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educate. engage. empower. TOBACCO-FREE COMMUNITY FORUM

TOBACCO-FREE RESOURCE GUIDE for Youth, Communities, Parents, and Schools

TOBACCO-FREE COMMUNITY FORUM Educate. Engage. Empower. April 28, 2021 This event made possible by the Poe Center for Health Education in partnership with Wake County Human Services, Wake County Public Schools, and the American Heart Association.

TOBACCO-FREE COMMUNITY FORUM AGENDA 9:15 a.m. - 9:30 a.m. - Log-In and Sign-On Slideshow of PhotoVoice Projects

9:30 a.m. - 9:40 a.m. - Welcome & Opening Remarks Honorable Sig Hutchinson, Wake County Commissioner Ann Rollins, Executive Director, Poe Center For Health Education Roxie Cash, Wake County Board of Education 9:40 a.m. - 9:45 a.m. - Recognition of Local Champions Presented by Youth Empowerment Team

9:45 a.m. - 10:00 a.m. - A Snapshot of Tobacco’s Impact on Youth In Wake County Sumedh Kotrannavar, Student at Carnage Middle School Teja Wasudev, Student at Cary Academy Nikhil Patel, Student at Enloe High School Gorja Yadav, Student at Enloe High School Lily Zahn, Student at Fuquay-Varina High School 10:00 a.m. - 10:20 a.m. - Latest Updates on Tobacco Impacts, Trends, and Statistics Jim Martin, Director of Policy and Programs with the N.C. Tobacco Prevention and Control Branch Division of Public Health, NC Department of Health and Human Services 10:20 a.m. - 10:45 a.m. - Youth Perspective on Local Tobacco Policy Needs Panel Moderator: Honorable Sig Hutchinson, Wake County Commissioner Panelists: Sumedh Kotrannavar, Student at Carnage Middle School Teja Wasudev, Student at Cary Academy Nikhil Patel, Student at Enloe High School Lily Zahn, Student at Fuquay-Varina High School 10:45 a.m. - 11:20 a.m. - Transition to Breakout Educational Sessions Community Session - Focused on Policy Action, facilitated by: Ann Rollins, Executive Director, Poe Center C. Michelle Mulvihill, Region 7 Tobacco Control Manager, Wake County Human Services Department/Public Health Division Lily Zahn, Student at Fuquay-Varina High School Parent/Caregiver Session - Facilitated by: Mel Downey-Piper, MPH, Vice President of Health Strategies, American Heart Association Susan Foster, Assistant Director, Substance Use Prevention, The Poe Center Sumedh Kotrannavar, Student at Carnage Middle School Youth Session - Facilitated by: Brian Glendenning, Senior Administrator, Healthful Living, WCPSS Teja Wasudev, Student at Cary Academy Nikhil Patel, Student at Enloe High School

11:20 a.m. - End of Breakout Sessions - Return to Main Session

11:20 a.m. - 11:30 a.m. - Goals for the Future & Next Steps Honorable Sig Hutchinson, Wake County Commissioner Ann Rollins, Executive Director, Poe Center For Health Education Youth Empowerment Team

11:30 a.m. Adjourn INTRO

Good morning parents, teachers, community leaders and fellow teens,

COMMUNITIES On behalf of the Youth Empowerment Groups in Wake County, I would like to thank you for joining us virtually and contributing your time to the 2021 Tobacco-Free Community Forum. As a teen, I have encountered and witnessed an alarming increase of tobacco use and have watched such products become normalized among the youth society. The issue of tobacco use has invaded our community and affected many of my peers. Today, in the US over5 million youth are currently using e-cigarettes and nearly 1 million use the product daily1.

For this reason, the Youth Empowerment Team of the Poe Center for Health Education in partnership with Wake County Public Schools, Wake County Human Services, and the American Heart Association have put together this event to address the disheartening increase of tobacco use through e-cig products among the youth in our community. In North Carolina youth, there has been an 1129% increase of e-cigarette use in less than a decade2. I hope that together we can create and implement a

YOUTHS solution to put an end to and eliminate this growing epidemic before it is too late.

To learn more about these current statistics, during this event we will be hearing more about tobacco’s impact on youth communities through: • Breakout sessions addressing different aspects of the issue. • Hearing from experts about these impacts that tobacco has caused. • Community leaders speaking and helping with finding resources.

With your help, I believe we can put a stop to this growing issue. We challenge you to leave here today feeling empowered to take this information and use it to implement your own ideas. Educate others and engage your community and your peers. We encourage everyone to help in any way that they can, remembering that every effort matters.

Thank you again, PARENTS

Thaleana Luu Senior, Wake Early College

Sources: SCHOOLS 1. 2019 United States Youth Tobacco Survey 2. 2019 North Carolina Youth Tobacco Survey Exceptional care, no matter where you are in North Carolina—or in life. UNC Health’s mission is to improve the health and well-being of all North Carolinians, especially during these uncertain times. We partner with other innovators to put health care at your fingertips, offering 24/7 virtual appointments, as well as developing clinical trials to give families more hope. From common to complex, we’ve got you covered—for life. unchealth.org

THANK YOU TO OUR PARTNERS

Wake County Public Wake County School System Human Services

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American Heart Wake County to support the North Carolina Association PTA Council Tobacco-Free Community Forum THANK YOU TO OUR SPONSORS:

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Fun 4 UnitedHealthcare UNC Health Raleigh Kids

Combating Youth Tobacco Use - Action Steps for COMMUNITIES COMMUNITIES • Model a healthy lifestyle free of tobacco products.

• Adopt a tobacco-free policy for your home and vehicle.

• Continue to educate yourself and commit to talking with your young person as they grow about tobacco and other drugs.

• Continue learning about this issue by exploring your Tobacco-Free Forum Resources, sign up for email alerts, and follow prevention organizations online.

• Support education opportunities in your school and community. Schedule an education session with your PTSA meetings, civic organizations, faith communities, events, etc. Contact one of the following organizations to schedule a presentation for your organization.

Wake County Tobacco Prevention & Control Program Poe Center for Health Education [email protected] [email protected]

• Share information found in this resource packet with friends and family through social media.

• Learn about and participate in national tobacco use prevention campaigns such as the Great American Smokeout in November and Kick Butts Day in March. www.TobaccoFreeKids.org

• Educate yourself on current tobacco policies impacting your community. Stay informed at WakeGov.com/tobaccofree and NCAllianceForHealth.org/TobaccoUsePrevention YOUTHS: WHAT CAN YOU DO?

Combating Youth Tobacco Use - Action Steps for Youth

• Learn and stay updated about this issue by exploring your Tobacco-Free Forum Resources.

• Sign up for email alerts and follow prevention organizations online.

• Join a community Youth Empowerment Group (Poe Center, YES! For Equity, 4-H) to educate your peers and community.

Interested in starting a Youth Empowerment Group in your school or community? Contact YOUTHS [email protected] to learn more.

• Learn about and participate in national tobacco use prevention campaigns such as the Great American Smokeout in November and Kick Butts Day in March. www.TobaccoFreeKids.org

• Participate in the Wake County Tobacco-Free Poster Contest. Entry form link: https://forms.gle/VxFCUfHJZjsq5Ac88

• Model a healthy lifestyle free of tobacco products.

• Encourage your family to adopt a tobacco-free policy for your home and vehicle.

• Share information found in this resource packet with friends and family through social media.

• Educate yourself on current tobacco policies impacting your community. Stay informed at WakeGov.com/tobaccofree and NCAllianceForHealth.org/TobaccoUsePrevention PARENTS: WHAT CAN YOU DO?

Combating Youth Tobacco Use - Action Steps for Parents, Guardians and Youth Serving Adults

• Model a healthy lifestyle free of tobacco products.

• Adopt a tobacco-free policy for your home and vehicle.

• Continue to educate yourself and commit to talking with your young person as they grow about tobacco and other drugs.

• Continue learning about this issue by exploring your Tobacco-Free Forum Resources, sign up for email alerts, and follow prevention organizations online.

Wake County Tobacco Prevention & Control Program Poe Center for Health Education [email protected] [email protected]

• Share information found in this resource packet with friends and family through social media.

• Learn about and participate in national tobacco use prevention campaigns such as the Great American Smokeout in November and Kick Butts Day in March. www.TobaccoFreeKids.org

• Educate yourself on current tobacco policies impacting your community. Stay informed at PARENTS WakeGov.com/tobaccofree and NCAllianceForHealth.org/TobaccoUsePrevention SCHOOLS: WHAT CAN YOU DO?

Combating Youth Tobacco Use - Action Steps for Schools and Communities

• Enforce tobacco-free campus policies which include e-cigarettes.

• Reject tobacco industry-sponsored prevention programs, which do not follow evidence- based strategies and best practices for effective prevention.

• Continue learning about the issue by exploring your Tobacco-Free Forum Resource List and follow resources on social media for the latest updates.

Wake County Tobacco Prevention & Control Program Poe Center for Health Education [email protected] [email protected]

• Model a healthy lifestyle free of tobacco products.

• Adopt a tobacco-free policy for your home and vehicle.

• Advocate for tobacco regulations in your town such as tobacco-free government buildings and recreation areas.

• Learn about and participate in national tobacco use prevention campaigns such as the Great American Smokeout in November and Kick Butts Day in March. www.TobaccoFreeKids.org

• Educate yourself on current tobacco policies impacting your community. Stay informed at WakeGov.com/tobaccofree and NCAllianceForHealth.org/TobaccoUsePrevention SCHOOLS

COMMUNITIES

RESOURCES YOUTHS for Communities, Youths Parents, and Schools

This guide has resources that apply to youths, communities, parents, and schools. Some resources apply to more than one group. Please visit poehealth.org for more information and resources, as well as any links you see written in this booklet. PARENTS SCHOOLS SCHOOLS PARENTS YOUTHS COMMUNITIES 2019 LEVELS

N S T Y ALARMING YOUTH

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UPDATED NOVEMBER 2017

E-Cigarette Health Advisory Nicotine risks for children, teens, young adults and pregnant women

This advisory seeks to inform health care professionals and parents of the health risks of nicotine exposure to children, teens and pregnant women related to the use of e-cigarettes (vaping devices).

With increased use and expanding availability of nicotine products such

as e-cigarettes, especially among young people, it is important to YOUTHS understand the facts about nicotine and its health effects. Studies have shown that nearly all e-cigarettes sold contain nicotine. Nicotine is addictive and can be toxic at high doses. Evidence also has shown nicotine can harm brain development during adolescence and young adulthood. Nicotine exposure, whether through traditional or new and emerging products, is unsafe for young people.

Nicotine products pose a serious health risk for youth.

The use of e-cigarettes and other e-cigarette n Nicotine exposure can harm or vaping products (such as vape pens, hookah brain development. pens, e-cigars and e-pipes) recently surpassed the use of conventional cigarettes to become the Adolescence — the transitional period between

most commonly used tobacco product among U.S. childhood and adulthood, typically ranging from ages PARENTS youth. [1] Given the use of e-cigarettes among teens 12 to 18 — is a critical window for brain growth and increased dramatically during 2011-2015, [1] it is critical development, when it is still “under construction.” [14, that public health officials and citizens understand 15] However, the brain continues to undergo structural the potential risks of using nicotine products for and functional development into young adulthood, young people. to age 25. [1, 78, 79] Consequently, young people are especially at risk of harm caused by nicotine exposure. A growing body of evidence from multiple countries shows that young people who have never smoked The brain undergoes significant neurobiological cigarettes — but currently use e-cigarettes — are development during adolescence and young more likely to smoke cigarettes in the future than are adulthood, which are critical periods of sensitivity to young people who do not use e-cigarettes. [8-13, 83-84] neurobiological insults, including nicotine. [79–82] Human clinical studies report similar findings — adolescent nicotine exposure leads to higher rates Evidence indicates that exposure to nicotine during of smoking behavior in adulthood. [8-13] Accordingly, adolescence can have long-term effects on brain [1, 16-18] young people should avoid use of all nicotine- development, and may increase the risk of containing products, including e-cigarettes. addiction to other substances by causing changes SCHOOLS

