Mark Moreno Hi, I'm Mark Moreno. I have the privilege of co-leading the MD Anderson EndTobacco™ Program. And I'm here today with Dr. Jennifer Cofer, the executive director of the EndTobacco™ Program. And this is the Cancerwise Podcast. Jennifer, thanks so much for being here. We've been working together on the EndTobacco™ Program for ten years, addressing the harms, and the impact of tobacco use on the population and on public health. 

Jennifer Cofer, Dr.P.H. Thank you for having me. It has been a great ten years of amazing milestones for the EndTobacco™ Program. And thank you for choosing this topic to talk to teens about vaping, specifically what parents can do if their child is vaping. 

Mark Moreno Thanks so much. So, today we're going to talk about vaping among kids and teens. And to begin our conversation, Jennifer, can you just share how many young people are vaping today? 

Jennifer Cofer, Dr.P.H. Grateful to have the opportunity to talk about tobacco use and vaping, specifically. So, I may use those words interchangeably because some people don't consider e-cigarettes a tobacco product, but I absolutely do because that's where they're generated from. But in the United States, when we look at youth population, we have 10% who are currently using some type of tobacco product. I always like to use a statistic, but also a real number. That's about 2.25 million kids who are using some type of tobacco product, whether it's oral nicotine product, a smokeless product, cigars, e-cigarettes or traditional cigarettes. Specifically with vaping, to answer your question, we've seen 1.6 million students still vaping e-cigarettes as of last year. It's a decrease from our highest point in 2019, when we saw an epidemic of almost 30% of our youth vaping. So, we've made tremendous progress over the past 5 to 10 years. But just to repeat, 1.63 million students are still vaping. And I think that's under-reported because they're answering a survey in schools. And so, we know that some students may not be answering honestly. But 1.63 million students, that's about 6% of our population still vaping. In Texas, specifically, we have a 14% e-cigarette rate, and our smoking cigarette rate has dropped to 3.4%. So, we are making great progress over the past 5 to 10 years. 

Mark Moreno Very, very encouraging to see that we see a decline in the percentage of youth that are using combustible tobacco products. But unfortunately, we have still at a stubbornly high rate use of vaping products. In December 2018, you may recall that then-U.S. Surgeon General Jerome Adams declared youth vaping an epidemic, and he did this over the course of a visit to MD Anderson, which was a real milestone visit. We were so excited to have our surgeon general here. Can you talk just a little bit about why is vaping really so dangerous for kids? 

Jennifer Cofer, Dr.P.H. As a public health professional, we were very grateful he specifically put out an advisory and a warning to parents, and to policymakers, and to educators about the highest rates of vaping among our youth. Twenty-seven to 30% vaping, at one point, is very concerning. That could be one out of three students. So, what's so dangerous about vaping? First of all, three things come to mind: the nicotine levels, the flavors in the products and the actual impact on mental health. So, I'll dive deep into each of those. Nicotine disrupts brain development. Our brains develop up until we're 25 and 26 years old. A lot of high school students think that they stop growing, their brain has stopped growing, but that's not the case. Nicotine impacts the synapses in the brain connections, and that impacts mood, learning, self-control. And so, it's really important to not have nicotine in the adolescence phase at all. And so, with the level of nicotine that we're seeing in vaping cartridges at 5 or 6 mg. A lot of people ask me, "What's that equate to in cigarettes?" So, we're seeing 5 to 6 mg equate to about 2 to 3 cigarettes. And we have some students who are vaping a whole device, and that could be impactful when that accumulates over time if they're daily vaping or if they're weekly vaping. But when it comes to flavors, 87% of our kids say that they're using a flavor. We know flavors are drawing them in, but it's nicotine that keeps them coming back to hit their vape. Flavors come in lots of different variety of names that are attractive to kids. A lot of the flavors tastes like cereal, which of course, kids grow up eating. So, that's what's drawing them in as well, and fun flavors that match what they're into as well. The type of nicotine has been studied to show mental health impacts, meaning it's amplifying feelings of anxiety or worsening symptoms of depression. There are many researchers looking into this specifically, but this is what kids are using to cope and manage their stress. And that's what causes alarm. 

