it becomes aerosolized. So turns into aerosol droplets. And that's what's inhaled. So that basically the function of them in the form of them hasn't changed that much. They all work the same way. But what we're seeing now is, the battery is smaller, the cartridge is smaller, it's just much more streamlined. They have they being the producers of the cigarettes predominantly in China, have been able to make the packaging incredibly sexy, and you know, really cool colors. So they are now tiny. And they also are increasing it despite the fact that their size is getting smaller, the capacity of the cartridge is increasing over time. So you can see a student might have something tiny that looks like a USB, you can conceal it within the palm of your hand. But it might have the equivalent of around five to 7000 puffs in that in that cartridge. These newer models are disposable, they don't come apart. You can't refill them, doesn't mean young people don't try. But the newer models are what we call the disposable pod type devices. I don't know if you've seen them, but they can even come in like squishy Gameboy type, like exteriors. So they look like toys, essentially some of these new products. Yeah.

And you did mention before that, you know, they started out as a nicotine source replacement. But I am aware that what goes into them is not like that there's sort of this concept of recreational vaping among young people that have no addictive chemicals traditionally associated with cigarettes. So what's the what's the sort of spectrum of contents of what these kids are actually inhaling?

Yeah. So in Australia, at the moment, there's legislation that's coming in soon at the moment, you cannot purchase nicotine containing e cigarettes unless you are over 18. And you hold a prescription from your GP to say, yes, we've discussed this, you're a smoker, and you can use it in nicotine to help quit smoking. So that's one that's ideally what they're used for. But what So what's happening here is that, in in China, where the products are mass produced, they know that nicotine is not permitted for sale direct to people who don't have a prescription. So the companies have simply omitted the nicotine label on them. They just don't say nicotine, because it is legal, currently, for people over 18 to vape non nicotine vapes, so if you wanted to go to a vape store and get a vape that claims to have zero content, nicotine, and just has flavorings. You can do that. However, when we actually test them, so there's a fantastic lab at the University of Wollongong who've been working with the New South Wales Department of Health with their seizures. So heaps of E cigarettes get seized from schools and other settings from retailers and they've sent them off to be tested. Most of them don't say that they have nicotine however, most of them due

to what concentration,

it it varies, the the most common concentration is around 5%. Nicotine. And the thing that's concerning is that it the concentration and the type of nicotine that is in these new products is quite different to what was in combustible cigarettes. It's a nicotine, what we call a salt. So it's nicotine that an acid has been added to to make it more palatable, it's really easy to keep going and keep puffing and you go, you don't get the throat burn that's traditionally associated with high concentrations of nicotine than you would get from cigarettes. So that's the other concerning thing. In terms of what else is in them, it's I was speaking to a friend of mine, who, who vapes and he said, You know, there's only four ingredients and, you know, some of its like vegetables. And essentially, essentially, there are, what will be advertised on the back of the packet is that it contains propylene glycol, which is just a carrier fluid, vegetable glycerin, the combination of the two produces the liquid, that then produces the vapor, the flavoring component, and then more often than not nicotine. So they're the four main key components of what's in the liquid. When we actually do a chemical analysis, though, the number of chemicals is as low as 300, as high as 2000. So the interaction between the heating and the flavoring produces more chemicals that are inhaled propylene glycol itself, while it's used in things like moisturizers, and some food products, it it shouldn't be it's not approved for inhaling. So there's the potential that these large molecules in this ingredient is essentially getting for want, you know, for simple in simple terms being lodged in the lungs, and producing inflammation. So it's not just the nicotine that's of concern. Other ingredients within the vapes, which should not be exposed to lungs, particularly young developing adolescent lungs, is really concerning.

Right? I mean, I'm trying to think how I can say this diplomatically, you mentioned that the majority of these are manufactured in China. And China has, shall we say? A very different regulatory approach to public safety and health than Australia necessarily does. Where does the production of E cigarettes sit within our current regulation, but you mentioned that some legislation was still yet to come in? So where does it currently sit in? You know, how will we keep you it's it sounds to me for what you're saying? Like, we're not actually doing a very good job of keeping track of who's making them or what's going into them?