NCState DEPARTMENT of North OF Carolina • Department of Health and Human Services • Division of Public Health HEALTH AND HUMANTobacco SERVICES Prevention & Control Branch Divisionwww.ncdhhs.gov of Public Health • NCDHHS is an equal opportunity employer and provider. 11/2017 SCHOOLS PARENTS YOUTHS COMMUNITIES n PAGE 2 Nicotine isharmfultothehealth ofunbornchildren. can befatal. and respiratory depression. nicotine poisoningincludenausea,vomiting, seizures addiction inyoung people. memory, attention, behavioral problems andfuture This could have negative implications for learning, causes long-lasting changesinbrain development. even insmalldoses,nicotine exposure inadolescence within thebrain. pregnant women andunbornchildren. of products containing nicotine posesdangerto The U.S. Surgeon General hasconcluded that use the pulseandbloodpressure. systems, causingbloodvessels to constrict, raising Nicotine affects the cardiovascular and central nervous found discrepancies between thelabeledand children are especiallyvulnerable. or absorbingnicotine canleadto nicotine poisoning; on behaviors andobesity, anddeficitsin attention development, auditory processing problems, effects infant death syndrome, impaired brain andlung negative long-term consequences, includingsudden Fetal exposure to nicotine canhave avariety of 52 percent occurring amongchildren underage5. to 215permonthinFebruary 2014, withnearly of callsrose from onepermonthinSeptember 2010 range from 0to 34mg/mL, Nicotine levels ine-cigarettes have beenfound to The amountofnicotine inproducts may vary widely. were leftoutinreach oftoddlers andchildren. were aboutingestion ofe-cigarette liquidsthat just eightin2011 to 121in2016. Many ofthesecases poisonings related to e-cigarettes increasing from Similarly, callsincreased inNorthCarolina with liquids used in e-cigarettes. calls to poisoncontrol centers for exposures to There hasbeenasignificantriseinthenumberof effects andcanbe toxic. Nicotine causesharmfulphysical

E-CIGARETTE HEALTH ADVISORY [71]

[17, 19-32] Animalresearch hasfound that [18,30, 33-37] [69, 70] [72] [75] [38,68] Nationally, the number andstudies have Nicotine poisoning Nicotine poisoning [20] Eating, drinking Eating, drinking Symptoms of E-CIGARETTE HEALTH ADVISORY [1,20]

• Division of Public Health • Tobacco Prevention & Control Branch Control & Prevention •Tobacco Health Public of NCDHHS •Division [73]

n e-cigarettes, buthasnotyet doneso. varying nicotine levels intobacco products, including Administration now hastheauthorityto address the the riskofatoxic exposure. The U.S. Food andDrug nicotine iscontained intheseproducts, increasing it isdifficult forthe consumer toknow how much other electronic nicotine delivery systems (ENDS), manufacturing standards for e-cigarettes and cocaine. in thebrain, andcanbeasaddictive asheroin or nicotine dependence inadolescence. that fetal nicotine exposure isassociated with dependence at lower dosesthanadults. adolescents are more likely to experience nicotine Human clinical reports confirm this pattern, showing them more susceptible to nicotine addiction. negative effects ofwithdrawal thanadults,making Further, young peopleare less sensitive to the products. measured nicotine content insomee-cigarette addiction. Nicotine isthedrugintobacco that causes and cognition. unnecessary exposure to nicotine. pregnant shouldavoid e-cigarettes to minimize Pregnant women andwomen whointend to become to humans. agree that results from animalstudies dotranslate do notexist dueto ethicalrestrictions, researchers nicotine addictiononthehumanadolescent brain While experimental studies testing theeffects of dose exposure. experience fewer negative sideeffects ofhigher- effects ofnicotine at lower dosesthanadults,and adolescents are more sensitive to therewarding especially vulnerable to nicotine addiction. developing, adolescents andyoung adultsare Nicotine ishighlyaddictive. [22,39, 43-49] [76] [38-42] [1] Because of the lack of quality and Becauseofthelackqualityand Existing animalstudies show that [15-17, 20, 26-28,56,57] Nicotine stimulates reward pathways [54,55] Becausetheirbrains are still

Studies alsoindicate [1,20] [15,20, 58-67] [8-13] [14,17, 50-53]

E-CIGARETTE HEALTH ADVISORY COMMUNITIES

PAGE 3 n E-CIGARETTE HEALTH ADVISORY NCDHHS • Division of Public Health • Tobacco Prevention & Control Branch

Recommendations for Health Care Professionals n Educate and advise

• Advise that nicotine exposure is unsafe for children, teens and pregnant women. – The nicotine contained in products such as e-cigarettes is highly addictive. – Accidental exposure to liquids contained in e-cigarettes and similar products can result in nicotine poisoning if it’s in high enough

doses, especially in children. YOUTHS • Advise that exposure to nicotine can harm the developing adolescent brain. • Advise pregnant women to avoid using nicotine products. • People of all ages interested in quitting tobacco can receive free coaching, and may qualify for free nicotine replacement medication from QuitlineNC at www.quitlinenc.com or by calling 1-800-QUIT-NOW (1-800-784-8669). n Protect children from nicotine poisoning

Inform parents and nicotine users that nicotine- containing cartridges and bottles are a potential source of poisoning through ingestion, skin or eye contact. Store these materials out of the reach of children, and call the Carolinas Poison Center PARENTS at 1-800-222-1222 for expert help in case of accidental exposure.

Recommendations for Parents of Young Children n Keep nicotine-containing products out of reach

• Nicotine-containing cartridges and bottles are a potential source of poisoning through ingestion, skin or eye contact. Store these materials out of the reach of young children. • Makes sure that products kept in the home are kept in child-resistant packaging, which is required SCHOOLS for all liquid nicotine sold in North Carolina and nationwide. [77] • Call 1-800-222-1222 for poison emergencies. E-CIGARETTE HEALTH ADVISORY

PAGE 4 n E-CIGARETTE HEALTH ADVISORY NCDHHS • Division of Public Health • Tobacco Prevention & Control Branch

COMMUNITIES REFERENCES 1. U.S. Department of Health and Human Services, 17. Goriounova, N.A. and H.D. Mansvelder, Short- 30. C ounotte, D.S., et al., Long-lasting cognitive E-Cigarette Use Among Youth and Young and long-term consequences of nicotine deficits resulting from adolescent nicotine Adults. A Report of the Surgeon General. 2016, exposure during adolescence for prefrontal exposure in rats. Neuropsychopharmacology, U.S. Department of Health and Human Services, cortex neuronal network function. Cold Spring 2009. 34(2): p. 299-306. Centers for Disease Control and Prevention, Harb Perspect Med, 2012. 2(12): p. a012120. 31. Alajaji, M., et al., Early adolescent nicotine National Center for Chronic Disease Prevention 18. England, L.J., et al., Developmental toxicity exposure affects later-life cocaine reward and Health Promotion, Office on Smoking and of nicotine: A transdisciplinary synthesis and in mice. Neuropharmacology, 2016. 105: p. 308-17. Health: Atlanta, GA. implications for emerging tobacco products. 32. R eed, S.C. and S. Izenwasser, Nicotine produces 2. Leventhal, A.M., et al., Association of Electronic Neurosci Biobehav Rev, 2017. 72: p. 176-189. long-term increases in cocaine reinforcement in Cigarette Use With Initiation of Combustible 19. U.S. Department of Health and Human adolescent but not adult rats. Brain Res, 2017. Tobacco Product Smoking in Early Adolescence. Services, National Institutes of Health, and 1654(Pt B): p. 165-170. JAMA, 2015. 314(7): p. 700-7. National Cancer Institute. Smoke-free Teens: 33. Abr eu-Villaca, Y., et al., Short-term adolescent 3. Barrington-Trimis, J.L., et al., E-Cigarettes and Health Effects. 2014 [cited 2014 November nicotine exposure has immediate and persistent Future Cigarette Use. Pediatrics, 2016. 138(1). 6]; Available from: http://teen.smokefree.gov/ effects on cholinergic systems: critical periods, 4. Wills, T.A., et al., Longitudinal study of yourHealthEffects.aspx#.VFu27PnF-pI patterns of exposure, dose thresholds. Neuro- e-cigarette use and onset of cigarette smoking 20. U .S. Department of Health and Human Services, psychopharmacology, 2003. 28(11): p. 1935-49. among high school students in Hawaii. Tob The Health Consequences of Smoking-50 Years 34. Abr eu-Villaca, Y., et al., Nicotine is a neurotoxin Control, 2017. 26(1): p. 34-39. of Progress: A Report of the Surgeon General. in the adolescent brain: critical periods, patterns 5. Primack, B.A., et al., Progression to Traditional 2014, U.S. Department of Health and Human of exposure, regional selectivity, and dose Cigarette Smoking After Electronic Cigarette Services, Centers for Disease Control and thresholds for macromolecular alterations. Brain

YOUTHS Use Among US Adolescents and Young Adults. Prevention, National Center for Chronic Disease Res, 2003. 979(1-2): p. 114-28. JAMA Pediatr, 2015. 169(11): p. 1018-23. Prevention and Health Promotion, Office on 35. Slikk er, W., Jr., et al., Mode of action: disruption 6. Unger, J.B., D.W. Soto, and A. Leventhal, Smoking and Health: Atlanta, GA. of brain cell replication, second messenger, and E-cigarette use and subsequent cigarette and 21. Centers for Disease Control and Prevention, neurotransmitter systems during development marijuana use among Hispanic young adults. Incidence of initiation of cigarette smoking – leading to cognitive dysfunction--developmental Drug Alcohol Depend, 2016. 163: p. 261-4. United States, 1965-1996. MMWR Morb Mortal neurotoxicity of nicotine. Crit Rev Toxicol, 2005. 7. Miech, R., et al., E-cigarette use as a predictor of Wkly Rep, 1998. 47(39): p. 837-40. 35(8-9): p. 703-11. cigarette smoking: results from a 1-year follow- 22. Unit ed States Public Health Service, et al., 36. Slotkin, T.A., Nicotine and the adolescent brain: up of a national sample of 12th grade students. Preventing tobacco use among youth and young insights from an animal model. Neurotoxicol Tob Control, 2017. adults: a report of the Surgeon General. 2012, Teratol, 2002. 24(3): p. 369-84. 8. Chen, J. and W.J. Millar, Age of smoking Atlanta, Ga.: U.S. Dept. of Health and Human 37. Gould, T.J. and P.T. Leach, Cellular, molecular, initiation: implications for quitting. Health Rep, Services, Public Health Service, Centers for and genetic substrates underlying the impact of 1998. 9(4): Disease Control and Prevention, National Center nicotine on learning. Neurobiol Learn Mem, 2014. p. 39-46(Eng); 39-48(Fre). for Chronic Disease Prevention and Health 107: p. 108-32. Promotion For sale by the Supt. of Docs., U.S. 9. Adelman, W.P., Tobacco use cessation for 38. U .S. Department of Health and Human Services, G.P.O. xiv, 899 p. adolescents. Adolesc Med Clin, 2006. 17(3): How tobacco smoke causes disease: the biology p. 697- 717; abstract xii. 23. Dw yer, J.B., S.C. McQuown, and F.M. Leslie, The and behavioral basis for smoking-attributable dynamic effects of nicotine on the developing 10. DiFranza, J.R. and R.J. Wellman, A sensitization- disease: a report of the Surgeon General. 2010, brain. Pharmacol Ther, 2009. 122(2): p. 125-39. homeostasis model of nicotine craving, U.S. Department of Health and Human Services, withdrawal, and tolerance: integrating the 24. Schochet, T.L., A.E. Kelley, and C.F. Landry, CDC: Atlanta, GA. clinical and basic science literature. Nicotine Tob Differential expression of arc mRNA and other 39. Unit ed States, et al., The Health Consequences Res, 2005. 7(1): p. 9-26. plasticity-related genes induced by nicotine in of Smoking: Nicotine Addiction: A Report of the adolescent rat forebrain. Neuroscience, 2005. 11. DiFranza, J.R. and R.J. Wellman, Sensitization to Surgeon General. 1988: Rockville, MD. 135(1): p. 285-97. nicotine: how the animal literature might inform 40. S tolerman, I.P. and M.J. Jarvis, The scientific case 25. P olesskaya, O.O., et al., Nicotine causes age-

