Prakash Chandran: Today on The Peds Pod, we are diving into the growing trend of nicotine pouches like Zyn and their alarming rise in teen use. These seemingly harmless products are anything but. Joining us to discuss and unpack the risks and health consequences is Dr. Michelle Bowden, pediatrician at the Adolescent Clinic and the Medical Director of the Eating Disorders Clinic at Le BonHeur Children's Hospital.

 Welcome to The Peds Pod by Le BonHeur Children's Hospital. I'm your host, Prakash Chandran. So, Dr. Bowden, thank you so much for joining us today. I really appreciate your time. Let's start with the basics. What exactly are nicotine pouches?

Michelle Bowden, MD: essentially, nicotine pouches are these small pouches that a person can insert kind of between their gum and outside of the lip, kind of like you would think of a chewing tobacco, but instead of it being something that you've got to spit out, it actually just totally dissolves.

and the pouches themselves contain nicotine. In addition to nicotine, they also contain flavorings, so there's kind of this, need for, there's an element that it tastes good in some way, and then it also gives a sense of this nicotine hit, that people appreciate for the benefits of what they appreciate about nicotine.

And we can talk about if those are real benefits or not, but that's how people describe them.

Prakash Chandran: one of the things that I wanted to address is, how prevalent they seem to be. I remember a couple years ago, only like a select few of my adult friends maybe, did these, and now I feel like I see These little zin cans everywhere and everyone is doing them. And I was curious if you had any opinions around what has caused this surge or this rise in usage.

Michelle Bowden, MD: Yeah. So essentially in 2023, what we saw is Zen or similar products went from selling about 180, 000 products a year to over 800, 000 products a year. Just a year's time, for some reason, and looking back now, we can begin to see some of those reasons, there was this huge increase, not just among adolescent users, but among, adult users as well.

And so you're right. we're not just talking about how it affects adults. We're also talking about how it affects adolescents as well. And what's really interesting is that in similar, conversations that we've had about things like, e cigarettes, these products the tobacco companies are never going to tell you that, they really seem like there's an element that's marketing really to a younger generation.

 we see that because number one, they're flavored products, right? It's not like we're asking people just to use these products that taste terrible and people are just using them for the high that they get from the nicotine. They taste like mint, or they taste like other fruit flavors or, cinnamon, things that really you'd associate with chewing a stick of gum that really kind of has this, positive association with the flavor in itself.

And so what we saw in the, really the e cigarette epidemic was that we were seeing a lot of teenagers begin to use these products, not for the nicotine, but because they tasted good because they were marketed in brightly colored packages. And so I think that definitely has an element of why we've seen this increase is because, even the way the products are packaged really leads to a younger market demographic.

And if you look at just the data of who's using these, about a quarter of people who are using them are people who are under 21 and the product clearly says it's for 21 and up, that's problem number one is that there's probably an element of some sort of marketing to a younger generation.

Element number two is that for reasons we don't totally understand, there's been a huge social media uptick and people purporting the benefits of using these products. they've even created a lingo for themselves. They call themselves Zenfluencers instead of influencers. really trying to tell people how great these products are, and unfortunately, not really talking about any of the risks that may be associated with these, especially for the younger generation.

so I think those two things combined have really seen us, this really steep increase in use of these. And in last year's Youth Risk Behavior Study, which is a large national study of kind of substances that adolescents use across the countries. We saw that the Zen pouches or similar products, pouches, nicotine pouches, were the second most commonly used type of nicotine products, second only to vapes.

So. If we think about, talking about cigarette use in teens, that's incredibly low right now. Zen pouches are actually above that even. so this is a product that isn't done yet, too. We expect it to continue to rise. we think this is, as pediatricians, a real issue that we need to address and provide great, public health awareness so that our adolescents and their parents understand that there are real risks to these too.

Prakash Chandran: Yeah, so you're touching on the risks, and you're saying that on social media, the Zin influencers are sharing or purporting that these are safer. Let's maybe talk about some of the health risks associated with some of these nicotine pouches like Zin.

Michelle Bowden, MD: yeah, unfortunately, with like a lot of these, post cigarette products like e cigarettes and pouches, what we saw is that they're often marketed or at least discussed as safer, quote unquote, products, than combustible cigarettes. think in some ways that could be true, but in some ways that's really questionable because we have, Years and years of data on the harmful effects of cigarette use, we really don't know about what the long term risks are in Zin products, right?

We don't know, what the potential consequences of using these 10, 20, 30 years down the road are because they haven't been around that long. So part of it is just that we don't know what the long term risks are. What we do know for certain is that nicotine has harmful effects in the developing brain, and adolescent brains are still developing, Adolescent brain is not going to be fully developed until you're 22, 23, 25. and because of that, they're particularly sensitive. to stimulant products like, nicotine that come in these in pouches. so as we think about the way our adolescent brains develop, all of us develop reward centers, right?