That's absolutely correct. So we aren't keeping track of who's making them what's going into them, because they are not a regulated product in Australia, yet we have no controls over what is in them. So we are essentially at the mercy of the producers in China who are making these and shipping them over in bulk. And then they're being distributed through easy Mart's and other convenience stores and young people are using, so we have no domestic system that that checks them, that identifies dangerous ingredients, sends them back takes them off the shelves, we have no system for that. For the this is predominantly the illicit market. So all the vapes we're talking about that young people are using, if they've got them from a friend, or if they've got them from a convenience store. This is where they're going to be coming from. They're coming through this import, train through China. For the products that if someone does is a smoker, and they say to their GP, I've tried patches, I've tried this, I've tried cold tape, nothing works, Can I at least try them. The Therapeutic Goods Administration or the TGA in Australia has produced a minimum standard minimum safety standard for E cigarettes, which for therapeutic use. It's called the TGA 11110. And while we don't have controls over the actual products, there is sort of like a set requirement that these products need to meet certain flavors like cinnamaldehyde can't be included in these products. But when they are tested because we don't have a domestic manufacturing process here, there are still trace elements of a lot of these chemicals which shouldn't be in there. So we are in this kind of weird halfway zone where we're trying to make them therapeutic. But we don't have our own local manufacturing. So what comes through, you know, the labeling might say yes, it ticks these boxes, but when it's actually tested a lot of the time, there are contaminant chemicals in them. So you're right there is no A way of determining what's in them. And you'll have to get my colleague, JD Morgan, who's who's a chemist on your podcast to talk about this. She's, she's incredible. She looks at these daily, and the amount of contaminants that she finds in ingredients that shouldn't be in there heavy metals that shouldn't be in there is frightening.

So you mentioned that E cigarettes first came on the scene in 2006. And on the one hand, that's nearly 20 years, but I'm well aware that in research terms, that's not that long at all. What do we know about the effects of vaping, particularly on young people, you know, it's taken us it's taken us a better part of a century to really come to terms with smoking and its effects in the public discourse. So where are we currently with our understanding of vaping? And what it can do to lungs, particularly kids lungs?

Yep, yep. So in Australia, we, you know, we're down under, we're tucked under there, things take a little bit longer to get here. So we didn't really start seeing increase in use, probably until about 10 years ago. So here we've got about 10 years where we've got increased use to the point that we might be able to track trends over time. And fortunately, we didn't have good data collection over that period of time. So we're, we're working with very scant data, the US and in the UK have been tracking it for a little bit longer than us. In in the US, there's a couple of really good quality, longitudinal cohort studies. So these are studies that have followed young people from over a period of time, who use E cigarettes. And they found that for for young people who use a cigarettes, whether they contain nicotine or not, it didn't matter, they had a three fold increase in the in bronchial inflammation, things like exacerbation of asthma was significantly increased. And again, it didn't matter if it was nicotine or not, it was purely just the act of using E cigarettes. And they even identified they were able to look at people who were smoking on it alone. People who using E cigarettes alone and people who who were smoking and using E cigarettes and it was that last group, the jewel users of cigarettes and E cigarettes that had by far the worst lung outcomes, so shortness of breath, increased phlegm, cough, that persisted over time, we found the same evidence in adults, a two fold increase in bronchial inflammation from the use of E cigarettes. So and this is just the start, you know, this was I think, around five years of data. So clearly, the process of inhaling these chemicals is harmful, it isn't harm free. One of the main mechanisms by which this is working, so propylene glycol is hydrophilic. So it attracts water, it's incredibly dehydrating. So if you if you're inhaling it in, and it's going through your lungs and through your mouth as well, it will dry out your mouth, it will dry out your lungs. And any dentists want to dry mouth is not a healthy mouth. So that also increases the risk of things like caries, poor oral health, and the same effects happening in the lungs. So yes, there is evidence that it is harmful to young people's levels. We are just at the tip of the the evidence, you know, we're still essentially waiting to see what happens in the long term. Some of your listeners and yourself included, maybe have heard of ivali or e cigarette and vaping associated lung injury. It was a very specific acute. And unfortunately, the lethal form of lung injury that was identified in the US back in 2018 2019. Where where people were presenting to emergency departments with extreme shortness of breath. And Around 70 people in the US died from from ivali. It's since been identified that that was due to a contaminant in the E liquid vitamin E acetate. So it's unlikely that ivali is something that we will see continue specifically in Australia, but it's an example of how easily a contaminant in a liquid can become incredibly dangerous if there's a bad batch. Or if young people are using E Liquids mixed with other drugs. So in this instance, it was mixed with cannabis.