PARENTS future human research. Nicotine Tob Res, 2007. that nicotine is addictive. Psychopharmacology 9(1): p. 9-20. dependent changes in gene expression in (Berl), 1995. 117(1): p. 2-10; discussion 14-20. the adolescent female rat brain. Neurotoxicol 12. Ginzel, K.H., et al., Critical review: nicotine for 41. Royal College of Physicians, Nicotine Teratol, 2007. 29(1): p. 126-40. the fetus, the infant and the adolescent? J Addiction in Britain. 2000, Royal College of Health Psychol, 2007. 12(2): p. 215-24. 26. Duncan, J.R., et al., Prenatal nicotine-exposure Physicians: London. alters fetal autonomic activity and medullary 13. Nelson, D.E., et al., Long-term trends in 42. Balfour, D.J., The neurobiology of tobacco neurotransmitter receptors: implications for adolescent and young adult smoking in the dependence: a preclinical perspective on the sudden infant death syndrome. J Appl Physiol United States: metapatterns and implications. role of the dopamine projections to the nucleus (1985), 2009. 107(5): p. 1579-90. Am J Public Health, 2008. 98(5): p. 905-15. accumbens [corrected]. Nicotine Tob Res, 2004. 27. Poorthuis, R.B., et al., Nicotinic actions on 14. Spear, L.P., The adolescent brain and age-related 6(6): p. 899-912. neuronal networks for cognition: general behavioral manifestations. Neurosci Biobehav 43. Henningfield, .E.J and R.M. Keenan, Nicotine principles and long-term consequences. Rev, 2000. 24(4): p. 417-63. delivery kinetics and abuse liability. J Consult Biochem Pharmacol, 2009. 78(7): p. 668-76. 15. England, L.J., et al., Nicotine and the Developing Clin Psychol, 1993. 61(5): p. 743-50. 28. Bublitz, M.H. and L.R. Stroud, Maternal smoking Human: A Neglected Element in the Electronic 44. de Wit, H. and J.P. Zacny, Abuse potential of during pregnancy and offspring brain structure Cigarette Debate. Am J Prev Med, 2015. nicotine replacement therapies. CNS Drugs, 1995. and function: review and agenda for future 16. Dwyer, J.B., R.S. Broide, and F.M. Leslie, Nicotine 4(6): p. 456-468. research. Nicotine Tob Res, 2012. 14(4): p. 388-97. and brain development. Birth Defects Res C 45. titzer,S M.L. and H. de Wit, Abuse liability of 29. T rauth, J.A., F.J. Seidler, and T.A. Slotkin, An Embryo Today, 2008. 84(1): p. 30-44. nicotine, in Nicotine Safety and Toxicity, N.L. animal model of adolescent nicotine exposure: Benowitz, Editor. 1998, Oxford University Press: effects on gene expression and macromolecular New York. p. 119-131. constituents in rat brain regions. Brain Res, 2000. 867(1-2): p. 29-39. SCHOOLS E-CIGARETTE HEALTH ADVISORY COMMUNITIES

PAGE 5 n E-CIGARETTE HEALTH ADVISORY NCDHHS • Division of Public Health • Tobacco Prevention & Control Branch

46. R ose, J.E., et al., Arterial nicotine kinetics during 63. Gupta,.C. P and S. Subramoney, Smokeless 79. Lebel & Beaulieu. Longitudinal Development of cigarette smoking and intravenous nicotine tobacco use, birth weight, and gestational age: Human Brain Wiring Continues from Childhood administration: implications for addiction. Drug population based, prospective cohort study into Adulthood. The Journal of Neuroscience, Alcohol Depend, 1999. 56(2): p. 99-107. of 1217 women in Mumbai, India. BMJ, 2004. 27 July 2011, 31(30):10937-10947. 47. Benowitz, N.L., Neurobiology of nicotine addiction: 328(7455): p. 1538. 80. Spear LP. The behavioral Neuroscience of implications for smoking cessation treatment. Am 64. Gupta,.C. P and S. Subramoney, Smokeless Adolescence. New York: WW Norton, 2010 J Med, 2008. 121(4 Suppl 1): p. S3-10. tobacco use and risk of stillbirth: a cohort study 81. Dahl RE. Adolescent brain development: a 48. Benowitz, N.L., Nicotine addiction. N Engl J in Mumbai, India. Epidemiology, 2006. 17(1): period of vulnerabilities and opportunities. Med, 2010. 362(24): p. 2295-303. p. 47-51. Annals of the New York Academy of Sciences, 49. Psychology Today. Nicotine. 2014 November 24, 65. Baba, S., et al., Influence of smoking and 2004;1021:1-22. 2014 [cited 2015 March 12]. snuff cessation on risk of preterm birth. Eur J 82. Gulley, Juraska. The effects of abused drugs 50. Chambers, R.A.,.R. J Taylor, and M.N. Potenza, Epidemiol, 2012. 27(4): p. 297-304. on adolescent development of corticolimbic Developmental neurocircuitry of motivation 66. England, L.J., et al., Effects of maternal circuitry and behavior. Nueroscience in adolescence: a critical period of addiction smokeless tobacco use on selected pregnancy 2013;249:3-20. vulnerability. Am J Psychiatry, 2003. 160(6): outcomes in Alaska Native women: a case- 83. C onner, M et al., Do electronic cigarettes p. 1041-52. control study. Acta Obstet Gynecol Scand, 2013. increase cigarette smoking in UK adolescents? YOUTHS 51. Casey, B.J., et al., Imaging the developing 92(6): p. 648- 55. Evidence from a 12-month prospective study, brain: what have we learned about cognitive 67. De Genna, N.M., et al., Prenatal tobacco BMJ, 2017; 0: p. 1-9 development? Trends Cogn Sci, 2005. 9(3): exposure, maternal postnatal nicotine 84. Hammond, D et al., Electronic cigarette use and p. 104-10. dependence and adolescent risk for nicotine smoking initiation among youth: a longitudinal 52. Ernst, M., et al., Amygdala and nucleus dependence: Birth cohort study. Neurotoxicol cohort study, CMAJ, 2017; 189: p. E1328-36 accumbens in responses to receipt and omission Teratol, 2017. of gains in adults and adolescents. Neuroimage, 68. Benowitz, N.L., Cigarette smoking and 2005. 25(4): p. 1279-91. cardiovascular disease: pathophysiology and 53. Ernst, M. and J.L. Fudge, A developmental implications for treatment. Prog Cardiovasc Dis, neurobiological model of motivated behavior: 2003. 46(1): p. 91-111. anatomy, connectivity and ontogeny of the 69. Benowitz, N.L., et al., Prolonged absorption with triadic nodes. Neurosci Biobehav Rev, 2009. development of tolerance to toxic effects after 33(3): p. 367-82. cutaneous exposure to nicotine. Clin Pharmacol 54. orres, T O.V., et al., Enhanced vulnerability to Ther, 1987. 42(1): p. 119-20. the rewarding effects of nicotine during the 70. Okamoto, M., et al., Tolerance to the convulsions adolescent period of development. Pharmacol induced by daily nicotine treatment in rats. Jpn Biochem Behav, 2008. 90(4): p. 658-63. J Pharmacol, 1992. 59(4): p. 449-55. 55. O’Dell, L.E., A psychobiological framework of 71. Cameron, J.M., et al., Variable and potentially the substrates that mediate nicotine use during fatal amounts of nicotine in e-cigarette nicotine adolescence. Neuropharmacology, 2009. 56 solutions. Tob Control, 2014. 23(1): p. 77-8. Suppl 1: p. 263-78. 72. Cantrell, F.L., Adverse effects of e-cigarette 56. hompson,T B.L., P. Levitt, and G.D. Stanwood, exposures. J Community Health, 2014. 39(3): Prenatal exposure to drugs: effects on brain p. 614- 6.

development and implications for policy and 73. Chatham-Stephens, K., et al., Notes from the PARENTS education. Nat Rev Neurosci, 2009. 10(4): field: calls to poison centers for exposures to p. 303-12. electronic cigarettes--United States, September 57. Slotkin,.A., T Fetal nicotine or cocaine exposure: 2010-February 2014. MMWR Morb Mortal Wkly which one is worse? J Pharmacol Exp Ther, Rep, 2014. 63(13): p. 292-3. 1998. 285(3): p. 931-45. 74. .S.U Food and Drug Administration. The Facts 58. Maritz, G.S., Nicotine and lung development. on the FDA’s New Tobacco Rule. 2016 [cited Birth Defects Res C Embryo Today, 2008. 84(1): 2017 March 21]; Available from: https://www. p. 45-53. fda.gov/ForConsumers/ConsumerUpdates/ 59. Pierce, R.A. and N.M. Nguyen, Prenatal nicotine ucm506676.htm. exposure and abnormal lung function. Am J 75. Schroeder, M.J. and A.C. Hoffman, Electronic Respir Cell Mol Biol, 2002. 26(1): p. 10-3. cigarettes and nicotine clinical pharmacology. 60. Sekhon, H.S., et al., Prenatal nicotine increases Tob Control, 2014. 23 Suppl 2: p. ii30-5. pulmonary alpha7 nicotinic receptor expression 76. Goniewicz, M.L., et al., Nicotine levels in and alters fetal lung development in monkeys. J electronic cigarettes. Nicotine Tob Res, 2013. Clin Invest, 1999. 103(5): p. 637-47. 15(1): p. 158-66. 61. Sekhon, H.S., et al., Prenatal nicotine exposure 77. U. S. Congress. Child Nicotine Poisoning alters pulmonary function in newborn rhesus Prevention Act of 2015. 2016 [cited 2017 March monkeys. Am J Respir Crit Care Med, 2001. 21]; Available from: https://www.congress.gov/ 164(6): p. 989-94. bill/114th-congress/senate-bill/142. 62. Sekhon, H.S., et al., Maternal nicotine exposure 78. Somerville & Casey. Developmental upregulates collagen gene expression in fetal neurobiology of cognitive control and monkey lung. Association with alpha7 nicotinic motivational systems. Current Opinion in

acetylcholine receptors. Am J Respir Cell Mol Neurobiology 2010;20(20:236-241. SCHOOLS Biol, 2002. 26(1): p. 31-41.

E-CIGARETTES: WHAT’S THE BOTTOM LINE

ELECTRONIC CIGARETTES WHAT’S THE BOTTOM LINE? COMMUNITIES

» E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.

» E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.

» While e-cigarettes have the potential to benefit some people and harm others, scientists still have a lot to learn about whether e-cigarettes are effective for quitting smoking.

» If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start. YOUTHS

WHAT ARE E-CIGARETTES?

» E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems.”

» Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes. Some resemble pens, USB sticks, and other everyday items.

» E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products—flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air.

» E-cigarettes can be used to deliver marijuana and other drugs. PARENTS

Tanks & Mods Rechargeable Disposable e-cigarette e-cigarette CS298852-A

For Print Only SCHOOLS E-CIGARETTES: WHAT’S THE BOTTOM LINE COMMUNITIES

WHAT IS IN E-CIGARETTE AEROSOL?

THE E-CIGARETTE AEROSOL THAT USERS BREATHE FROM THE DEVICE AND EXHALE CAN CONTAIN HARMFUL AND POTENTIALLY HARMFUL SUBSTANCES:

CANCER-CAUSING VOLATILE CHEMICALS ORGANIC COMPOUNDS ULTRAFINE HEAVY METALS SUCH AS PARTICLES NICKEL, TIN, AND LEAD

NICOTINE YOUTHS FLAVORING SUCH AS DIACETYL, A CHEMICAL LINKED TO A SERIOUS LUNG DISEASE

It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.

ARE E-CIGARETTES LESS HARMFUL THAN REGULAR CIGARETTES? PARENTS

E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette VS aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds,

YES, but that doesn’t and cancer-causing agents. mean e-cigarettes are safe. SCHOOLS

For Print Only E-CIGARETTES: WHAT’S THE BOTTOM LINE

WHAT ARE THE HEALTH EFFECTS OF USING E-CIGARETTES?

COMMUNITIES SCIENTISTS ARE STILL LEARNING ABOUT THE LONG-TERM HEALTH EFFECTS OF E-CIGARETTES. HERE IS WHAT WE KNOW NOW.

Most e-cigarettes contain nicotine, which has known health effects

» Nicotine is highly addictive. 1» Nicotine is toxic to developing fetuses. » Nicotine can harm adolescent brain development, which continues into the early to mid-20s.

Nicotine is a health danger for pregnant women YOUTHS » and their developing babies.

Besides nicotine, e-cigarette aerosol can contain substances that harm the body.

» This includes cancer-causing chemicals and tiny particles that reach deep into lungs. However, e-cigarette aerosol generally contains fewer harmful chemicals than smoke 2from burned tobacco products. PARENTS

E-cigarettes can cause unintended injuries.

» Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. 3» In addition, acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid.

For Print Only SCHOOLS E-CIGARETTES: WHAT’S THE BOTTOM LINE COMMUNITIES

CAN E-CIGARETTES HELP ADULTS QUIT SMOKING CIGARETTES?

E-CIGARETTES ARE NOT CURRENTLY APPROVED BY THE FDA AS A QUIT SMOKING AID.

The U.S. Preventive Services Task Force, a group of health experts that makes recommendations YOUTHS about preventive health care, concluded that the evidence is insufficient to recommend e-cigarettes for smoking cessation in adults, including pregnant women.

