During her residency, Dr. Lena van der List encountered a young girl struggling to breathe with no signs of a typical respiratory illness. After several tests and examinations, the patient admitted that she’d been using vapes.
Van der List remembers this as one of her first experiences dealing with a youth patient seeking care due to vape usage. “It took a long time for her to share that she had been vaping," she recalls.
Now, a practicing pediatrician at UC Davis Medical Center, Van der List says that what was initially seen as an issue for her colleagues in adult medicine has become an increasingly frequent concern in her own pediatric practice in Sacramento.
Since the inception of e-cigarettes, the rise of new discreet cigarette alternatives like vapes and nicotine pouches complicates efforts to protect children's health. Addiction to these products is a challenge for those responsible for children, nearly 1 in 2 U.S. youth who have tried vaping once report current use, according to the 2023 National Youth Tobacco Survey.
In Sacramento, healthcare providers, researchers, and youth collaborate to tackle local usage and support teenagers struggling with nicotine addiction.
Dr. Van der List has witnessed firsthand the challenges teens face in seeking support to quit nicotine. She says some of her patients have expressed discomfort using school restrooms due to constant misuse and concerns about second-hand vape exposure.
“A lot of my teens do say that they vape daily or socially. If they report that they don’t, many discuss seeing it,” she said. “I had a patient who didn’t feel comfortable using the restroom at school because there was so much vaping going on in the bathroom — I think it’s rampant in Sacramento high schools.”
Various strategies are being implemented on Sacramento County school campuses to discourage vaping. These include vape detectors and anonymous reporting services.
For students who are aware of nicotine product distribution, the Sacramento City Unified School District suggests a service called WeTip, which allows students to report any misconduct anonymously.
A parent’s perspective and a seemingly never-ending crisis
Sacramento parent Franshelle Brown says figuring out how teens get vapes is not easy. Brown, a parent to her 17-year old highschool student son, has now caught her son with a vape on multiple occasions.
“I think he’s sneaking and doing so, but I can’t prove it,” she says.
Brown first became aware of her son’s usage when a concerned parent shared a post of her son with a cloud of vape smoke coming from his face. She says confronting him was difficult since he denied his usage.
Since then, he has been sent home from school for suspected use on school grounds.
“I’ve brought it up to his therapist, I brought it to his godfather's attention, and I told anybody who would listen,” Brown said. “He says it helps to keep him calm.”
Brown continues to make efforts to help curb his usage but fears her son does not realize the addiction he could be developing. She now monitors her son’s activity more closely, but he has continued to figure out ways to obtain vapes without her knowledge.
Health advocates argue that retailers play a significant role in the ongoing struggle against teen vaping. Sacramento has implemented tobacco retail license guidelines to reduce the density of storefronts that sell tobacco products.
According to a study by the National Library of Medicine, the density of tobacco retailers near schools can be associated with increased youth usage and reduced success during quit attempts.
The City of Sacramento has 346 tobacco retailers, 178 of which are located within 1,000 feet, or roughly three blocks, of a school. Over 51% of tobacco retailers potentially expose many students to these products daily.
Dr. Van der List says understanding the severity of the crisis is difficult since youth are not always willing to be forthcoming to adults and their doctors about their habits. This complicates efforts to gauge the true extent of the problem.
California banned the sale of most flavored tobacco products four years ago by approving Senate Bill 793. The bill targeted e-cigarettes and was a response to concerns about a rise in e-cigarette and tobacco use by teenagers.
The campaign to pass SB 793 was a battle. Advocates for the bill, including public health officials, educators, and parents, argued about the dangers of flavored tobacco products. They presented evidence that flavors like “gummy bear” and “cotton candy” were designed to lure young users. Governor Gavin Newsom signed the bill into law in August 2020.
Despite a ban to decrease youth appeal among teenagers, usage of vapes has only grown in the state, rising from 17.6% in 2022 to 18.3% in 2023, according to the California Youth Tobacco Survey. The state trend is opposite to the national average, which shows a decline in usage as a whole.
Barriers to treatment: Healthcare professional perspective
For 12- to 18-year-old patients, a visit to Dr. Van der List begins with a private interview to assess their home life, education, activities, drug use, sexuality, and mental health. This is part of their physical check-up, and they can talk to the doctor confidentially, without their parents present.
“In cases where teens disclose to me that they feel addicted to their vapes, I find myself scrambling to find the resources they need,” she says.
Nicotine salt vapes, often used by teens, carry significant health risks. Studies show they deliver high levels of nicotine, leading to intense addiction. Many teens are unaware that nicotine concentration impacts brain development and emotional well-being. Addiction makes it hard to quit, potentially leading to lifelong dependency.
She says often, patients don’t even know how much nicotine they are consuming. Unlike cigarettes, smokeless alternatives typically deliver more nicotine per single use.
Due to the novelty of vapes and other products, most cessation research has historically focused on adult usage, complicating the understanding of how to treat a child who is experiencing addiction, she says. This innovation in nicotine delivery has outpaced research on their addictive potential and effective cessation strategies tailored to adolescent users.
When working with young patients trying to stop using nicotine, she relies on guardian cooperation and suggests that the child's guardian be supportive and understand the situation.
"When we can get the parents involved, and when the parents are supportive but not punitive, those kids are the most successful,” she said.
Making suitable recommendations, such as nicotine replacement therapies like gums, patches, or lozenges, is challenging, she says.
“Most of us working with youth don't have much experience or training in assisting teens with nicotine addiction,” she admits. “This wasn’t an issue that developed until later in life, so most of the time, our adult medicine colleagues were the ones providing nicotine replacement or smoking cessation services.”