Well, yeah, that actually leads on to another interesting part about E cigarettes. My understanding is they're also quite popular as an alternative to smoking cannabis. because people put THC oils in them, does that function differently? Or is there is there a different set of issues with that use of vaping? Or is it much the same unregulated manufacturer,

much the same unregulated manufacturer with the cannabis containing vapes. In Australia, they are less common, because we don't have a big market for them in the same way as the US does with the vaporizers. But people are accessing accessing them through the dark web. So crypto markets, one of the biggest markets for E cigarettes on the dark web. So this is where illicit drugs are sold. Other bizarre things, weapons are traded, and it's quite easy to access. Cannabis is the top illicit liquid that goes into E cigarettes, we're also seeing things like MDMA, opioids, being added to these devices. We know less about it, because the use is is less. But we do know that in the US, in particular, the rates of cannabis use are going up among young people because of the accessibility because of the perceived safety. You know, I'm not burning it, I'm just I'm just heating it, it's just steaming the plant material. So I think that's definitely something to keep an eye on in Australia as well. And I'll just add that we know that for the young people who use E cigarettes, they are significantly more likely to go on to smoke regular cigarettes, but also more likely to go on to smoke cannabis as well. So there's definitely a link there. We're still teasing out whether it is causal, you know, it's one causing the other? Is that a risk factor? Are these kids just riskier? More likely to take risks? So they're more likely to smoke? Or is this something that's precipitating their addiction? That makes them want to seek out other drugs? But yeah, the cannabis liquids and additives is something that we really need to be keeping our eye on. We don't have good routine data collection for it yet.

Well, on that topic. I mean, you mentioned the difference between Australia and the US. And, you know, one significant regulatory differences, the number of states in the US that have legalized recreational marijuana use, and I think the I think they're on track towards a national decriminalization, whereas it's not the case here except in a very select number of jurisdictions. Does the US have a different manufacturing and regulation approach to vapes, particularly cannabis based ones than we have here like it? Is there a supply of more regulated safer products available? Or are they still importing the largely Chinese manufactured materials?

For the most part, the US are importing Chinese manufactured products, you will notice the difference, you can tell if a product that has been destined designed for and destined for the US market ends up here, because it will actually have a label on the front saying warning contains sticker team warning, over 21 use only. So they are still predominantly accurate, you know, importing their their vapes through China as well. So the major, you know, contaminants and issues around that the same in the USSR here.

Well, can I just ask one more question, because the the notion of this kind of gap in our regulatory framework is something that fascinates me, like how did we get to the point where potentially harmful product is being freely sold over the counter of, you know, cigarettes stores, and tobacco stores, and even just corner stores that import products directly? How did we How did that happen without it being subjected to greater scrutiny?

It's, it's absolutely fascinating. I agree. You know, you think we are an island nation, obviously, we have really strict border controls. If you think if you were to think about any other drug, it would just be unthinkable that you could go up and say, you know, do you have this? Can I purchase it over the counter? And here's some cat. So a few different things. I suppose. Australia opted early on to go for this what we call a therapeutic model, where it would be allowed, but only for certain people, which has its merits, you know, obviously you want to only allow it for the people who legitimately need it and can benefit from it, which is great. But the difficulty in obtaining it. So you'd have to go to a GP more often than not pay your out of pocket gap fee for seeing your GP. Then you get a script and then you take that script and you go to community pharmacy or you call them up and say do you have anything? Lots of community pharmacies don't participate in this process. So the it, the ideal scenario is where people use this prescription pathway is not used very frequently. In fact, it's it's much less used than the than the illicit market where you could just instead of all of that, you could just go down to 711 and get something straight away. But because of the fact that we opted for this prescription, this therapeutic pathway, it left the door open, it left a regulatory door open, whereby anything that was non nicotine was allowed to freely come in and be sold to people over 18 via vape stores. So essentially, my perception is that the people producing these products have gone here is our way of getting in. Let's try flooding the market with these products. So what happens at border control is that huge shipments of vapes come in. And so picture boxes and boxes of these things is, you know, millions of them coming in every day. And on the outside of the box that says, you know, vapes, 0%, nicotine, flavorings, cherry, vanilla, whatever. In order to enact the, the laws that we have currently, a Border Force official would have to open that box. And there are many, many boxes that come in that look like that. Take it out, test a product or send it off to get tested to see if it had nicotine or not. And if it did have nicotine, then sees that at the border and stopped going through. So that was where we started. Like, that was essentially the loophole that let our market get flooded with nicotine containing vapes, because we had this kind of, you know, if it doesn't have nicotine, it's fine. So they thought, Okay, we'll just say that it doesn't have nicotine. So Minister Butler's latest announcement was to ban all disposable vapes. So we wouldn't have to go through this checking process at the border. At the same time, so complicating all of this, you know, you said, How is it possible that these products can get into the hands of young people via 711 via easy mod via these tobacco stores. Organized crime is involved very much, it is actually quite sophisticated. The syndicates involved in this in the same way, as per illicit drugs. And they have essentially piggybacked on on this loophole. And for the most part, the distribution of these vapes in convenience stores is not being run by the local shop owner or the employees behind the counter. It's being run by organized crime syndicates, who have very sophisticated delivery systems. So if if a shop is reported to New South Wales Health, and everything has been all their products are gone, they've been seized, they've been fined, they can have new products delivered to their door ready for sale in a matter of hours. So the makes the enforcement really difficult. So we've got this therapeutic pathway that is not really working, opened up the door for products to come in, and just a sheer bulk quantity, which makes enforcement really hard. So they're the three key things in my mind that have led to this bizarre scenario where we just can't stop these products coming in, which just seems wild.