HOWEVER, e-cigarettes may help non-pregnant adult smokers if used as a complete substitute for all cigarettes and other smoked tobacco products. PARENTS

TO DATE, THE FEW STUDIES ON THE ISSUE ARE MIXED.

Evidence from two randomized controlled trials found that e-cigarettes with nicotine can help smokers stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes.

A recent CDC study found that many adults are using e-cigarettes in an attempt to quit smoking. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products (“dual use”). Because smoking even a few cigarettes a day can be dangerous, quitting smoking completely is very important to protect your health. SCHOOLS

For Print Only E-CIGARETTES: WHAT’S THE BOTTOM LINE

WHO IS USING E-CIGARETTES?

COMMUNITIES E-CIGARETTES ARE THE MOST COMMONLY USED TOBACCO PRODUCT AMONG YOUTH.

In 2018, more than 3.6 MILLION U.S. middle and high school students used e-cigarettes in 4.9% the past 30 days, including: MIDDLE SCHOOL 20.8% IN THE U.S., STUDENTS HIGH SCHOOL YOUTH ARE STUDENTS MORE LIKELY

YOUTHS THAN ADULTS TO USE E-CIGARETTE

AMONG CURRENT E-CIGARETTE USERS AGED 45 YEARS AND OLDER in 2015, most were either current or former regular cigarette smokers, and 1.3% had never been cigarette smokers. IN CONTRAST, AMONG CURRENT E-CIGARETTE USERS AGED 18–24 YEARS, 40.0% had NEVER BEEN regular cigarette smokers PARENTS In 2017, 2.8% IN 2015, AMONG ADULT E-CIGARETTE of U.S. adults were current USERS OVERALL: e-cigarette users 29.8% were former regular cigarette 58.8% were current regular smokers cigarette smokers 11.4% had never been regular cigarette smokers For Print Only SCHOOLS COVID-19 AND LUNG HEALTH COMMUNITIES

SMOKING, VAPING & COVID-19: WHAT ARE HEALTH ORGANIZATIONS AND EXPERTS SAYING?

Dr. Nora Volkow, Director of the U.S. National Institute on Drug Abuse “Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. …

Thus far, deaths and serious illness from COVID-19 seem concentrated to those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19. …

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, YOUTHS but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection.” (COVID-19: Potential Implications for Individuals with Substance Use Disorders – NIDA, Mar. 24, 2020)

“Much is still unknown, but it can be expected that persons who smoke, vape, or use certain drugs will be at increased risk for infection and its more severe consequences...” (Dr. Nora Volkow, “Collision of the COVID-19 and Addiction Epidemics,” Annals of Internal Medicine, Apr. 2, 2020)

U.S. Food and Drug Administration “Cigarette smoking causes heart and lung diseases, suppresses the immune system, and increases the risk of respiratory infections. ... People who smoke cigarettes may be at increased risk from Covid-19, and may have worse outcomes from Covid-19.” (“FDA Shifts Its Covid-19 Stance on Vaping, Smoking Impact,” Bloomberg Government, Apr. 15, 2020)

U.S. Centers for Disease Control and Prevention PARENTS "We also know that tobacco smoking can increase the risk for developing lung disease, making it harder to recover from lung diseases or infections such as COVID-19. And so we do encourage you to have your patients quit smoking or think about that, and they can call 1-800-QUIT-NOW or visit the CDC website at http://www.cdc.gov/quit for help or more information about that." (Dr. Georgina Peacock, "COVID-19 Response At Risk Task Force Lead, CDC, Underlying Medical Conditions and People at Higher Risk for Coronavirus Disease 2019 (COVID-19)," CDC Clinician Outreach and Communication Activity (COCA) Call, Mar. 27, 2020)

“Cigarette smoking can suppress the immune system and cause heart and lung diseases. A person who smokes may be at greater risk for, and may have a harder time recovering from, COVID-19.” (Dr. Brian King, “Update with CDC for Chronic Disease Partners on COVID-19,” American Lung Association, Apr. 17, 2020)

World Health Organization “Tobacco smoking is a known risk factor for many respiratory infections and increases the severity of respiratory diseases. A review of studies by public health experts convened by WHO SCHOOLS on 29 April 2020 found that smokers are more likely to develop severe disease with COVID-19, compared to non-smokers. …

1400 I Street, NW Suite 1200 Washington, DC 20005 Phone (202) 296-5469 Fax (202) 296-5427 www.tobaccofreekids.org SCHOOLS PARENTS YOUTHS COMMUNITIES Smoking, Vaping & COVID Vaping Smoking, to to “Smoking damages your lungs and other parts of your body, and it makes y anduse COVID smokers are at higher risk of developing severe disease and death. developing severe illness when affected by COVID respiratorydisease and diabeteswhich people put with conditions these at higher risk for majoralsoa risknoncommunicable factor for cardiovasculardiseaseslike disease,cancer, function making it harder for bodythe to fight off coronaviruses and other diseases. Tob COVID the lung’sthe airways both of which can increase likelihood complications of if exposed to COVID “Cigarette smoking and vaping are linked to lun AlbertRizzo, M.D.,Chief MedicalAmerican Officer,AssociationLung News,Mar. 25, 2020 Dr.Frieden:Chief Tom Coronaviruscardiovascularand disease theirown justnot for sake smoking, be physically active,and get their blood pres and the most likely to die, it’s more urgent than ever that we act, now, to help people quit Becausepeople with chronicdisease arethe mostlikely requireto scarceintensive beds, care maki rev Governments can protect heart health by raising taxes on tobacco (we’re going to need the t 14 least twice likelyas to die.Smoking is especiallydea “People with Save Lives TomDr. Frieden, former really lean ( in.” disease,but most importantly, you can spread it to your loved ones,and so we n know you can get this disease,you can be hospitalized from this disease, you can die from this in Italy who vape. could be because we knowwe have highera proportion of people in the United States and also other countries that saw this hit earlier, and we’re looking into that. There are theories that it “Well, so far the demography definitely seems to be experience immediatebenefits.” Quit smoking today by calling 1 “Give your lungs bestthe chance at notfighting only #COVID19, but all respiratory diseases. #coronavirus youif do become ill. #COVID19” make noticeable improvements in days/weeksthe after quitting, giving you edgethe to fight “Right now, in this moment, it is your day to quit smoking. JeromeDr. Adams, U.S. Surgeon General ( protected by coronavirus andcancer @WHO, Twitter, Apr. 22, 2020 #COVID19 enue, andenue, tobaccotaxes the are imesodds greaterof dev ng all public places smoke - 19 is an infectious disease that primarily attacks lungs.the Smoking impairs lung

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COVID-19 AND LUNG HEALTH COMMUNITIES

Smoking, Vaping & COVID-19: What are health organizations and experts saying? Page 3

19. Therefore, long-terms smokers and e-cigarette users may have a higher risk of developing chronic lung conditions associated with severe cases.” (COVID-19: What Those with Lung Disease Should Know – American Lung Association, Mar. 26, 2020)

Dr. Neal Patel, Pulmonologist and Critical Care Medicine Specialist, Mayo Clinic “Smoking makes you more susceptible to COVID-19, because it destroys some of your lung’s natural defense mechanisms. Vaping may do the same thing. … I recommend people stop vaping to maintain lung health and reduce the risk of developing severe disease if they contract COVID-19.” (What smokers should know about COVID-19 - Mayo Clinic, Mar. 24, 2020)

Dr. J. Taylor Hays, Director of the Nicotine Dependence Center, Mayo Clinic “There is a long history of smokers having more severe respiratory illness in general and this is for a few well-established reasons. They clear mucus less efficiently, the cilia which get

infectious particles and secretions out of the lungs, work less efficiently. Smoking also causes YOUTHS inflammation in the airways, which is made worse with respiratory illnesses. …

People who quit for even a short time see an improvement in lung health quite quickly. For most smokers who don’t already have serious lung injury, they will see immediate improvements in their health, and less opportunity for severe diseases including COVID-19.” (“Smokers At Higher Risk Of Severe COVID-19 During Coronavirus Outbreak,” Forbes, Mar. 23, 2020)

Cleveland Clinic “As with cigarette smoking, vaping can also compromise the respiratory system. This means that people who smoke or vape are more susceptible to lung infections. According to Dr. Humberto Choi, a pulmonologist and smoking cessation specialist at the Cleveland Clinic], recent studies have shown that aldehydes and other components found in vaping liquids can impair the immune function of cells found in the airway and lungs.” (Teens, Vaping and Coronavirus (COVID-19): Is There a Connection?, Mar. 20, 2020)

Massachusetts General Hospital PARENTS “Smoking and vaping have harmful effects on the body, including making it harder for the body to fight infections. This includes serious infections like COVID-19 (also called coronavirus). … Quitting smoking and vaping can help protect you and your family from COVID-19.” (“Smoking, Vaping and COVID-19: About the Connection and How to Quit,” Mar 26, 2020)

Dr. Stanton A. Glantz, Director of Center for Tobacco Control Research & Education, University of California San Francisco “When someone’s lungs are exposed to flu or other infections the adverse effects of smoking or vaping are much more serious than among people who do not smoke or vape.” (“Reduce your risk of serious lung disease caused by corona virus by quitting smoking and vaping,” Stanton A. Glantz blog, Mar. 29, 2020)

Dr. Susan Walley, Chair of the American Academy of Pediatrics Section on Tobacco Control "Right now, if you need a reason to quit, look no farther than COVID-19." (“Teens who vape SCHOOLS should consider quitting now. Here's how to do it,” Mashable, Mar. 23, 2020.)

Truth Initiative “As we confront the coronavirus, it is more important than ever for smokers to quit and for youth and young adults to stop using all tobacco products, including e-cigarettes, to protect their SCHOOLS PARENTS YOUTHS COMMUNITIES impact of a coronavirus worse.” ( is“It abundantly clear from the research into previous coronaviruses that smoking makes the smoking decreases you compromise your lungs is going to increase your risk of being susceptible. knowWe that “Well, if there was evera reason to quit, here's another one. Anything that’s going to C TaraDr. Narula, Cardiologist, Lenox H they're immune to COVID other lung infections. And I guess what would I suggest is that young people shouldn't think that vapingand inhaling foreignsubstances into yourlungs could make you more susceptible to “It's so early in terms of the studies that are being done, but Bloomberg School of Public Health JoannaDr. Cohen, D Alok Dr. Patel, Pediatrician, New York are breathing cleaner air, and who don’t smoke( .” who aresmokin “Given what we know now, it is very likely that people who areexposed to more air pollution and Environmentat Harvardthe T.H.Chan School Publicof Health Dr. on together.” ( It’s really scary to think aboutwhat could be happening in those that have both of these going people become critically ill from COVID and that these chemicals have abilitythe to deepgo intoyour lungs and cause damage. When know“We that Smoking, Vaping & COVID Vaping Smoking, experts 2020) health.” ( remains the single most effective thing people can do to improve their and their family’s health other health conditions which will all carry on at the same time as crisis. Stopping smoking also helps improve heart and lung conditions, wound healing and many “We are doing everything we can to peoplekeep as safe and healthy as possible through this CharlieDr. Kenward, General Practitioner with NHS Bristol (UK impactthe of a coron Matt Hancock, SecretaryState offorHealth and coronavirus?,” CBS This Morning, Mar. 10, 2020 susceptible to coronavirus?,” CBS News, Mar. 10, 2020 202026, coronavirusthe on oftop it, it could be a problem.” ( someone is creating some sort of lung injury as a result of smoking or vapi agesthe of 18 and 34 vape it’sso anecdotal at this point, but it does stand to reason that if m they “ SanjayDr. CNN Gupta, Chief Medical Correspondent Youngpeople are notimmune from coronavirus.this People between the ages of20 and 44, ontributor AaronBernstein, interimD

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Campaign for Tobacco-Free Kids, May 28, 2020 YOUTHS PARENTS SCHOOLS SCHOOLS PARENTS YOUTHS COMMUNITIES Drug UseTrends Among Teens U.S. 10% 20% 30% 40% 10% 15% 20% 25% 25% 30% 10% 20% 30% 40% 60% 70% 80% 10% 15% 20% 50% 5% 5% 40% 2 3 1 0% 0% 0% [ 10% 12th gradestudentsconductedbyresearchers attheUniversityofMichigan, Past-Year MarijuanaVaping 8% 6% 4% 2% 2017 2010 Past-Year *Data collection stopped prematurely due to the COVID-19 pandemic. Completed surveys represent about 25% of the size ofatypicalyear’sdata about 25%ofthe represent surveys Completed COVID-19 pandemic. due tothe prematurely stopped *Data collection 2017 2010 2% collection. However, results were gathered from a broad geographic range andwerestatisticallyweightedtobenationallyrepresentative. collection. However,resultsweregatheredfromabroadgeographicrange Monitoring theFutureisanannualdrugusesurveyofeighth,10thand 2015 graders 8th Surge of Nicotine Vaping Levels Off,butRemains High