That deep part of our brain that says, man, I enjoy doing that thing. I want to do that thing again, right? Maybe it's a workout. Maybe it's a food that you love. Maybe it's being around people that make you feel safe and good about yourself. but that reward center lights up in our brain and that reward center is it.

Titularly sensitive in teenagers. And when we start activating that reward center with substances that aren't natural substances like nicotine, we have a much higher tendency to develop dependence and potentially even abuse to those products. which can cause long term damage. Like. potentially beginning to affect our mental health.

We know that nicotine affects concentration. So if you're doing Zen pouches while you're at school, your attention is not going to be as good. we know that it can potentially affect our mental health and that's some research that's ongoing that we're trying to figure out regardless, even though we're still getting a lot of data about this, what we are for certain about is that there's no amount of nicotine that's safe in an adolescent brain, and so these are never going to be safe for teenagers.

Prakash Chandran: just to get a sense, to give us a comparison. So Compared to a cigarette, for example, how much nicotine does a, Zin pouch have, inside of it, or some, similar product?

Michelle Bowden, MD: Okay, so this is where it gets really like Mind blowing to me, the nicotine concentration is so high for what most people are using, So if you get one of the packages of Zen that has, 8 to 12 nicotine pouches in it, most people will use about half of that packet in a day.

So maybe 4 to 6 pouches. Each of those pouches is going to contain probably somewhere between 3 and 6 and 8 milligrams of nicotine in each pouch. if you were to be an average user and buying 6 milligram and you use Maybe six of those in a day. The nicotine equivalent is three packs of cigarettes or a pot and a half from an average e cigarette, The difference is that these dissolve in an hour, right? It's gone. You get this really high concentration of nicotine because it's in your mouth and because it dissolves so quickly. And so you feel like an hour later you need another one, and then another one after that. It doesn't have the longevity that e cigarettes or combustible cigarettes have, and so we're really seeing kids get much higher levels of nicotine from these products than they would from combustible cigarettes or even from e cigarettes.

Prakash Chandran: Yes, and then there's the addictive nature to it. Not only do you have the nicotine consideration, but the fact that it tastes like candy, right? Like people will just take it for the taste. So when you combine the two, people will just continually be using it. And I think that is the risk that you're speaking about, right.

Michelle Bowden, MD: Exactly. and really what the data suggests right now is that, about 75 percent of teens who start using a nicotine patch are still using it months later, which probably does speak to that, addictive potential. We also know if we, because e cigarettes have been around longer, if you look at the e cigarette data, what we actually found was that as kids maybe their entry point to nicotine was an e cigarette, But whereas in adults, we said, Hey, these actually may help you quit smoking.

In teens, we actually saw that their risk for using traditional combustible cigarettes was higher if they'd ever used an e cigarette. that's part of the concern is, that addictive potential says, well, what if I can't get a hold of, and this was a real issue, right? People couldn't get ahold of Xen for a while because people wanted it so badly.

It just, you couldn't find it on the shelves. Well, then do you go to e cigarettes or do you go to combustible cigarettes? and again, if you've channeled that reward system in your brain to need some sort of external exposure to really get that dopamine release to feel satisfied, is it possible that even leads into other substance use?

And so, Those are all concerns that we just don't know the answers to yet, based on what we know about the adolescent brain and what we know about our history with other tobacco type products, that there are some real concerns that this could be the trajectory that we see teens go down if they continue to use these products.

Prakash Chandran: So I want to shift the conversation to, things that parents can do, I am, I am a parent, to prevent their teens from using things like, zin pouches, and I think the hard thing about this is from what I have seen, they are.

so discreet Like sometimes you have no idea if someone is using them until they pull out a can in front of you and Insert another one if they choose to do that I actually know for a fact that one of my friends who's a pair of their kid I've seen him kind of using zin and I don't think that my friend is aware of it, so this is a really hard, situation because unlike cigarettes unlike some other, products like, vaping, where you can see the smoke, you just don't know, if your kid is using it or not. So, my question to you is, in this world where it is discreet and you have the social media consideration, you have your friends using it, you have the addictive quality, what can we as parents do to help prevent the usage of these things?

Michelle Bowden, MD: yeah. parents, I think we can't make decisions for our kids, but we can give our children the ability and the knowledge to make good decisions for themselves. so I think being really honest, having really honest conversations about, you know, These products is a really good starting point and as parents, we often are very reactive and I would actually suggest that we be proactive about these products, right?