And, you know, you mentioned a couple of times that one of the manufacturers tricks, I suppose, is just simply to not put a label on it saying it has nicotine, do non nicotine vapes exists because like the common, you know, we're gonna get on to talking about addressing this in schools, particularly, but one of the common comments by young people, one of the common beliefs by young people is that there is such a thing as a non narcotic vape. But do they really exist? Or is that mainly just a marketing loophole?

Look, they do exist, but they are incredibly rare. I would be very, very surprised that if any of the vapes that young people say they are using a genuinely nicotine free, there is essentially no market for that kind of product. You inhale it, it tastes a little bit like strawberry, but there is no reason to keep going back to using that product. When we have tested them, by way, I mean, you know, the other people in Australia who work in labs, when they've been tested, it's sort of around 80 to 90% are nicotine containing So yes, there are some on the market that are nicotine free. If people are purposefully wanted to use nicotine free products, you're just never going to know what you're getting. That's that's the problem. So it might be that you have a batch that genuinely are nicotine free or they might be a faulty batch. But for the most part, your odds are 80% Plus that if you don't buy something you Sit will have nicotine in it

right? Well, let's let's transition to talking about vaping, particularly in schools. I mean, as I mentioned, you know, it certainly is something I've encountered in schools. And there's a number of myths and myths, conceptions about the safety of vaping. Among young people, part of the work you've been doing is contributing to this positive choices, set of resources for schools. What's the underlying approach to engaging students in learning more about the health hazards of vaping?

I think the first thing we need to think about is making sure that we don't treat a cigarette as a special case, you know, yes, they are new. Yes, the market is a little bit different. But at the core of it, at the crux of it, it's about student resilience, it's about developing appropriate coping mechanisms that mean, you don't feel like you need vapes in the same way that you don't feel like you need to have a drink of alcohol, you don't feel like you need to have, you know, a joint. So when we go back to it, it's about what are our guiding principles for improving the resilience, the assertive refusal skills, or the pro social skills of young people in schools. And on top of that, we just layer specific information about E cigarettes, about nicotine about the market about tobacco companies, so people can understand that, look, my behavior around this should be the same as if someone is getting drunk at a party. And I don't want to I would say, Look, that's not for me. It's the same response for E cigarettes but adding a layer of education and understanding on top of that. So that's ultimately what that's sort of like the core of what we're trying to do with positive choices resources in the Matilda center is to engage young people in the conversation, not make it too specific about the substance, but to talk about their development more holistically. You know, this is a new product on the market, I'm sure, in a in a few years, it'll be something else, maybe cigarettes will wane. But we need to make sure we future proof our responses. So that's what we're trying to do. We are so through the Matildas center, and through our Futures Institute, we're developing a four module e cigarette prevention program, which is aligned to the curriculum across different states. And a lot of it is around teaching students how to gather information, how to critically evaluate what's in front of them, you know, to not be duped by tobacco companies. Recognizing when help is needed, you know, if they are feeling like they can't cope, or if they're using their, their vapes as a means of coping, we want to give them a toolbox essentially, of skills so that they can cope in more productive and effective ways.

When it comes to that kind of informed choice approach to education. Now, you know, young people notoriously don't have very good developed risk assessment mechanisms mentally. And what you're up against, when trying to get young people to make informed choices is basically peer pressure, you know, the sense of, you know, the vaping themselves, you know, a student or a young person might develop a dependency on nicotine, but ultimately, they probably got into it for reasons of peer pressure beforehand. So how effective can that informed choice approach be in the face of what can sometimes be quite overwhelming peer pressure?