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2016, 3.8% graders 12th Marijuana UseRemainsSteady 11,800 students from

* 11.6% 2018 2020 2020 2020 graders 12th graders 8.6% graders graders 8th 35.2% 8th 8th 2017 11.4%

16.8% 28% 22.1% 4.5% 9.6% 19.1% 8.1%

2019 Amphetamines graders 10th graders 10th graders 10th 2020

25% 30% 10% 15% 20% 10% 20% 30% 40% 50% 60% 70% 80% 1% 2% 3% 4% 5% 40% 2 3 5% 1 0% 0% 0% graders 12th graders 12th graders 12th Signiﬁcantly Among OlderGrades 112 schools across the 2018 Vaping Decreases Signiﬁcantly 2010 2010 14.7% Daily orNear-DailyMarijuana Past-Year JUULUseDropped

0.8%

Past-Year Alcohol Use Daily MarijuanaUse 2019 graders graders 8th 8th Among 10thGraders 11.7% 0.7% Graphic continued onthenext page. Inhalants 28.7% 2019 2015 2019 3% 2015 graders 10th graders 10th 20% 1.7% 2020

28.4% drugabuse.gov 3.5% 2020 2020 2020 2020 graders 12th graders 12th 22.7% 6.9% 4.4% 1.1% 2.5% ]

34.5% 30.7% 20.5% 55.3% 40.7% 16.6% 2020, 4.6% 2020, 5.3% 2020, 6.1% COMMUNITIES YOUTHS PARENTS SCHOOLS 2020, 6.1% 2020, 5.3%2020, 2020, 4.6% 2020, 16.6% 40.7% 55.3% 20.5% 30.7% 34.5%

] 2.5% 1.1% 4.4% 6.9% 22.7% 12th graders 12th graders 2020 2020 2020 2020 3.5% drugabuse.gov 28.4%

2020 1.7% 20% 10th graders 10th graders 2015 3% 2019 2015 2019 28.7% Inhalants Graphic continued on the next page. on the next continued Graphic 0.7% 11.7% Among 10th Graders Among 8th 8th graders graders 2019 Daily Marijuana Use Past-Year Alcohol Use Alcohol Past-Year

0.8%

Past-Year JUUL Use Dropped JUUL Past-Year Daily or Near-Daily Marijuana Daily or Near-Daily Marijuana 14.7% 2010 2010 Vaping Decreases Significantly Decreases Vaping 2018 across the across schools 112 Significantly Among Older Grades Older Among Significantly 12th graders 12th graders 12th graders 0% 0% 0% 1 5% 3 2 40% 5% 4% 3% 2% 1% 80% 70% 60% 50% 40% 30% 20% 10% 20% 15% 10% 30% 25%

2020 10th graders 10th graders 10th graders

Amphetamines 2019 8.1% 19.1% 9.6% 4.5% 22.1% 28% 16.8%

11.4% 2017 8th 8th 35.2% 8th graders graders 8.6% graders 12th graders 2020 2020 2020 2018 11.6% *

from from students 11,800 Marijuana Use Remains Steady 12th graders 2016, 3.8%

5.6% 2019

Past-Year Nicotine Vaping Held Steady Vaping Nicotine Past-Year 2016 Gradual Decline in Alcohol Use Slows Use in Alcohol Decline Gradual 10th graders Trending Upward Among Eighth Graders Among Upward Trending 2015 2015 10th graders Marijuana Use Past-Year Marijuana Vaping Holds Steady Holds Marijuana Vaping Past-Year 6.8% DRUG USE TRENDS AMONG U.S. TEENS U.S. AMONG TRENDS USE DRUG Cough Medicine Cough United States participatedStates United survey.* 2020 the in 2018 Nicotine Vaping Nicotine Amphetamine, Inhalant & Cough Medicine Misuse Cough Medicine Inhalant & Amphetamine, More than More 2016, 3.5% 2% 8th Monitoring the Future 2020 Survey Results Survey 2020 Future the Monitoring graders Long-term trend of decreasing alcohol use among all grades levels off. levels all grades use among alcohol decreasing of trend Long-term

Daily or Near-Daily Daily or in the past two weeks 2015, 1.6% Past-Year Substance Misuse Among Eighth Graders Misuse Among Substance Past-Year Ann Arbor, and funded by the National Institute on Drug Abuse. Ann Arbor, and funded by the

Monitoring the Future is an annual drug use survey of eighth, 10th and 12th grade students conducted by researchers at the University of Michigan, Ann Arbor, and funded by the National Institute on Drug Abuse.

More than 11,800 students from 112 schools across the [ United States participated in the 2020 survey.* ]

*Data collection stopped prematurely due to the COVID-19 pandemic. Completed surveys represent about 25% of the size of a typical year’s data collection. However, results were gathered from a broad geographic range and were statistically weighted to be nationally representative.

Surge of Nicotine Vaping Levels Off, but Remains High

Past-Year Nicotine Vaping Held Steady

40% 34.5% 30.7% 30%

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10%

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8th 10th 12th graders graders graders

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8th 10th 12th 8th 10th 12th graders graders graders graders graders graders

2019 2020

Past-Year Marijuana Vaping Holds Steady

Daily or Near-Daily Marijuana Past-Year Marijuana Vaping Vaping Decreases Signiﬁcantly Among 10th Graders

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8th 10th 12th graders graders graders 2019 2020 DRUG USE TRENDS AMONG U.S. TEENS

Marijuana Use Remains Steady

COMMUNITIES Past-Year Marijuana Use Daily Marijuana Use

40% 40% 35.2%

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Gradual Decline in Alcohol Use Slows

Long-term trend of decreasing alcohol use among all grades levels off.

Binge Drinking* Past-Year Alcohol Use

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2010 2015 2020 2010 2015 2020

*5 or more drinks in a row 8th 10th 12th in the past two weeks graders graders graders SCHOOLS

Graphic continued on the next page. Amphetamine, Inhalant & Cough Medicine Misuse Trending Upward Among Eighth Graders

Past-Year Substance Misuse Among Eighth Graders

10%

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Cough Medicine Amphetamines Inhalants

drugabuse.gov COMMUNITIES YOUTHS PARENTS SCHOOLS 2020, 6.1% 2020, 5.3%2020, 2020, 4.6% 2020, 16.6% 40.7% 55.3% 20.5% 30.7% 34.5%

] 2.5% 1.1% 4.4% 6.9% 22.7% 12th graders 12th graders 2020 2020 2020 2020 3.5% drugabuse.gov 28.4%

2020 1.7% 20% 10th graders 10th graders 2015 3% 2019 2015 2019 28.7% Inhalants 0.7% 11.7% Among 10th Graders Among 8th 8th graders graders 2019 Daily Marijuana Use Past-Year Alcohol Use Alcohol Past-Year

0.8%

Past-Year JUUL Use Dropped Past-Year Daily or Near-Daily Marijuana 14.7% 2010 2010 Vaping Decreases Significantly Decreases Vaping 2018 across the across schools 112 Significantly Among Older Grades Significantly Among 12th graders 12th graders 12th graders 0% 0% 0% 1 5% 3 2 40% 5% 4% 3% 2% 1% 80% 70% 60% 50% 40% 30% 20% 10% 20% 15% 10% 30% 25%

2020 10th graders 10th graders 10th graders

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11.4% 2017 8th 8th 35.2% 8th graders graders 8.6% graders 12th graders 2020 2020 2020 2018 11.6% *

from from students 11,800 Marijuana Use Remains Steady 12th graders 2016, 3.8%

5.6% 2019

Daily or Near-Daily in the past two weeks 2015, 1.6% Past-Year Substance Misuse Among Eighth Graders Among Misuse Substance Past-Year Ann Arbor, and funded by the National Institute on Drug Abuse.

Binge Drinking Binge *5 or more drinks in a row Surge of Nicotine Vaping Levels Off, but Remains High Off, but Remains Levels Vaping Nicotine of Surge 8th graders 2015 Monitoring the Future is an annual drug use survey of eighth, 10th and collection. However, results were gathered from a broad geographic range and were statistically weighted to be nationally representative. 2% 2010 2017 *Data collection stopped prematurely due to the COVID-19 pandemic. Completed surveys represent about 25% of the size of a typical year’s data Past-Year Past-Year 2010 2017 2% 4% 6% 8% Past-Year Marijuana Vaping Past-Year 12th grade students conducted by researchers at the University of Michigan, at the University 12th grade students conducted by researchers 10% [ 0% 0% 0% 1 3 2 40% 5% 5% 50% 20% 15% 10% 80% 70% 60% 40% 30% 20% 10% 30% 25% 25% 20% 15% 10% 40% 30% 20% 10% Drug Use Trends Among U.S. Teens Among Drug Use Trends COMMUNITIES Fuquay-Varina Zebulon Raleigh Garner Cary Apex Knightdale Wake Forest Morrisville Springs Holly Wendell Rolesville http://www.tobaccopreventionandcontrol.ncdhhs.gov/ for more information. information. more for http://www.tobaccopreventionandcontrol.ncdhhs.gov/ Source: (http://www.tobaccopreventionandcontrol.ncdhhs.gov/lgtoolkit/index.htm). Toolkit Implementation Government Local see the and TF SF policies, implementing on guidance and resources For legislation. Note: which in or invited is public the which system; parks Municipality's of the part comprising water controlled by the the by controlled Definitions: TOTAL # OFPLACES STATEWIDE Table Table pdated on a regular basis. Please contact NC TPCB 919 at TPCB NC contact Please basis. on a regular updated Information NORTH CAROLINA MUNICIPALITY CAROLINA NORTH rrent policies cu on based Government Buildings Government Municipality OR SMOKE ; Government Grounds Government - area owned, area NC MUNICIPALITY 100%TOBACCO-FREE/ that have been passed and reported to the TPCB and therefore do not reflect the status of ongoing efforts by counties to pas to by counties efforts of ongoing the status do reflect not and therefore TPCB to the and reported passed been have that the public is permitted is public the leased, and occupied andoccupied leased, SMOKE-FREE WRITTENREGULATIONS - FREE WRITTEN REGULATIONS - unenclosed area owned, leased or occupied by the Municipality; the by occupied or leased owned, area unenclosed Recreation Areas Recreation WAKE WAKE WAKE WAKE WAKE WAKE WAKE WAKE WAKE WAKE WAKE WAKE

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OR SMOKE Local Health Dept. Region Dept. Health Local 5 5 2 7 4 5 8 10 SMOKE-FREE WRITTEN REGULATIONS WRITTEN SMOKE-FREE FREE that havepassed beenand reportedTPCB to the and therefore notdoes reflect statusthe of ongoing efforts by Government Grounds NC COUNTYWIDE 100% TOBACCO-FREE/ 100% COUNTYWIDE NC area owned, leased, and occupied by the County ; - WRITTEN REGULATIONS WRITTEN n enclosedn to area whichthe public invited iswhich or in TOBACCO- a - Government Buildings based on current policies : STATEWIDE Informationregular updated on a basis. PleasecontactTPCB919 at NC NORTH CAROLINA COUNTYWIDE 100% : Table TOTAL # PLACES OF Definitions otherwise controlled by the County of land or body of waterbodycomprisingof land or of partCounty's of the parks system; Public Places Note: countieslegislation. to pass resourcesFor and guidance on implementing Smoke Implementation Toolkit (www.tobaccopreventionandcontrol.ncdhhs.gov/lgtoolkit). Source www.tobaccopreventionandcontrol.ncdhhs.gov/ for more information. DURHAM BUNCOMBE ORANGE WAKE PITT GUILFORD NEW HANOVER MECKLENBURG COMMUNITIES lawsuits to prevent tobacco-control Tobacco companies have grown bolder intheirefforts to keep people addicted andmisinformed: Not onlyare more kidsandyoungadults usinge-cigarettes, theyare usingthemmore often. or weaken They fund significant Theyare threat. gainingpopularity, especiallywithkidsandyoungadults. But e-cigarettes andother products like cigarillos, hookahandsmokeless tobacco posea Thiscould save millionsof lives.is withinsight. The tobacco endgame–thepath to endingtobacco useandnicotine addictionintheU.S. – policies. They are themost populartobacco now report (vaping). usinge-cigs product usedbyadolescents. age 26,theyare likely to never start. has not started usingtobacco by product byage18.Butifsomeone of smokers first tryatobacco Nearly high schoolagekids 1

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appeal to kids. to appeal Ban flavors andBan flavors heart.org/tobaccoendgame to reduce reduce to sweeteners in your life about the dangers of any tobacco or nicotine use. or nicotine any tobacco about the dangers of in your life air laws YOUTH AND TOBACCO: A NEW CRISIS A NEW TOBACCO: AND YOUTH clean indoorclean sales and marketing of all tobacco products. For example: example: For products. all tobacco of and marketing sales support proven strategies and public policy: strategies support to proven also continue must We of the design, manufacturing, manufacturing, the design, of regulation need stronger oversight.government We for strong, comprehensive tobacco policies. tobacco comprehensive strong, for Advocate Talk with young people Talk . yourethecure.org at and state efforts in your community local Join merchandise branding. merchandise campaigns event sponsorships andevent © Copyright 2019 American Heart Association, Inc., a 501(c)(3) not-for-profit. All rights reserved. use prohibited. All rights Unauthorized 2019 American Heart Association, Inc., a 501(c)(3) not-for-profit. © Copyright 2. 3. 1. will require strong strong will require use by kids and young adults endgame and preventing the tobacco Reaching like efforts marketing Restrict public education placements, price promotions, promotions, price placements, celebrity endorsements, movie celebrity E-CIGARETTES, VAPES, AND JUULS: WHAT TEENS SHOULD KNOW.