Like I want my kid to hear about these things and their risk, not from some kid in the locker room or somebody in their math class. I want them to hear about them from me. and I think as parents that sometimes feels really intimidating, but it can be as simple as like, Oh, It's right after the holidays.

We were at a family Christmas party and, Aunt Marjorie was using Zen. Do you know anything about Zen? Tell me, do you have any friends that use Zen? Like, tell me what you know about it. And so it just, it can be really natural conversations from things that happen all around you. and in that conversation, you're asking for feedback from your teenager, but you're also in that conversation able to say, well, did you know that actually the, CDC says that there's no nicotine that's safe for teenagers because it can be addictive and because it can cause these problems with attention and mood and other things.

so providing them with some information where not everything they're getting is from social media, from their friends at school, but actually having an adult speak into that and give them some alternative information feels really helpful in those scenario and to do it before they've had the opportunity to try it for themselves.

so I think primary prevention, that's what I would call it. Primary prevention is a great way to start. Start, those conversations with our kids. I think the second thing is that if you do start to notice Again, let's be educated about like, if I find this round container, and my kid's like that's gum, let's like question that, right?

That's how we were with vapes for a while. I was like, that's a USB, and we're like, no, that's not a USB. That's a vape. And so when we're really, Being mindful of that, not to gotcha our kids, but to say, Hey, I found this. Like, can you tell me more about what this is, why you're using it? Let's have a conversation about that again, just to provide them with some knowledge.

but also, monitoring for, the behaviors that might then become problematic, right? If your kid's got falling grades in school. And maybe we need to talk about substances including nicotine, right? If your kid is starting to have mood issues, or you're noticing, you know, most of us have had a friend that's trying to quit cigarettes, or trying to quit vapes, or trying to quit maybe even zen, you know, the symptoms, right?

They get super irritable when they're, feel like they need more nicotine, or they're, feel like they don't have the energy they used to have or, kind of those perceived benefits that they were getting. We can notice those as people in our kids lives. And that again might be a place to bring up those conversations.

It's like, Hey, it seems like things have been kind of off lately. let's have a conversation about that and just start the conversation in that way. but, I think as parents, it's, It's still our job make sure that our kids have the information they need to make really good decisions, and that we're also giving them alternatives, helping them understand that, hey, you know what, like, know it feels like everybody is using these pouches, but it's really only like 2 percent of teenagers right now.

 so helping them understand that it's not the end of the world, even if they feel like this is, you know, Something everybody's doing. It's really not that way because social media is not reality. so helping them kind of reframe things in that way to make safe and good decisions for their health.

Prakash Chandran: I think that is really good advice. Just arming them with the Right.

 information so they can make the best decision, you know, with your guidance. just before we hop off, Dr. Bowden, is there anything else that's worth covering just around helping, parents stay informed about the upcoming, information about these in pouches or just more information about keeping their, children safe?

Michelle Bowden, MD: Yeah. You know, kind of the things on the horizon are, right now, there's not a whole lot of, regulation for, these products in the United States. so that's something that's kind of in some conversations among the legislature. We've made a lot of progress around.

 originally cigarette, legislation and e cigarette legislation more recently to really limit access to these products, but that doesn't exist quite as well right now, for these nicotine, pouches. And so, really just, if you can, and if you're willing being, an advocate for those things, again, to help keep our kids safe, I think it's a really important part of what we do as parents.

 the other thing is to be aware that, if we're buying products, especially products, not from the U S. You can get some really, really high dose nicotine, and really, really high dose nicotine can actually cause nicotine, overdose symptoms, which are things like palpitations and sweating and high blood pressure, things that are really true physical symptoms that can be really dangerous for kids, if you start seeing those kind of symptoms, take your child to their pediatrician, take them to the emergency room, have them evaluated for those things.

And make sure that you're asking them, that their pediatrician is asking them about substance use in those conversations, because those can be really scary symptoms. But if we don't address the core issue, which is the product that calls those, then potentially it could happen again. and that's not something that we want to see for our kids.

Prakash Chandran: Yeah, absolutely not. Well, Dr. Bowden, thank you so much for this information today. I think this is the perfect place to end.

Michelle Bowden, MD: Thanks so much.

Prakash Chandran: That was Dr. Michelle Bowden, pediatrician at the Adolescent Clinic and the medical Director of the Eating Disorders Clinic at Lab Bonar Children's Hospital. If you found this podcast to be helpful, please share it on your social channels and be sure to check out our entire podcast library at lab bonner.org/podcast.

For more topics of interest to you, I am Prakash Chandran, and this has been the Peds Pod by Lab Bonner Children's Hospital. Thanks for listening.