Mark Moreno Kind of building upon that, how do you talk to your kids about it? If you're a parent, how do you address some of these concerns and issues with your children? 

Jennifer Cofer, Dr.P.H. It's a great question, and one I want to make sure we talk through thoroughly, because a lot of the people in my neighborhood or in my family and friend group have asked, "Well, how am I supposed to talk to my high school student, my middle school student, or even my upper elementary school student?" And it's all about age-appropriate conversation and engagement. The first thing I tell parents is to make sure you are educated on the actual facts. Ninety-nine percent of the devices on the market have nicotine. So, when a student or your child says, "It's just water vapor." Or, "It's just flavored whatever it is," it's not true. There's a lot of nicotine in these devices. Like I said, about 99% of these devices in our retail markets have nicotine. So, most everything that they are vaping or in their friend group is vaping nicotine. So, be prepared and know the facts, educate yourself and actually prepare your conversation because you never know when it pops up with a middle schooler or high schooler. They could ask a question. But I actually think about being proactive. So, you're driving to and fro appointments, or errands or going to practice, drop your kid off at practice. If you drive by a vape shop, which there's unfortunately one on almost every corner, ask your child, "What do you know about vape? What do you think they're selling in there? Or what do you think a vape is?" And see what their knowledge level is of the product. You'll immediately know where to engage, depending on that response. You can also be non-confrontational and avoid judgment if they start talking about certain friends that vape or talk about what they were exposed to. Being caught off guard or dramatically responding is not always going to continue the conversation, depending again on the age. A sixth grader is going to be very different than your senior in high school. So, I think age-appropriate conversation is important. But it is very critical you have the conversation with your child. It is absolutely known that they have likely been exposed, or it's been in the bathroom at school where kids are vaping and they're exposed there, or they're hearing about it in social settings. But finding the right time, being calm and open, preparing yourself, making sure you're knowing the facts, as well as not being dramatic and doing scare tactics of, vaping is going to wreck your lungs. But think about what they're into as the conversation evolves. Are they into sports or are they into band? And they need their lungs to blow into an instrument? Think about having that conversation that directs them to what their interests are, of, why do you think you would want to vape and put something that would damage your lungs and that would risk, you know, your ability to play a sport or play the instrument? So, looping It back to them and their interest is very important. I listed off a lot of things. Anything you want to add as a parent of adult children who were teenagers at one point? 

Mark Moreno Our son was an athlete. And so, really helping him understand the harms of potentially using those types of products and what that could do to his performance and his ability to to compete at the highest level in the sport that he just loved so much. So, what are some of the signs and symptoms that parents can look for regarding the use of these products? 

Jennifer Cofer, Dr.P.H. Great question. I think first off, smell. Second would be some physical symptoms. And then three, you want to look for devices. So, regarding the smell, if you've been in a rental car, or hotel room, or walked past anyone that's vaped, you definitely can smell fruit or a sweet scent. That is absolutely the first thing that is an indicator that your child might be vaping, or their friends might be vaping. So, that is just a lingering prominent factor that you could easily find. The other physical symptoms are actually, it's a long list, but it's going to vary depending on if they're an occasional, hitting the vape once a weekend or if they're actually daily vaping. If they are daily vaping, you could see impact, and again, this goes back to the nicotine, impacting their mood, impacting their personality. They could be more irritable, they could be more restless and not sleeping well. Physically, they could have more respiratory infections, which could lead to pneumonia. You can see increased thirst. There is impact on the oral cavity. So, you could see more flavoring needing to salt food or add flavor to water because the vaping can impact their taste buds. You can also see an impact of voice changes or their throat, coating on their throat because of the vaping, again impacting the oral mucosa in the mouth and the throat. You could see nosebleeds as well. So, acute, meaning short-term, symptoms could be ear, nose, throat-related, respiratory, increased cough, but also physically, mood changes, irritability, restlessness, can't sleep very well. So again, it depends on the amount of nicotine they're using. And then I'll lead into the device type. So, if a parent is going to go and look in the room or in their belongings, it's not a normal device anymore. They are made into fun shapes or sizes or devices that look like a highlighter, like your highlighter. There's been another device that's been a video game. The video game is embedded into the device and every puff is a point, or every puff gets you to the next level. We are seeing some changes with those types of devices, but they are out there. We've seen hoodies that have hidden pockets for vapes to go into. So, a student could hit the vape in school and put it away in their hoodie. And so, we've seen other types of devices that are, again, attractive to kids. I don't find a 40-year-old trying to go get a highlighter to vape. So, that's one thing out there that I know was addressed this past session, looking at technology where vapes are embedded into technology or devices attractive to kids. 