E-cigarettes, Vapes, and JUULs What Teens Should Know YOUTHS

What are e-cigarettes? Aren’t e-cigarettes less harmful than tobacco? Isn’t it just water vapor? Electronic cigarettes, or e-cigarettes, include vapes, hookah pens, or JUULs. They are battery-powered • The aerosol produced by e-cigarettes isn’t water vapor devices that heat an e-liquid sometimes called “e-juice” and it isn’t harmless. that often contains nicotine. E-cigarettes are inhaled like regular cigarettes and produce an aerosol cloud of nicotine or other substances. They are not proven to be The aerosol inhaled from these products is a safer alternative to cigarettes. often a mixture of harmful chemicals like nicotine, formaldehyde and acrolein. Is there a difference between using e-cigarettes and JUULing? • Virtually all e-cigarettes contain nicotine – even the ones labeled “nicotine free”. This is because there are no rules • No. JUULs may look different, but they’re actually a about how e-cigarettes or “e-juice” are made. There is no type of e-cigarette. way to know exactly what is in an e-cigarette.

• “E-juice” and JUUL pods flavored like fruit or other Every JUUL pod contains highly addictive treats carry the same health risks as the unflavored nicotine. JUUL does not make any nicotine- products. Also, the flavorings used are typically not free pods. Some JUUL pods claim to have safe to be inhaled into the lungs. roughly as much nicotine as an entire pack of cigarettes.

• The aerosol cloud produced by a JUUL might not look as thick as other e-cigarettes’ or regular cigarette smoke, but it still contains many of the same chemicals and has the same health risks. YOUTHS

No e-cigarette has been found to be safe and safe to be found has been e-cigarette No quit smoking. to help people effective quit smoking, to wants who someone know you If (1-800-586-4872) can call 1-800-LUNGUSA they safely. learn about quitting to visit www.Lung.org or In the majority of states, the minimum age of sale for sale for of age the minimum states, of the majority In is the minimum age states is 18; in three e-cigarettes is 21. and DC the minimum age 19 and in six states to their e-cigarettes added schools have Many policies and the consequences school tobacco-free the same often are using them on school grounds for cigarettes. as smoking traditional In many states, it is illegal for retailers to sell states, it is illegal for retailers In many it is also and in some states e-cigarettes, youth to possess e-cigarettes. illegal for youth • • more: Learn for office Association Lung American local your Contact youth other and groups youth leadership on information or www.Lung.org 1-800-LUNGUSA initiatives. tobacco Is it legal for people to sell e-cigarettes to sell e-cigarettes to people it legal for Is use them? or buy to youth for or youth • • quit? help someone Can e-cigarettes

WHAT TEENS SHOULD KNOW. KNOW. SHOULD TEENS WHAT E-CIGARETTES, VAPES, AND JUULS: JUULS: AND VAPES, E-CIGARETTES, 1-800-LUNGUSA | Lung.org | 1-800-LUNGUSA In the short term, e-cigarette aerosol can irritate your your can irritate aerosol e-cigarette the short term, In likely it more can also make It and eyes. lungs, throat the flu. get or colds catch you’ll that Nicotine is highly addictive and exposure during exposure and addictive is highly Nicotine brain. can harm the developing adolescence E-cigarettes contain chemicals that can cause that chemicals contain E-cigarettes brains. teen and alter damage lung irreversible Youth who use e-cigarettes are more likely to go on to likely more are who use e-cigarettes Youth cigarettes. use traditional to

E-cigarettes contain harmful chemicals such E-cigarettes known to cause which is as formaldehyde, as a weed which is used and acrolein cancer, damage. lung irreversible killer and can cause • • •

• What are the health risks of e-cigarettes? of the health risks are What PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS and Young Adults to HelpProtect Children, Teens What Families Needto Know VAPING PARENTS

1 in 4 More than Tobacco Youth National CDC’s 2019 Survey, high school students reported vaping in the past month. Teen using a JUUL Teen 3 3 3 4 5 8 9 10 10 11 12 13 ...... What is vaping? What ...... look like? devices do vaping What is being vaped? What appeal? is vaping’s What EVALI - Vaping-Related Lung Injuries Lung - Vaping-Related EVALI the signs of vaping? are What vaping? against safeguard do to parents can What child is vaping do if your to What respond? should parents and how the signs of EVALI are What This guide was made possible by a grant from from a grant made possible by This guide was The Achelis & Bodman Foundation 2020 Fall End Addiction, to © Partnership Vaping? of Effects the Health are What is Vaping? What What Is in This Guide? What Is in This Marijuana and Vaping and Do Should Know Parents What Vaping has become one of the most popular forms of substance use among young people, people, among young use of substance popular forms one of the most has become Vaping of inhaling and exhaling is the act Vaping risks and harms. health of its evidence growing despite include the ingredients Typically, device. vapor when using an electronic produced the aerosol contain products Some vaping toxic. many of which are chemicals, and other flavorings nicotine, drugs. marijuana or other (CDC), 27.5% of high school and Prevention Control Disease for Centers the U.S. to According (also product using a vaping in 2019 reported 10.5% of middle school students and students a 32% represent numbers 30 days. These past in the or e-cigarette) as an electronic known school among middle 114% increase and a staggering among high school students increase of vaping. about the dangers awareness growing despite before, the year just since students the from our children protect to can we do all that to want we and caregivers, As parents a child Whether brain. developing person’s on a young have can vaping that effects negative help this guide can regularly, or vapes vape to begun has already tried vaping, yet has not and risks are the health what youth, to is, why it appeals vaping what down We break you. harms. its people from young protect do to can you what / VAPING Introduction drugfree.org | drugfree.org Families Guide for 2 | Vaping VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 3 |Vaping Guide for Families |drugfree.org chamber orby usingareplacement pre-filled podorcartridge. computer oroutlet charger andby replacing eitherby fillingthe thee-liquid, while others can bereused by charging thedevice intheUSB portofa objectsand other like everyday apen,eraser orlipstick. Someare disposable products,modern technology suchasUSB sticks/flash drives orcell phones, doses ortemperature limits. Today, vapes are smallanddiscreet andresemble customized ormodifiedby theconsumer to have different flavors, nicotine or “mods,” donot looklike cigarettes orother tobacco products butcan be familiar andappealing to smokers. Larger devices, known astank systems intentionally looked like cigarettes, cigars orpipessothat would feel they Vaping products, orvapes, come inmanyshapesanddesigns.Originaldevices What dovapingdeviceslooklike? marijuana orTHC,thepsychoactive ingredient inmarijuana. other chemicals. Somevaping products contain (or are modified to contain) of most vaping includenicotine, liquids(e-liquids) flavoring chemicals and or e-cigarettes. Less formally, somesimplycall them“vapes.” Thecontents formally, theseproducts are sometimes referred to aselectronic cigarettes, insteadJeweling), ofvaping, whenreferring to theuseoftheseproducts. More device, manyteens andyoung adults usetheterm “JUULING” (pronounced the riseinpopularityofJUUL,currently themost popularbrand ofvaping electronic vapor device whenitheats upits liquidingredients. Because of Vaping istheact ofinhalingandexhaling theaerosol that isproduced by an What isVaping? generally banned inpod-based orclosed-system devices like JUUL, products among youth. Now that flavors, asidefrom mentholand tobacco, are and local governments have begun to shiftthelandscape ofpreferred vaping making themfeel harmless. Recent crackdowns onflavors by federal, state bear andcotton candy often remind teens ofhappy childhood experiences, makingiteasiere-liquid, to inhalethe aerosol. Sweet, funflavors like gummy flavors masktheharsh taste ofnicotine andother chemicals contained in the unmistakably child-friendly flavors, manywithfunandenticingnames.The Thousands of flavoring chemicals. Vapes come inthousandsoftasty, commonly vape flavored withnicotine e-liquids ormarijuana(THC). Although manysubstances can bevaped, teens andyoung adults most What isbeingvaped? VAPING / What isvaping? loopholes

is legal. marijuana in stateswhere marijuana products products andtoall tobacco-nicotine applies toall The 21-agelimit local laws. many stateand federal lawand according to the ageof21, for anyoneunder Vaping isillegal devices. other everyday itemsother andtech everyday cellphones, lipstick, watches or pipes, whileothers resemble regular cigarettes, cigars or Some vaping devices looklike USB sticks, guitar picks,small

PARENTS Vaping tricks, such as “The Dragon,” tricks, such as “The Dragon,” Vaping major another are above, shown of vaping. attraction What is vaping? What What is vaping’s appeal? and relatively seen as cool hide and generally to easy discreet, are vapes Most the harsh help cover that flavors in thousands of tasty harmless. They come might be these products the sense that and override of the chemicals taste some that rush’ or ‘head sensation a brief positive harmful. They also produce people like. those who make rapidly can which very have also of nicotine, high doses Most Some young dependent on the product. or become develop an addiction vape where competitions,” and “cloud tricks” the “vape to also drawn people are aerosol. the vape’s when exhaling shapes or patterns cloud-like they form or ‘mod’ style with modifiable devices, usually performed These tricks are it their lungs and then exhale deep into aerosol will breathe People vapes. eyes or nose. their ears, through is one, and peer pressure Curiosity many reasons. for say they vape Teens to drawn and they are vaping members Theyfamily see friends or is another. tricks. Some also say they do do vape to it’s others, For flavors. the appealing also and it’s products tobacco is less harmful than other it they feel it because discreet. are driving kids to flavored disposable vapes that have even have that vapes disposable flavored driving kids to are in the regulations enticing flavors. in countless and come content higher nicotine 2mg/ml from than more to range doses can Nicotine nicotine. of High levels trying race,” arms nicotine in “a 59mg/ml, engaging are and some companies or cigarettes in regular those found exceed levels that the dose to raise to contains JUUL, vapes, popular most one of the Currently, vapes. competing to – an amount equal States United pod in the 59mg/ml in each of nicotine cigarettes. of about 1-2 packs which many The aerosol, particles. and ultrafine metals Other chemicals, of many chemicals, consists actually vapor, believe water is harmless teens – and and dangerous toxic – many of which are and fine particles metals heavy when vaping. the lungs and bloodstream seep deep into in found are marijuana ingredients drugs. Increasingly, Marijuana or other a creates in marijuana that compound THC (the psychoactive including vapes, sometimes are of marijuana, or CBD. Vapes form sense of being high), the leaf drugs, as well. inhale other used to / VAPING drugfree.org | drugfree.org Families Guide for 4 | Vaping VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 5 |Vaping Guidefor Families |drugfree.org VAPING / reduced abilityto fightoffinfections. particles that go deepinto thelungsandcause lungdamage, cell damage and Most contain cancer-causing andother toxic chemicals, heavy metals andtiny The other ingredients invapes, includingtheflavorings, are harmfulaswell. dizziness, respiratory failure, coma andparalysis. rise to seizures aswell asnausea, vomiting, diarrhea, excessive salivation, doses ofnicotine can lead to nicotine toxicity, whichinsevere cases can give starting to smoke cigarettes oruseother addictive products. Taking inhigh People whovape can quicklybecome addicted andare at increased riskof (including inflammation, asthma and reproductive andwheezing) organs. pressure andtheriskofheart attack andstroke), respiratory/lung functioning negatively affects the cardiovascular system (increasing heart rate andblood in manycases asmuchormore thanintraditional cigarettes. Nicotine Nearly allvapes contain nicotine, oneofthemost addictive substances, and situations. and impulsecontrol inaway that can affect theminschool,sports andsocial severe lunginjury. Vaping alsonegatively affects teens’ attention, learning, behavioral andmoodchanges, headaches, seizures, vomiting andpotential The more immediate health effects include coughing andwheezing, combustible cigarettes. if itmightnot bequite asunhealthy anddangerous assmokingtraditional, It isnow widelyrecognized that vaping isunhealthy anddangerous, even of Vaping? What aretheHealthEffects than are adults by nicotine. years isespeciallyrisky. Young peoplewhovape are affected more intensely adulthood, roughly age 25-30,useofany addictive substance priorto these most at riskfor addiction. Because thebrain continues to untilearly develop Vaping exposes young peopleto nicotine at atime whenthehumanbrain is the typeofdevice usedandhow itisused. from vaping varies considerably dependinguponthecontents ofthee-liquid, shallow, aswell asincreases heart rate andbloodpressure. Nicotine exposure physical andmental activity. Itcauses breathing to become more rapid and Nicotine isastimulant that system makes thenervous prepare thebodyfor ! Exposure to Nicotine What are thehealth effects of vaping?