Peer pressure, yes, is one of the key reasons key drivers behind young people experimenting with substances, you know, my friend is using this or try it, or you know, you're in a circle at a party and something is being passed around, it's really difficult to be in a position where, when you're trying to fit in, you know, you're a 1415 1617 year old, and you're trying to fit in and you're trying to be cool. And to push up against that is really difficult. So what we try to do is engage young people in the conversation at the outset, to get them involved in the response. So some examples of the way that you could commence appeal and conversation is putting out to your class, you know, what do you think about vapes just, you know, tell me what you think about them, or what concerns you about them, and this can start digging into their misperceptions, whether they think they're cool or not. They can get a bit of an understanding of what we call social norms. So our our interventions are based heavily on social Almost theory. So the thinking that everyone uses them so I should to to fit in. So countering that and going well actually, most people don't. If we're talking about 30% of young people who have ever tried them, the 70% of young people never have. So a countering that and providing normalizing evidence to go actually, it's not most people who use them. And if you have an open conversation in your class, you'll start to make that more transparent and realize that most people don't, or most people are a little bit concerned about them to try and dampen that peer pressure that misperception that everyone's using them. So I should two other ways to engage young people in this response is, you know, to go what, what would make you not use them? Or what what concerns you about them? If someone was to design an intervention or resource, what would work and what wouldn't work? And give them a voice in this whole, you know, response to a cigarette, but basically challenging normative perceptions around everyone who uses them, is key to tackling that peer pressure type response. Interestingly, when we look at the evidence of what are the top reasons you use them, peer pressure is there. It's not number one, but it's, you know, in the top five, number one is typically curiosity. Everyone's talking about them, what is this? You know, is it amazing? Am I missing out? And number two is the desirability the flavors, the colors, you know, the, the ease of accessibility? So these are actually the two main things that are driving use of E cigarettes, which is quite different to other substances, like alcohol, for example.

You mentioned that there were only about 5% of young people we're using regularly. When we're thinking about targeting students in schools for preventative education or intervention. Is the usage more prevalent, among particular demographics? Like who are the students more at risk that might need to be prioritized for this intervention?

Definitely. Unfortunately, it's always the case, it's Boys, boys are more likely to use E cigarettes than girls. It's the same with other substances. Children of Aboriginal or Torres Strait Islander status are also more likely to use them. Young people who come from families where E cigarettes are used, unsurprisingly are more likely to use them, or other key risk factors that are drivers for other maladaptive behaviors. So people from lower socio economic backgrounds, families have a general disadvantage. So when we when we think about time targeting, these are the key risk factors we have. Also, they're slightly older students are the ones who are more likely to use frequently. So we start to see experimental use, unfortunately, you know, as young as tin, but not the more regular use and addicted what we'd call dependent use, from until about 16 to 24. So when we if we think about targeting, and specific responses for trying to really get them to stop that older boys in the senior classes, from from disadvantaged schools, that would be where rates would be highest?

And is there much of a difference between treating it as a like preventative measure when it's younger, treating it as a early intervention measure when they're likely to be experimenting? Or, you know, once students have really developed a habit? Is there any point at which it's more or less effective? And are there different approaches, I suppose also at those different stages,