Only adults over the age of 18 can purchase nicotine replacement products over the counter, meaning children must be prescribed nicotine replacement by a healthcare provider.
Determining the appropriate dose for teens is particularly challenging, as they often give vague reports of their nicotine consumption compared to adult smokers, who can typically quantify their intake more clearly, Van der List says.
As the development of teen nicotine addiction research continues, Dr. Van der List stresses the need for a more supportive and understanding approach to help these young individuals overcome their addiction.
“Even if they themselves are not smoking, it's really affecting the mental health of others around them doing it,” Dr. Van der List says. “Can you imagine not being able to use the bathroom at your high school? I'm worried about a fear and feeling that school isn't a safe space for them because of these issues.”
A new research center
UC Davis established a Tobacco Cessation Policy Research Center last year in 2023. Dr. Elisa Tong, an expert in tobacco studies, is now leading the state's first Tobacco Cessation Policy Research Center. The center received $3.7 million in funding from the Tobacco-Related Disease Research Program to operate for four years.
The center runs seminars for UC Davis students to educate current and future healthcare professionals about tobacco control and cessation strategies. The course covers various topics, including health equity, the history of tobacco control, and practical policy advocacy.
“We had different Public Health Partners come to talk about Health Equity or the history of … the tobacco industry, what’s the legacy of the California Tobacco Control Program, and what’s going on at the local level,” Dr. Tong said.
Students participating in the program were asked to write letters to legislators about tobacco-related issues, incorporating data and health equity considerations. This hands-on approach aims to develop their advocacy skills and deepen their understanding of the policy-making process.
Dr. Van der List believes these advancements and efforts by the center can provide much-needed clarity and resources for future healthcare providers tackling youth nicotine addiction.
The center focuses on helping Sacramento pharmacies. One significant effort is working with local pharmacies to ensure they have the necessary resources for tobacco cessation. Dr. Tong explained, “We are working on a project to improve access to nicotine replacement therapies and other cessation resources at community pharmacies.”
According to Dr. Tong, a notable example is Pucci’s Pharmacy in Sacramento, which could now furnish nicotine replacement medications without a prescription for teens, under state law provisions.
The center also ensures that pharmacies like Pucci’s can receive reimbursement for providing these medications, making them more accessible to teens and young adults who need them.
“While not all youth have created a severe enough chemical addiction where tobacco replacement is needed, they should be able to access these resources if necessary,” Tong added.
These efforts combine clinical practice, policy advocacy, and public health education to create a robust support network for affected individuals.
"The whole environment has changed, and we haven't caught up on the healthcare side,” Dr. Tong says. “There are many priorities competing for attention, and we need to improve [tobacco cessation health care] systematically.”
The center's initiatives include four policy projects. These projects are focused on improving access to healthcare, addressing delivery barriers for substance use disorder facilities, engaging healthcare providers in local policy adoption, and reforming state-issued healthcare plans to ensure comprehensive tobacco treatment coverage.
Dr. Tong expresses that the center’s work is to create a sustainable impact and educate those working in tobacco cessation health. This aligns with Dr. Van der List's hopes for further research development.
"No one wants to share that they're struggling or have an addiction just to be met with, 'Sorry, I don't know how to help you with that.’ Our role as providers is to ensure we have resources to help them when they come to us,” Dr. Van der List says.
Local advocacy against tobacco usage
California Youth Advocacy Network student members rally at the state capitol for their annual Youth Quest conference on March 18, 2024. Members spoke to state legislators about their lived experience on their campuses in California.Tony Rodriguez/CapRadio
In Sacramento, groups like Sacramento BREATHE and the California Youth Advocacy Network, or CYAN, empower young people across California to advocate for tobacco-free communities. Kim Vagadori, the Executive Director of CYAN, emphasizes the importance of youth involvement in these efforts.
“Our youth program focuses on engaging young people in local tobacco-free initiatives, providing them with the training and support needed to become effective advocates,” Vagadori says.
CYAN’s Youth Quest event, an annual rally in Sacramento, is a cornerstone of the organization’s advocacy work. This event gathers youth advocates from across the state to meet with legislators, raise awareness about the tobacco industry's tactics, and promote tobacco-free policies. Participants engage in legislative visits, educational presentations, and a press conference, demonstrating their commitment to creating a healthier future for their peers.
Among the participants at Youth Quest is the Sacramento Breathe Youth Advisory Board. Sacramento BREATHE is an organization dedicated to improving the region's lung health and actively works to reduce local tobacco use. The nonprofit’s youth advisory board is a coalition of teenage students from various Sacramento high schools who oppose tobacco use. The coalition offers a range of youth perspectives on what kids are experiencing with tobacco on Sacramento County campuses.
Ellen Brickey, the board's adult supervisor, meets with the teenagers twice monthly to discuss tobacco use prevention, research, brainstorm educational campaigns, advocate for smoke-free environments in Sacramento, and conduct community tobacco litter clean-ups.
Brickey says obtaining vapes for teens can be shockingly easy. Many underage youth can access flavored vapes through online orders or from individuals selling them directly, undermining the ban's effectiveness.
Board members must not be active tobacco users. According to Brickey, even though the teen members do not use the product themselves, they are concerned for their peers who do. Through this work, Brickey has developed a deeper understanding of how adolescent nicotine use is driven by mental health. She says the most vulnerable youth are often the most susceptible to tobacco use.
“The only real response to it is punishment. We haven't created a safe space where they can say, ‘I'm struggling with addiction,’” Brickey said. “We're screaming at them to get out of the bathrooms with it. We've decided that's the problem, not why so many of them vape in the first place. ‘How can we help meet them where they are?’”
This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2024 California Health Equity Fellowship.
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