lung damage. found tocause that havebeen compounds harmful form additional aerosol, they to producean they areheated or drinking, once safe wheneating been deemed chemicals have of theflavoring Although some

PARENTS

and vaping find it extremely difficult to quit vaping due to the very high doses of nicotine the ease of consuming it through vapes. Many people who are able to stop smoking cigarettes by switching to What are the health effects of vaping? of effects health the are What Multiple tobacco product use product Multiple tobacco Cigarette smoking Cigarette Addiction Exposure to toxic chemicals and other harmful and other chemicals toxic to Exposure ! ! ! ! of those who do not of those who do not times the likelihood five have people who vape Young or pipes. The cigars hookah, such as cigarettes, products use tobacco to vape Teens and young adults who vape are significantly more likely than those likely more significantly are who vape adults and young Teens end up smoking traditional – to times as likely – about four vape who do not and had cigarettes people who never smoked This is true of young cigarettes. and consistent Strong in doing so. or interest to likelihood of, no intention quit smoking. to way or reliable a safe is not vaping that also shows research to quit smoking. difficult it more make actually can many people, vaping For Nicotine is a highly addictive substance. People who vape can quickly become quickly become can who vape People substance. is a highly addictive Nicotine risk of increased at and are all vapes, is in nearly that the nicotine to addicted When a person substances. addictive or use other cigarettes smoke to starting including withdrawal experience a short period, they can even for vaping, stops and difficulty sleeplessness headache, fatigue, irritability, cravings, strong driving them right back intense, be quite can These symptoms concentrating. many people who quit. In fact, to even when they want product, the nicotine to find it extremely vaping to switching by cigarettes smoking stop able to are of ease and the veryto the vaping due high doses of nicotine to quit difficult vapes. it through consuming Vapes contain a number of chemicals, metals and ultrafine particles that are are that particles and ultrafine metals a number of chemicals, contain Vapes and then inhaled. Because an aerosol form to heated poisonous when they are vanilla, – such as cinnamon, popular flavors certain makeup, of their chemical harmful. Although some of the flavoring especially mint – are and butter, they are or drinking, once when eating been deemed safe have chemicals that additional harmful compounds they form an aerosol, produce to heated some that also is evidence There lung damage. cause to been found have the the e-liquid and enter seep into can of vape components and other metals ranging lung damage causing process, and inhalation lungs during the heating severe. mild to from / VAPING ingredients | drugfree.org Families Guide for 6 | Vaping VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 7 |Vaping Guidefor Families | drugfree.org immunityeffects vape oronlyuseother tobacco products. in more nicotine andother potentially toxic chemicals thanpeoplewhoonly and situations where smoking is impossible. Dual users, therefore, actually take users,’ smokinginplaces andsituations where can they andvaping inplaces majority ofpeoplewhovape to helpthemquitsmokingendupbecoming ‘dual VAPING / its symptoms iselevated amongthose whovape. immune systems, one’s vulnerability to contracting thevirusand experiencing importantly, because vaping weakens thecardiovascular, respiratory and between one’s hand,thedevice andone’s mouthwhilevaping. Perhaps most of theneedto remove masksto vape andbecause ofrepeated contact risk ofcontracting (andtransmitting) thevirusmightbehigher simplybecause was higheramongthosewhoboth even vaped andsmoked cigarettes. The with thevirusandriskofbeingdiagnosedexperiencing its symptoms vaped were 5timesmore likely thanthosewhohaven’t vaped to bediagnosed ofadolescentssurvey andyoung adults found that young peoplewhohave transmitting andexperiencing thehealth effects of COVID-19. Arecent national Vaping posesasignificant riskto young peoplewhenitcomes to contracting, viral infections includingCOVID-19. associated withchronic bronchitis andreduced abilityto fightoff bacterial and inflammatory processes anddepress immunefunction inlungs,andare stroke, aswell asinflammation, asthma alsocan andwheezing.They cause increasing heart rate andbloodpressure andtheriskofheart attack and More andmore, nicotine andother chemicals invapes are beingtiedto poisoning, resulting invomiting, seizures, ordeath. brain injury through orskincontacte-liquids themouth,eye can experience nicotine explode. Thisresults inburnsandother injuries.Young peopleexposed to stored improperly orhave beenmodifiedby theuser, can malfunction or Vaping devices, especiallythosewithpoorqualitybatteries that have been ! ! Cardiovascular, respiratory, reproductive and Injuriesandpoisonings What are thehealth effects of vaping? tobacco products. only useother only vapeor than peoplewho toxic chemicals potentially and other more nicotine actually takein Dual users

PARENTS

The level of THC in marijuana vapes can be far Therefore, higher. vaped marijuana tends to be much more potent than smoked marijuana. Marijuana and vaping Marijuana Academic or job difficulties, school dropout Academic anxiety issues including depression, health risk of mental Increased and suicidal thoughts psychosis and, in some cases, use and substance other and (addiction) Marijuana use disorder addiction Impaired attention, learning, problem-solving skills, memory problem-solving learning, and attention, Impaired functions cognitive other driving to especially related time and coordination, reaction Impaired

▶ ▶ ▶ ▶ ▶ Marijuana and Vaping Marijuana or cannabis marijuana consume to devices vaping of using The practice many that show data Recent widespread. increasingly is becoming products Many are nicotine. vaping just not are older teens, especially who vape, youth a high. produces in marijuana that ingredient THC, the psychoactive vaping 19% of 10th graders 21% of 12th graders, that 2019 show from data National a each year, marijuana in the past vaping reported and 7% of 8th graders 15% that show data Other national year. the previous over increase significant those who ever and 43% of used vapes, of middle and high school students, marijuana. vaped have vapes marijuana, the levelmarijuana of THC in plant-based most from Different potent be much more to tends marijuana vaped Therefore, higher. be far can marijuana. than smoked which brand, (e.g., PAX devices vaping nicotine look like Some marijuana vapes forms; or extract concentrate in loose leaf, come JUUL products); resembles virtually odorless. and names; and are flavors in youth-friendly available are to lead quickly and can the bloodstream enters The THC inhaled when vaping marijuana Vaping consequences. health negative and other addiction overuse, mood swings and eyes, dry appetite, bloodshot mouth, increased cause can Marijuana vaping and suicidality. psychosis the risk of depression, increase can lung injuries and of vaping-related spate in the recent has also been implicated Lung use Associated product or Vaping, (E-cigarette, as EVALI known deaths Injury). long-lasting have can it is ingested, of how Marijuana use, regardless include: effects Negative teen brain. on the developing effects / VAPING

| drugfree.org Families Guide for 8 | Vaping VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 9 |Vaping Guidefor Families |drugfree.org especially intheabsence ofalunginfection. be contacted immediately ifachilddemonstrates thesymptoms ofEVALI, Since EVALI maybealife-threating condition, ahealth care professional should not safe for inhalation into thelungs. meat, fruits andvegetables, orinvitamin orskincare products. However, itis is generally considered safe for eating infoods suchasvegetable oils,cereals, that appears to beprimarilyresponsible isVitamin EAcetate. Thisingredient containing vapes have beenimplicated incases ofEVALI, andtheingredient a regulated More than150different marijuanadispensary). brands ofTHC- cases have beenidentifiedinwhichtheadulterated vaping product came from sales appear to betheroot inthemajorityoftested cases (althoughseveral ingredient inmarijuana, andthoseboughtthrough illegal channels.Illegal avoiding useofanyvapes, especiallythosecontaining THC,thepsychoactive the federal government isinvestigating its precise cause, ithasrecommended and death. Most cases require admission to ahospital for treatment. While gastrointestinal problems, low oxygen and,insevere levels cases, lungfailure Symptoms includeshortnessofbreath, weight loss,nightsweats, fatigue, has ledto nearly 70deaths across thecountry. product hassickened useAssociated Lung more Injury), than2,800peopleand associated withvaping. Thecondition, known asEVALI (E-cigarette, orVaping, In thepast year, there hasbeenawave ofsevere lunginjuriesanddeaths EVALI -Vaping-RelatedLungInjuries marijuana. marijuana, isabouttwice ashighamongteens thanamongadults whouse The likelihood amarijuanausedisorder, ofdeveloping oraddiction to VAPING / Marijuana andvaping services at or emergency 1-800-222-1222 control centerat your localpoison symptoms life-threatening In the country. deaths nearly 70 and hasledto than 2,800people sickened more EVALI has In thepastyear, theeventof across