Mark Moreno Well, thank you so much for that. And you're so right. And it really does bring to mind the importance of policymaking and the role that regulations or laws can play in curbing behavior or addressing these kinds of risks, you know, where the industry has become so creative in developing these types of devices that are so attractive to our youth. In the most recently concluded state regular legislative session. Our legislature adopted a bill and the governor signed it into law, which would prohibit the marketing and the selling of vape products that are disguised as office supplies, or USB ports, or headphones, or video games as you just described, or other devices. Can you talk just a little bit about the impact that these policies can have on the access and the use of these kinds of products for our children? 

Jennifer Cofer, Dr.P.H. Absolutely. You said the best phrase, policy does shape behavior. Just like seatbelt laws are now a natural for helping reduce car-related, car accidents that impact people. The same thing with how they regulate e-cigarettes are going to impact how our youth have access to them. So, policies do shape behavior, and we're very grateful these lawmakers saw what we saw in the marketplace was appalling. New types of devices trying to attract the kids in. Again, they're buying them for flavors or the device type. So, this policy that you referenced helps reduce the access points where kids can go buy it, or where their older siblings can go buy it. The influence of policymakers, the school leadership, retail outlets, families and friends, all of these are influential to our kids and keeping them from starting vaping.

Mark Moreno So critically important. And again, another area that's probably too easily overlooked. Can you talk just a little bit about what you discovered through your incredible research in your PhD program, and how impactful those kinds of policies can be in this particular instance? 

Jennifer Cofer, Dr.P.H. Absolutely. Thank you for bringing that in. It was a great opportunity to research, actually, did young adults, 18 to 24, to actually ask them and have conversations with them individually. And also a survey. It was over 5,000 students that took the survey in Texas colleges. I asked them what a possible tax number would be that could impact them to think about quitting or cutting back, because we do know that tobacco taxes have impacted youth and young adult consumption as well as adults, meaning the higher the price, the more we see a decline among adults using, the amount they use and even preventing kids from ever starting. Thinking about a price on anything that you would use, if it goes up in price, you think about maybe not buying it a second or third time, if it's out of your range of your budget. So, the same thing I brought to college students, who may not have loose change around if their, just depends on their status. But most college students I was talking to were working part-time, and they were really budget mindful, but they also were vaping. So, we talked about how much it cost, and I asked them if I put a tax on your product, would you think about quitting or cutting back? And it wasn't until we reached a higher level amount of tax did they say yes they would cut back or quit. So, that proves again what we know for decades of taxing traditional products, that if you do add a price and the price strategy increases, we will see people decrease the use of these products, which again, just takes home between these surveys and conversations, it's an opportunity in Texas for policymakers to think about establishing a meaningful price on e-cigarettes. If you think about the tobacco marketplace, cigarettes are taxed, smokeless is taxed, but our vaping products are not taxed in the state. So, it's an opportunity, again, both for public health to get a meaningful price to help people think about quitting, but also it could bring revenue in for the state as well. 

Mark Moreno Thank you so much for that. And providing just a little, a sort of deeper analysis into how impactful tax policy can be. And in Texas, we're making some strides and they're modest, but we're making some strides. MD Anderson has been a part of a statewide tobacco prevention and control coalition, which you help lead, and our department also contributes significantly to the development of those kinds of policies for the state. Now, turning our attention to a little more touchy subject, and I'm just really curious to hear your perspective. How can you look around really in your kids’ room or their belongings if you're a parent or a guardian to see if they're hiding or if they're disguising vaping products? Tell us a little bit about what you think on that. 

