Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Bob Underwood. Before we introduce our guests, I'd like to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast, and then click the claim CME button.

Now, I am thrilled today to be joined by two guests who bring both a medical expertise and real-world teen insights to our conversation. And today, we're talking about vaping and nicotine pouches. So first up, we have Dr. Thuylinh Pham, a board-certified urgent care pediatrician at Children's Mercy, Kansas City, and she's seen firsthand how vaping impacts young patients, and she's passionate about helping parents and providers spot the early warning signs.

And also, here to share what it really looks like from the teen perspective, we have Addisyn Davis, a student from North Kansas City High School, and an advocate with Next to Rise, a young leadership program focused on prevention and awareness.

So to both of you, we've got some questions. So, first, let's start off with Dr. Pham. What are the biggest misconceptions that teens have about vaping and nicotine pouches being safer than cigarettes? We're going to ask you, and then we're going to turn it over to Addisyn to see what she thinks.

Dr. Thuylinh Pham: So, we've had decades-long studies showing the adverse effects of cigarettes on both youth health and adult health long term. Now, when vaping first came into market, there was a big misconception that it was water vapors only, and there was not the carcinogens that we saw with cigarettes, which we found it's just not true. It is too early to really know those long-term datas. And now, we have even newer markets of nicotine pouches, which we have no long-term studies at all with that. And we can only assume what we've seen with oral nicotine use or oral tobacco use.

Host: So Addisyn, what do your peers think about vaping or nicotine pouches? Do they think that they're safer than cigarettes?

Addisyn Davis: Yeah, I feel like I hear a lot that teens think it's safer than cigarettes or that it's not quite as addicting. And people overestimate how often that it's being used, and they feel like their peers are using it much, much more than they actually are.

Host: Right. That's kind of fascinating. And I think the part of it is it doesn't have the image that a cigarette might have otherwise as well. So, what are some of the warning signs that parents and caregivers should look for? What are the things that might indicate that a teen is using nicotine pouches or vaping when they're not actually kind of being upfront about it? Dr. Pham, what are your thoughts on that?

Dr. Thuylinh Pham: That is a really hard one, because the youth that are using vaping and nicotine pouches are not what I would consider your overly high-risk teen. I am seeing everyone: from the straight A student, to the high athletes to the popular kids, to the band kids. It's anyone.

And so, what is really important is having a routine screen in your office for every child visit, whether it's well child or it's sick, and that is aligned with AAP's screening policy for anyone 10 and up. Most times when I see kids in clinic, it's because they are scared that there's an effect of the nicotine on their health or their parents have caught them or schools have caught them, and now there's parental and adult involvement.

Host: Got it. Yeah. Once they're involved, then they want to bring them in for sure. And Addisyn, anything that you know that stands out when there may be one of your peers who's either vaping or using nicotine pouches?

Addisyn Davis: I feel like oftentimes, from what I notice, we do have a lot of more at-risk youth that are vaping and are using nicotine pouches. But I also feel like something to really pay attention to is if you see a child like visibly hiding things or just secrecy when you walk inside of the room, like you open the door and then they're like jumping around trying to hide stuff. I feel like that's very much so one warning sign as well as if someone's really, really protective of like their pockets or their bags. That typically, from what I have seen, signifies that there's something going on.

Host: Sure. That makes sense. And Dr. Pham, you already said that one of the ways that these kids often present is that they come in with their parents, but what are the health risks that they present with and what are you most concerned about as a provider?

Dr. Thuylinh Pham: Oh my gosh. When I was first seeing nicotine issues in teens, we really had the gamut from anything from nicotine toxicity to nicotine addiction with withdrawal. So with toxicity, kids would call get nic sick, in which they would vape or smoke so much, they would cause nicotine poisoning. And that would be nausea, vomiting, abdominal pain, headache, dizziness, tremors. If you ingest enough nicotine, it can lead to respiratory distress and cardiac failure and including death. And that was one of our scarier things that we were concerned about with. These kids who are vaping these high amount of nicotines.

Now, the opposite ends are once these kids are addicted and they're having to frequently vape, what we are seeing is a lot of nicotine withdrawal symptoms, so increase of anxiety and depression, they're not sleeping, they can't concentrate. They're really irritable and restless. So if you notice like significant mood changes in school or at home when they're around people, a lot of time it's the withdrawal symptoms. I have had kids who tell me they've had to wake up in the middle of the night to vape, because they wake up in withdrawal.

Host: Wow. Now, what about nicotine pouch use? Is there anything specific about that? We already mentioned irritability, nausea, those come with nicotine. What about oral issues? Is there anything specific about the pouch use?

Dr. Thuylinh Pham: So, the pouch use, it's a little bit early, but we are starting to see some irritation with like mouth ulcers and sores. There is that increased risk of long-term oral cancer, just because nicotine in itself is a carcinogen.

What I'm most concerned with the nicotine vapes and pouches is the level of nicotine in them is much higher than your conventional combustible cigarettes. So if you look at the nicotine vapes-- so right now, we're not talking Juul, we're talking about Elf Bars and Geek Bars, which some of them carry as much as like eight packets of cigarettes' worth of nicotine in one cartridge. The nicotine pouches, they're advertised from anywhere from 1.5 to 15 milligrams. But studies have shown that they can have as much as 47 milligrams of nicotine, because there is no FDA regulations that is verified what that nicotine is.