so Prevention is always better than cure. It sounds like such a, you know, like such a cliche, but it's so true. You know, for every dollar that we invest in prevention, we end up saving $7 down the track by stopping someone getting to the point where they're dependent, and then they need medical assistance, or they need to pay for treatment. So for the for the younger kids. So the kids who may be experimenting or may not have started yet, it would more be around providing social norms theory. You know, this is actually what's happening. Not everyone is using them, and then upskilling them with assertive refusal. So a good example is, you know, someone who is at a party or at a park after school, and they have a vape and then they offer it to someone who has never used before. And they say have a go and have a path. It's it's, you know, it's kiwi is it's amazing. And then they offer it again. And then again, it's like go on have a try go on, for that young person who's never tried before who's in a position where, you know, they might be feeling a little bit powerless to give them the power to say no thanks. I don't variable, I'm not interested. And and to get them to practice that in schools. So the the educational modules that we're developing, go through practice scenarios like that, so that young people can practice saying, No, I'm gonna thanks. No, it's not for me. Look, I know you're interested in it. And I know it's for you. But you know, it's just not my thing. And to get them feeling confident in doing that. So that's where a lot of the focus is on the early prevention so that they never enter into that use behavior in the first place. So that's what we're trying to work. That is always more effective than trying to treat addiction later on, particularly nicotine addiction, nicotine is an incredibly effective drug. It's a relaxing, it's a stimulant, you get this boost of dopamine and serotonin. Look, no wonder it's addictive, it can make you feel relaxed if you're stressed out. So preventing that initial step into the use of that drug is the most effective way that we can respond. And then the approach is different. So if we've got young people who are finding that it is part of their regular coping mechanisms, and the at the moment, that's, that's the minority. But there will be students who say, Look, I can't sleep without it, or I can't get through class. Without it, our approaches would be more around management of nicotine addiction. My my PhD, and most of my career has been in helping people quit smoking, and it's just, it just blows my mind that we're talking about this with young people. But a lot of the strategies that we use with smokers is similar to what we would use with young people. So identify the moments where you feel like you really need it. And fill those moments with better coping mechanisms. The younger you start, the earlier you start, the better they are at using those alternative coping mechanisms. So if they're struggling to get to sleep, you don't need to be of aid. You, you know, read a book, try mindfulness, try doing box breathing, feeling all of those moments where they feel vulnerable, with something that will be helpful, not just for preventing a cigarette use, but for general resilience and coping skills later in life. So yeah, for the affiliate, early, early stage kids, it's more around refusal, confidence and saying no, understanding real trends. And then for people who are using it's more around, how can we help you cope better?

When you talk about helping young people, or helping anybody combat that feeling of need, or that that sort of emotional or psychological sense of dependency? I mean, obviously, nicotine is a chemical known for building a physical dependency, but how, how do you how much of it is a balance of the psychological and the behavioral habits versus the actual physical dependency?

Yep. So when 100% Right there, they both interact. So you know, you have the behavioral component of reaching for the vape, feeling it in your hand feeling the you know, the physical inhalation, and then you know, the kind of ritualistic moment where you release that cloud, that's all a behavioral in the same way that we have a coffee and you sit down in the sun, and it's nice. And then there's the actual drug. So nicotine, as I said, is incredibly effective, and it hits your lungs, it goes into the blood, and then it goes to the brain within within a matter of seconds. So the the actual dependency can occur quite quickly. For people who are genuinely struggling above and beyond those behavioral reinforcers. That's when we start thinking about nicotine replacement therapy. So in Australia, nicotine replacement therapies are approved for use for anyone aged over 12. If you're between the ages of 12 and 18. And you're struggling, I would say a GP first before going in and using it. But essentially we're getting to the point where if someone is so dependent on the actual substance, they will probably need a low dose of nicotine during the course of the day just to take that edge off so they aren't feeling like they, they need the drug. When when it's not there when we are very dependent on a drug and it's not there in our brains and In our systems, the withdrawal symptoms can be close to unbearable, you know, the irritability, nausea, fatigue, shaking, inability to function to pay attention, when it starts getting to that point, that is when we would probably need additional pharmacotherapy to help ease that. I do a few talks to schools and to teachers. And there are sort of three main questions you could ask if you feel like someone might be at that point where it's turning into a physical dependency. And the first is how soon after you wake up, do you typically have your first vape? If it's within 30 minutes? That's a strong sign that yes, they do have a genuine dependency on nicotine? Do you vape when you're at home on your own, or in other instances where you are alone, and if they say yes to that, again, it's highly likely that they are dependent on nicotine, because a lot of the use is social, you know, it's in a group after school or after sports, or at parties. And the third, which is quite serious, but we do see it, do you ever wake up to vape? You know, are you waking up? Because your body is craving it? And if they say yes, then definitely there is a dependency there. So there's a little sort of toolkit that people can use to determine whether it's just a bit of a behavioral Crux or if genuinely, we might need to seek out treatment from a GP, and go to a pharmacy and, and purchase you can get nicotine patches, which you put on all day. Nicotine gum, you probably can't use in schools, but there's also a spray and other forms lozenges that you can put in your mouth for people who are genuinely struggling with that addiction.

And sorry, just something you said there that really caught my attention was the idea that we have prescribed nicotine therapies for children as young as 12. You know, that's obviously, you know, early years of high school. So just how prevalent is that degree of substance use in children that young?