Jennifer Cofer, Dr.P.H. So, that is touchy. You don't want to have a gotcha moment, and you don't want to automatically just lead with punishment. And you're going to be livid if you find something. But think about it as an opportunity to see if your student, your child needs an intervention because nicotine addiction is very serious. We don't want this, again, to impact our adolescents and specifically their adolescent brain development. So, if you think about, I need to look for these devices just from that perspective so that we can have an intervention early. So again, because it's a serious matter, the earlier you can intervene in a child's life specifically for nicotine addiction, the better it will be for their body to reset and heal when they're fully quit, and have them on a pathway free of nicotine for their life. Kind of avoiding it and not addressing it could keep them leading an addiction to nicotine for their adult life. And I know no parent wants that for their child. So, addressing it early is important. So, think about I'm going to look through my child's room just, again, for intervention. Let me see if I need to notice physically what's happening to them, or look for devices, again, not for punishment or a gotcha moment, but an opportunity for intervention and to reset their health and their mind. 

Mark Moreno Oh, great points. And what does age-appropriate intervention look like along those lines? 

Jennifer Cofer, Dr.P.H. Definitely different from a sixth grader to, again, a high schooler, a junior, a senior. And for again, privacy reasons, the household establishes their own rules, I would assume, with every parent and child. But what we can see for age-appropriate intervention for nicotine addiction, that is important to bring in your health care provider, whether it is a pediatrician or a health care provider that's family practice. There are guidelines for treating nicotine addiction for 18 and over. But for those that are under 18, there are some new guidelines out there from the Academy of Pediatrics we would want to refer to. There are some medications and interventions that can help their child quit, depending on their nicotine dependance level. Again, if they're vaping every day, multiple devices a day, or if they're vaping on a weekend, it is dependent on the nicotine level addiction. But that's where we would highly recommend partnering with the provider and talking to them about how much they are vaping. That's very touchy. If a child doesn't want to go see the doctor for this issue. So again, that's where we encourage the parents to do some intervention. It also could just be counseling. We have physical counselors, we have mental health counselors, the school counselor, depending on the role that they play. But counseling could be beneficial as well because they could be using it to manage stress or to cope with something else going on in their lives. And so, having a therapist of some sort, a licensed professional counselor, is going to be of utmost importance, too. So, both a health care provider and/or a licensed counselor. 

Mark Moreno Complementing, you know, those insights around interventions, I'd like to maybe spend a minute or two to talk just a little bit about resources that are available to parents or to school leaders. 

Jennifer Cofer, Dr.P.H. At MD Anderson, we have our own program that's available for schools online, and it's free. It's called ASPIRE, and it's a prevention program to embed in classrooms. We also have our own health educators at MD Anderson that can go out and educate high schools through assemblies or through small classroom lectures, where they bring out the pig lungs or the gross mouth, and they can educate on tobacco harms. But there's also national programs. American Lung Association has a vaping conversation guide for parents, and it's a great tool. It's free, downloadable on their website, but they had many important take-home messages for parents. If this was a podcast that prompted a lot of attention and you weren't able to take notes, go to that resource guide for parents. The other most important program that I'd love parents to write down this number is a text to quit program called EX Program E-X Program. It is a number that they can text for free, confidential help. It's available 24/7. It has behavioral health and other mental health messaging embedded into age-appropriate texting. It is an evidence-based resource from our colleagues at the Truth Initiative, and MD Anderson is partnering with them to promote this key word to help our young people quit. Anyone over the age of 13 and over can text this program for support. They can text the number 887-09 and they put in a keyword "vape free TX" for vape free TX. So, that is the keyword. One more resource that MD Anderson offers in case families are looking for their own support to quit as adults. We have studies and trials available for free to help individuals quit smoking, and in fact, quit all tobacco products or any tobacco product. So, I would love for any family to visit our own website at MDAnderson.org/Tobacco, and that will route them to any studies or trials they may qualify for if they need assistance in quitting smoking. And of course, the national 1-800-QUIT-NOW number is available for anyone as well. 

Mark Moreno So, Jennifer, thanks so much for being here today and having this discussion. Again, it's so wonderful to celebrate the 10th anniversary of the EndTobacco™  Program. And thank you all for listening to the Cancerwise Podcast from MD Anderson. If you enjoyed this episode, don't forget to follow or subscribe on Apple Podcasts, Spotify, YouTube or wherever you get your podcasts. And be sure to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789, or you can visit MDAnderson.org.