And then, you add on the science of these nicotine. So, we're talking about how it absorbs into your blood. These absorb at higher levels of nicotine than your traditional combustible cigarettes. So if you were to smoke a cigarette. And 30 minutes later, we measured your blood, it would be at about 11 nanograms per ml of blood. If you were to use one six milligram pouch, and we measured it later, it's about 17 to 18 nanograms in the blood. And so, we're seeing a higher absorption rate even.

Host: Yep. Absolutely. And yeah, that all makes sense in terms of how it's being ingested and getting into the bloodstream to start with. So Addisyn, let's talk about social media. What trends or peer pressures in that area might play a rise in the nicotine pouch use or vaping amongst teens?

Addisyn Davis: I feel like a lot of it is the flavoring and the marketing towards youth. And the fruity flavors and the really colorful packaging, it disguises the product as harmless or fun. And obviously, you have your warning signs, but we're more likely to see fun colors and younger kids are more likely to see it as fun colors.

I feel like bathrooms as well, the school environment, whenever you hang out in the bathroom, which hopefully you don't because you're there to do your business, it often becomes a hangout spot that is really well known to be an area that people go to vape. And if you're in there frequently, say for whatever issue, you're more likely to be exposed and experience that temptation.

I also feel like a lot of influencers make vaping feel like it's no big deal. You see it on TikTok, on Instagram. You see influencers as well as people that you see around school that are making it seem like it's not a big deal, even though the health effects are obviously very, very significant and long term.

Host: Yeah, absolutely. And which kind of brings us to our next question is what do teens perceive as the risks of nicotine addiction? And what would you say to someone who thinks pouches are harmless because they are tobacco-free?

Addisyn Davis: I feel like teens currently don't have as much of an understanding about the dangers of nicotine. Obviously, you get like very surface-level education about it, but you don't get the in depth. This is what it does to your brain. This is how you are affected. This is how it rewires you. I think definitely that the nicotine in them, as Dr. Pham was saying, it is just as harmful as tobacco. It does cause all of these long-term effects. It is something that's not naturally occurring in your body; therefore, it should not be there.

Dr. Thuylinh Pham: I'm just going to add to Addisyn, because so many people tell me like, "Isn't vaping better? Isn't these pouches better than smoking?" And honestly, what we are seeing in the youth populations that, if they start nicotine with vapes and with pouches, they're actually moving to combustibles and that is contradictive of what the adults population, is that if they are long-term smokers, they will move more towards vaping to "minimize" that risk of all the other combustibles, but we're not seeing them actually quit from the nicotine addiction part. This isn't like nicotine replacement therapy where it's well-monitored, and your goal is to get off of nicotine completely.

Host: Yes. I think that's absolutely true. And one of the things that's being debunked is there was originally, I think, an intent that this would be a way to wean off and that's not actually happening. So Addisyn, back to you in terms of what advice would you give adults, teachers, doctors, parents who want to better understand and support teens who are dealing with nicotine use or nicotine addiction.

Addisyn Davis: The main thing that I would recommend is to educate yourself first. That way, you have a full understanding of how these teens are being affected, not just how nicotine affects people in general, but especially the youth brain. And once you're able to understand that, you can approach them in a manner that would not maybe irritate them or make it seem like you are attacking them.

Definitely avoid using scare tactics. I have seen that happen, and it doesn't help . Make sure you're educating them about the issues with vaping as well as with nicotine use. And also, we see a lot of vaping as a result of stress and anxiety, and ensure they know how to cope with their feelings in a healthy manner, and also offer alternatives to that oral fixation, like replace it with a water bottle or replace it with something fidgety to use.

 Another thing that I feel is very, very, very important is to create judgment-free and honest communication between your kid and start that at an early age. That way, they feel they're able to come to you whenever they're struggling with something like that.

Host: I think that's great advice overall . Folks, this has been really, really informative to me and I think to everyone who's been listening really appreciate it. Is there anything either of you would like to add as we close out for the day?

Dr. Thuylinh Pham: My biggest thing to add for teens and youth and parents is that you are not alone. That there are mental health resources that are free in every state through their local tobacco quit services.

Here in Missouri, we have programs that are specifically text for teens that are confidential. Teens can also receive nicotine replacement therapy confidentially through their providers. I think it's really important, like Addisyn said, to have a judgment-free treatment option. You don't need to be putting down judgment on these teenagers who are trying to get help. What we do is we need to support them and understand that slips and relapses happen, but it's moving forward together and creating a good quit plan.

Host: That's awesome. Addisyn, anything from you?

Addisyn Davis: Yes, I agree with that completely. You hear a lot about people using vaping and nicotine using it as a coping mechanism. And it's very important that we are also prioritizing mental health in these cases as well, and also surrounding ourselves and making sure our children or the youth are surrounding themselves with positive influences and using that positive peer pressure, because you hear about negative peer pressure so much. But positive peer pressure does the same thing. So if you are struggling with nicotine and vaping or other use, it is so important to surround yourself with people that are going to support you and are going to help you with getting through and overcoming that challenge.

Host: That's awesome. Thank you both for being with us today. This has been really, really great. As a reminder, claim your CME credits after listening to this fascinating episode today. And you can do so by visiting cmkc.link/cmepodcast and click the Claim CME button. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm your host, Dr. Bob Underwood. This is Pediatrics in Practice, a CME podcast.