Thankfully, not very. So, in in Australia, I mean, I've been working in this field for 1415 years, and for the most part, it's been people aged 25 Plus that you're talking about needing nicotine replacement therapies. So there is a very, very small percentage of of young people who who need this treatment. Previously, it was very disadvantaged group. So So young kids living rurally, or regionally, were smoking rates were very, very high in the home. And who were smoking, not using E cigarettes, but there were smokers around, you know, age seven up, that's where we were seeing it previously. But the fact that now, look, it's definitely on the rise, we're going to see more very young people wanting to use these products. And there is still a lack of certainty around, you know, I had teachers asking the other day, so can you just go in and buy it? If you're under 12? If you're, if you're if you're 12? And up, sorry? Or do you have to get a prescription for it, because it's been so rarely used in this age group, but I think we will see an increase, but at the moment, it is the very, very tip, you know, the 0.1% of people. But I think it's something we need to keep an eye on.

And just because I don't think we actually mentioned it explicitly at the beginning of discussion, when you said that, you know, we're talking about prescription therapies right now, but when it comes to the vapes, especially the ones that are not labeled as having nicotine, is it possible for young children to just walk into the stores and buy them? Or is there some restriction around their sale generally?

Yes, so for the legitimate market of non nicotine vapes, you do have to be over 18. So, in in major capital cities, or also online, there will be vape stores and these are legitimate vape stores and they can sell non nicotine liquids. These are typically produced in Australia. So you can go in there, you can even sample them if you like, you can try out the different flavors, but you do have to show ID and you do have to be over 18 In the same way as purchasing a packet of cigarettes or alcohol. Having said that, there are very few people who would just you know, go down to their vape store and buy nicotine free and then go home on their merry way. And in fact, they're raspberry. What people do is they buy the flavors here because they can test them out. And then they buy typically from New Zealand or from China, high concentration nicotine so that they can mix that and use it in their vape so even though there is a legitimate market for nicotine free vapes and vape juice in Australia, it's it's mostly so people can access it via bricks and mortar stores, but then they go and mix it with something else anyway.

Yeah, I suppose I'm asking more from me. spective of understanding that there in Australia is no legal way that a high school aged student should have any kind of vape or e cigarette about them anyway, like it's a restricted sale item.

Correct? Yeah, yep. Yep. Anyone under 18? Shouldn't have one, right? I think so people may have seen various news stories and on different channels on TV with this. It's a real dichotomy, a real divide. The people who think a cigarettes should be completely banned off the market, not here at all. And the people who believe that they do have their place that they are, the benefits in helping people quit outweigh the harms of young people starting up using vapes. And the main argument behind that is that nicotine is a rather benign drug. You know, yes, it has high addictive liability. If you administer nicotine in its purest form, for example, via patch, you're not going to have, you're not going to get cancer from that, you're not going to get, you know, any kind of other cardiovascular harms from using it in that way. Bar from maybe a very small percentage of people who have an underlying heart condition. But what's being ignored in this discussion, is the mental health impact is is the impact of having young people who are reliant on a substance, whether it'd be benign or not, if rely on the substance so that they're not using other appropriate coping mechanisms to get through their lives. Life is tough. It's school is hard, but it does, it does. Sadly, it doesn't get that much easier. When you're navigating University and jobs and relationships and all sorts of stresses, we want to make sure that young people are developing appropriate coping mechanisms from a young age, and if they're reaching for their vapes, and they're finding that nicotine is filling that for them. Or if they're struggling to go to sleep or struggling to concentrate, these are all negative health effects, which a lot of people are essentially ignoring. It's not cancer doesn't matter. It's not cardiovascular disease, you know, so that's fine. I think we need to be thinking about the whole of person. And the harm. So that's something that I just wanted to, to add in terms of when we talk about harms, it's not just the lungs, there is evidence of harms. It's it's less concerning than cigarettes, but there's still a harm there. And we're still working out the evidence. But all the other harms around social integration, feeling like you're part of a group, depression and anxiety are elevated among young people who use E cigarettes. So we need to be conscious of that as a harm as well. Can

I just pick up on that? I mean, you mentioned before that the students most at risk are those who tended to come from disadvantaged backgrounds, those who lived in rural, isolated areas. And, you know, as much as I'm a lay person, when it comes to the medical side of things, I suppose I personally have always subscribed a bit more to the health approach to drug addiction and issues, which tends to view the use of substances as a symptom rather than as a criminal act in and of itself. And you say that anxiety and depression are elevated? What's the sort of cause effect relationship are they using? Because they're depressed and anxious? Are they depressed and anxious because they're using?

I completely agree with you with the health response? You know, substance use is a health issue that should have a health response. And that is something that we fully subscribe to. When it comes to depression and anxiety. It's really interesting. We call it bidirectional. So young people who have elevated rates of depression and anxiety symptoms are more likely to start vaping. And young people who vape are then more likely to develop elevated depression and anxiety symptoms. So it's going both ways. We don't know what the chicken and the egg is

here, the anxious chicken or the depressed egg. Exactly.

So one potential theory is that nicotine is acting on that same reward pathway that depression and anxiety work on. So we know that depression is associated with inappropriate release of serotonin. So one of the major responses to that the medication is serotonin selective serotonin reuptake inhibitors or SSRIs. So it's working on that same pathway that nicotine works on in terms of increasing serotonin release, so that potentially there is some link there that nicotine is acting on this pathway and triggering some kind of risk factor that precipitates young people to use nicotine, whether it's because they're depressed and they have an altered serotonin pathway. So then the nicotine helps to attenuate that or the other way around. If they're not depressed or anxious, they start using nicotine products and then it it activates something in that pathway that makes them more susceptible. This, this interaction is something that concerns me a lot, because it is very, it's a very strong link. And we already know that rates of depression and anxiety are increasing among young people. And anxiety is one of the major concerns that young people state throughout that's impairing their function over school. So if we're seeing an interaction between anxiety and nicotine, and we're seeing an increase in e cigarette use over time, I think that's something we really need to keep an eye on and make sure that if we've got an anxious young person, we want to help them as much as we can with a health response, as you say, and treat the nicotine addiction, if that's the case as a symptom of a bigger health issue that's underlying that.

So you know, one of the things I find about Well, I suppose we'll talk about this in just a moment. But one of the things I often find about these kinds of intervention programs is they sometimes deal with a single issue in isolation, and not necessarily as connected to a symptomatic of a larger problem.

Exactly, yeah. So we try to counter that the evidence indicates that when a program is more holistic, that it looks across every hole of person function, it is more effective.

Well, let's just let's talk a bit more about the positive choices, resources for schools, because you mentioned that they're aligned to the curriculum in different states and territories. Where do they fit? Where are schools being encouraged to address this issue within the curriculum?

Yep. So with most health and social issues, it's falling within the PDH PE component of the curriculum. So wherever substance use or drug and alcohol use is currently covered. That's where we align to the curriculum. So Personal Development, Health and Physical Education is where that fits. And I know that teachers are currently expected to solve the world's issues through schools. So with with positive choices, we try to as much as we can support teachers in supporting their students. So we have, we're currently running a trial, which is in New South Wales, in Queensland, in Western Australia. So we have worked behind the scenes with the Department of Education in those states to make sure that our program aligns with the respective curriculums. And we're working within, in New South Wales, stage four, so year seven, and eight. So we're trying to make sure that everything that the program does is not in addition to what the parent that the teachers rather, are currently delivering in schools, but aligns and fits in nicely with the conversations that they're having anyway.

And while we have mentioned schools, primarily, I understand there's also resources for parents, that might be interesting, because a lot of teachers are going to be dealing with these issues with their own children as well.

That's right, so So the trial that I just mentioned, is being run through our Futures Institute, which you can google you'll find it. And it's quite a specific trial that is testing a curriculum aligned program called our futures vaping. So that's happening at the moment. positive choices is basically a landing page where what we have done as researchers at the University has gone through, we've gone through all of the evidence of all the different resources that exist that are out there, we have selected them based on their evidence rating. So if we believe they meet, if they meet the cup, they will be hosted there. So the positive choices website has dropped down sections for parents, it has dropped down sections for teachers and also for young people. And you can filter the resources by via you know, where you're coming from, and how you want to respond. And then also search via the specific drug. So if you go to the positive choices portal, and you're a parent, and you choose that and you're typing vaping, or E cigarettes or anything, it'll all link to the page, all of the resources that we would recommend that young that parents have a look at, that download will appear there, which also includes things like podcasts like this lectures from experts in the field, a downloadable, factsheets, apps that you might use, everything is hosted there. So it's a it's an attempt to be a catch all to make it easy, as easy as possible, because at the moment we are, you know, it's good and bad, but being inundated with all these different things, you know, where do you start? If you're looking for information and resources, I would recommend starting at positive choices because we have gone through that vet Same process for you. And it's it's easy to navigate as well.

Well, I will make sure that there is a link to those websites. And indeed, I have here an email with a wealth of related resources about smoking and vaping programs for school. So I'll make sure that all of those are in the show notes for this episode for anybody who wants to click through and have a look. Emily, once again, thank you very much for your time and best of luck with the trials for this project in schools.

Cam it's been such a pleasure. Thank you for having me. Thank you.