911. , call

PARENTS Kids often brag about their vaping exploits on social media. Look for pictures or for pictures Look on social media. exploits vaping about their brag Kids often social media and other Twitter YouTube, Snapchat, on their Instagram, references in their online searches. terms of popular vaping note Take accounts. and concentrating difficulty irritability, anxiety, to may lead nicotine Vaping eyes, dry in bloodshot and mouth result marijuana can Vaping loss of appetite. is a there in behavior and mood. Sometimes, and shifts appetite increased thirst, enjoyed. once were that in activities in friends and a decrease change noticeable cough, headaches, breathing, vaping may include trouble of side effects Physical or swelling such as itchiness reactions and allergic pain chest throat, dizziness, sore lung disease symptoms, of asthma worsening include effects severe of the lips. More disease. and heart or failure Some of the chemicals used in e-juices dry used in e-juices Some of the chemicals and nose. As out the mouth a result, stronger for a desire and may show nosebleeds liquids, have some kids drink more is reduced). perception flavor (when the mouth is dry, flavors caffeine develop a sensitivity to nicotine who vape adults and young Some teens can stimulants Taking multiple stimulants. are and caffeine nicotine both because energy drinks and has cut caffeinated child drank If your anxiety. of in feelings result of vaping. or quit, it may be because back “VG” for an atomizer, for such as “atty” messages slang in text may see vaping You “nicked” Getting e-juice. to referring or “sauce” in e-juice found glycerin vegetable “nic sick” and feeling with high doses of nicotine the euphoria experienced to refers with associated or lightheadedness nausea/vomiting palpitations, heart to refers vapes. of nicotine the overuse Be on the lookout for purchases made online and charged to your credit card or card credit your to made online and charged purchases for Be on the lookout gas stores, big box in the mail. Kids also buy them at arrive that unusual packages friends. or from stations there where of a flavoring a whiff may catch you is faint, vaping While the smell from or chocolate smell bubble gum if you example, For source. be no other to appears can Marijuana vapes product. vaping nicotine It might be a flavored note. take cake, smell. a skunk-like produce You may find devices that look like flash (USB) drives, e-liquid bottles, pods/ e-liquid drives, bottles, flash (USB) like look that may find devices You gel marijuana, Aside leaf from packaging. or product e-juice) contain (that cartridges scoop to (dabs), small tools marijuana extract highly concentrated contain that jars are substance) (a yellowish-brown wax THC oil or contain that dabs and cartridges marijuana. signs of vaping What parents should know and do should know parents What Appearance and behavior Appearance changes symptoms Physical Social media and online references Decreased caffeine use caffeine Decreased slang Vaping Increased thirst / nosebleeds / thirst Increased flavors in stronger interest Online purchases / packages in / packages Online purchases purchases the mail / store Scent Equipment What Parents Should Know and Do Know and Should What Parents may be vaping: child your that some indicators are The following / VAPING | drugfree.org Families Guide for 10 | Vaping What are the signs of vaping? What are the VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 11 |Vaping Guide for Families |drugfree.org What canparentsdotosafeguardagainstvaping? VAPING / Set agoodexample resistance skills Role play expectations Convey your why Try to understand Have conversations Know thefacts What parents shouldknow anddo having fun,feeling cool, fitting in,reducing stress andaddressing anxiety ordepression. to encouragetry andreward healthier choices andensure that your childhasother means of and make sure that theseconsequences are not overly harsh or long-lasting. At thesametime, expect your childnot to vape. Ifyou chooseto set consequences, besure to follow through Set clear expectations. Share whyyou donot want your childto vape andpointoutthat you normal’ orjust like theirpeers. vape. Research shows that suchoverestimations increase theriskthat willvape they to ‘be children ontheirperceptions ofnorms.Teens tend to overestimate how manyoftheirpeers your child’s needsthat can beaddressed inahealthier way. Itisalsoimportant to challenge about vaping?” or“How doesvaping make you feel?” Answers to thesequestions highlight It helpsto understand whyyour childisvaping by askingquestions like: “What doyou enjoy Some maybecome addicted to nicotine andcontinue vaping to avoid withdrawal symptoms. habit-forming askidsdoitto address other needssuchasrelief from boredom andanxiety. to dovape tricks,orbecause thinkit’s they cool orwant to fitin.Over time,vaping can become Most kidsstart vaping dueto curiosity, because friendsandfamily vape, theappealing flavors, calmly and,ifyou can,vaping. before try they information rather to to scare have thantrying theseconversations them,andtry frequently, the perceived benefits. Whenanswering theirquestions, offer honest, accurate, science-based their perspectives, acknowledge thepotential appeal andhelpthemweigh therisksagainst conversation going suchas,“What doyou thinkaboutvaping?” Intheseconversations, get and safety rather thanthreats Try andpunishment. usingopen-endedquestions to get the passing avape shop. Beready to listen rather thangive alecture andbesure to focus onhealth from theschoolaboutvaping policies,ads,seeingsomeonevaping onTVorthestreet or there’syou thinkaboutit, likely noshortage ofways into thisconversation: stories, news letters Look for opportunitiesto discussvaping withyour childinacalm andreasonable way. When presentation to thisguidecreated by Partnership to EndAddiction. & e-Cigarettes page , download marijuanatalk our kit orfindacompanion PowerPoint instead ofseekingoutinformation from unreliable sources. To learn more, visitourVaping questions inanhonest andcredible way. Itisbetter for themto come to you withquestions vaped (e.g.,nicotine and/or marijuana,flavor types)andbeprepared to answer your child’s brands anddevices (e.g.,JUUL,Suorin,Kandypens,PuffBars, Stig, Posh), know what isbeing Learn aboutthecauses andconsequences ofyouth vaping, befamiliar withthepopular equipment andsuppliessecured. Set apositive example by being vape- andtobacco-free. Ifyou dovape orsmoke, keep your direct contact eye andconfident bodylanguage can helpyour childbeprepared. the situation. Practicing something alongthelinesof“Nothanks,I’m not interested,” saidwith “What would you sayifsomeoneoffered you their vape?” See how your child would handle to beinsocialsituations where are they offered anopportunity vaping. to try You mightask, Teach your childskillsto resist pressures to use.Children inmiddleorhighschoolare likely PARENTS It is important to think of youth vaping as a health rather than a discipline problem. It is than a discipline problem. rather as a health vaping youth think of to It is important of pull to the addictive especially vulnerable are youth vaping, and veryto quit difficult who try people quit unaided, many young quit will While some may be able to to nicotine. concentrating difficulty irritability, including anxiety, symptoms, withdrawal experience is a relatively vaping that the fact (due to research limited Despite and loss of appetite. quit is through young person to helping a approach effective phenomenon), the most recent underlying mental potential address to also important and peer support. It’s family counseling, addictive or use other vape to the desire to might contribute that problems or emotional substances. quit adults and young help teens to available are programs online and text-messaging Several guide young caregivers and other help parents to platforms digital other are and there vaping, seek to it is best vaping, to be addicted seems to person If a young quitting. people toward medications prescribe Physicians may choose to of their pediatrician. out the help and advice aged children for or, therapies replacement including nicotine addiction, nicotine address to There cravings. help control to or Wellbutrin (bupropion) Chantix (varenicline) 14 and older, marijuana vaping. to addicted who are youth treat to available no medications are currently marijuana addiction. treating to approach is the best counseling Professional If you discover that your teen is vaping, address it as you would any other risk to your child’s child’s your to risk any other would it as you address is vaping, teen your that discover If you the lines keep to child. It is important or punish your yell lecture, to the urge resist to Try health. safety, and about their health concerned are you child that your open, show of communication a useless standoff. dissolving into the discussion from and keep This includes limited forces. strong against working are parents vaping, to When it comes tendency natural people’s and young and marketing clever advertising regulation, government used an addictive never before and many who have tryto risky things. Kids of all backgrounds, and the right interventions, can you love With patience, vaping. into been lured have substance, life. living a healthy to back child quit and get help your Vaping is serious and worthy of concern. Just about all vaping products contain nicotine, a nicotine, contain products about all vaping Just of concern. serious and worthy is Vaping can be serious. The vast and broad are effects health drug, and the negative highly addictive 21. age before product using a nicotine started addiction majority of people with nicotine 40% said that found students of middle and high school survey of parents recent this, a Despite believe If you products. use of vaping child’s about their own all concerned at not they were that addressing. an issue worth is definitely it regularly, or is vaping child has tried vaping your What parents should know and do and should know parents What Get help Get Go easy Go easy on yourself Take a health Take approach How worried worried How should I be? What to do if your child is vaping What to do be very can Vaping of passage.” a phase or a “harmless rite it is just assume that try to child vapes, If your not with it. bored or become out of an addiction grow just people do not and most addictive / VAPING | drugfree.org Families Guide for 12 | Vaping VAPING: WHAT PARENTS NEED TO KNOW TO HELP TEENS HELP TO KNOW TO NEED PARENTS WHAT VAPING: PARENTS VAPING: WHAT PARENTS NEEDTO KNOW TO HELPTEENS 13 | Vaping Guidefor Families |drugfree.org fatality, shouldnot: they CDC recommendations, whichindicate that, inlightofits andpotential severity Parents shouldlet theirchildren know aboutthiscondition. Share these Symptoms can include: the publicto bealertto thesignsandsymptoms andknow how to respond. the country, theCenters for Disease Control andPrevention (CDC)encourages A In lightoftheemergence ofEVALI (E-cigarette,V or parents respond? What arethesignsofEVALI andhowshould VAPING / ssociated L ▶ ▶ ▶ ▶ ▶ ▶ ▶

other chemicals ofconcern. illnesses, evidence isnot yet sufficient to ruleout contribution of appears that vitamin Eacetate istheingredient responsible for the Add vitamin Eacetate to e-cigarette orvaping products. Whileit through retail establishments. are not intended by themanufacturer, includingproducts purchased Modify oraddanysubstances to e-cigarette orvaping products that in-person oronlinedealers. containing THC,from informal sources, suchas friends,family or Buy anytypeofe-cigarette orvaping products, particularly those Use anyTHC-containing e-cigarette orvaping products. Fever, chillsorweight loss Nausea, vomiting, abdominalpain ordiarrhea Cough, shortnessofbreath orchest paint njury), whichhassickened thousandsofyoung peopleacrossung Injury), What parents should know anddo aping, product use services at or emergency 1-800-222-1222 control centerat your localpoison sympto life-threatening In theeventof immediately provid your healthcare EVALI, contact consistent with symptoms experiencing If yourchildis er ms, call 911.

THE 101 ON E-CIGARETTES thee-Cigarettes 101 on >

Vaping is becoming an increasing epidemic among teens. In 2018, e-cigarette use nearly doubled in high school students.

What is vaping? Vaping is the act of inhaling and exhaling the aerosol, often referred to as vapor, which is produced by an e-cigarette or similar device. The term is used because e-cigarettes do not produce tobacco smoke, but rather an aerosol, often mistaken for water vapor, that actually consists of fine particles. Many of these particles contain varying amounts of toxic chemicals, which have been linked to heart and respiratory diseases and cancer.

What is an e-cigarette? 1 Drip Tip Electronic cigarettes (e-cigarettes) are battery-powered devices

Where you place PARENTS your mouth to that can deliver nicotine and flavorings to the user in the form of breathe in the vapor an aerosol. Most have a battery, a heating element, and a place 2 Atomizer to hold a liquid or nicotine salts. Flavors that make e-cigarettes so appealing can have toxic effects themselves, although they are The heating component which results in a vapor GRAS (generally regarded as safe) when ingested in food or drinks.

3 Power Button Why are e-cigarettes unsafe for The power button attaches to the battery and is used to send kids, teens and young adults? power to the Atomizer • Nicotine can harm the developing adolescent brain 4 Battery • e-cigarettes contain nicotine • Nicotine addiction that occurs with e-cigarette use may lead to transition to use of combustible tobacco products • Addiction itself, whether to nicotine or other drugs, can drive undesirable behaviors THE 101 ON E-CIGARETTES

What do e-cigarettes look like? E-cigarettes come in a wide variety of shapes and sizes; mini (often called cig-a-like), mid-size, vape pens, vape pod systems like JUUL, e-hookahs, e-cigars, advanced vape pen mid-size mod box “usb” JUUL personal vaporizers or mods; even ones e-cig device shaped to look like pens and usb drives.

What Is JUUL? JUUL is a rapidly growing type of e-cigarette that became available in the US in 2015. It now accounts for about 72 percent of the market share of vaping products in the United States.

• JUUL is particularly appealing to adolescents and young adults because it has a slim design shaped like a USB flash drive (which makes it easier to hide). • It comes in different colors, and a wide variety of flavors, including The JUUL nicotine many that appeal to kids. refill (“pods”)contain as much nicotine as • JUUL does not emit large smoke clouds, making it optimal for a pack of 20 regular discreet use. cigarettes. Average • Not only is nicotine high in JUUL pods, it is present in a benzoic acid pod length varies salt rather than a free base which increases the rate of nicotine but can last up to PARENTS delivery and decreases the harsh sensation in the mouth and throat. 200 puffs.

Noting this unprecedented What can parents do? spike in e-cigarette use in • Do not use any tobacco products youth, in December 2018, the • Talk with your kids about the dangers of smoking and US Surgeon General issued an the importance of avoiding any tobacco use advisory for parents, teachers (conventional cigarettes or e-cigarettes) and health professionals • Educate your kids that e-cigarettes contain nicotine, about the negative health a HIGHLY addictive substance consequences of e-cigarettes in kids. • Advocate for comprehensive tobacco prevention policies (that include e-cigarettes)

TO: LEA Superintendents

FROM: Ellen Essick, Ph.D. Section Chief, NC Healthy Schools

Susan Kansagra, MD, MBA, Section Chief NC Division of Public Health, Chronic Disease and Injury Section

DATE: February 21, 2019

PREVENTING AND REDUCING E-CIGARETTE USE AND OTHER TOBACCO USE AMONG STUDENTS We want to congratulate you for NC’s nearly two decades of success in promoting 100% tobacco free schools, which was the major driver in lowering cigarette smoking rates among NC middle and high school students to historic lows since 1999. However, progress is eroding due to what the US Surgeon General recently called “the e-cigarette epidemic among youth.” We know what works to effectively protect young people from all forms of tobacco, including e- cigarettes, cigarettes, cigars and little cigars, and hookah. We are writing both to offer support and to ask for your help by taking additional actions.

Implement Effective 100% Tobacco-Free School Policies As you know, G.S. 115C-407 requires that every North Carolina school district have a written 100% tobacco-free school policy that prohibits the use of any tobacco products, including e- cigarettes on campus and at school-related events for students, staff and visitors. Please educate

and train school staff to support this policy and tobacco-free school compliance. This link PARENTS provides information on effective communication strategies and enforcement protocols.

For students who violate the tobacco-free schools’ policy, we recommend: • Confiscating all tobacco products, including e-cigarettes and e-cigarette paraphernalia, cigarettes, cigars, smokeless tobacco and snuff, and hookah tobacco and paraphernalia from students and not returning them to the students. • Using an educational program entitled ASPIRE as an alternative to out-of-school suspension. It is a free, bilingual, online tool that helps middle and high school teens learn about being tobacco free. • Offering cessation support to any student who is ready to quit. If your school does not have cessation services available, see cessation resources below.

Your Regional Tobacco Control Manager is available to provide technical assistance on tobacco- free policy issues and to implement a tobacco prevention and control program, including e- cigarette/vape/Juul educational program.

SCHOOLS

STANDARDS, CURRICULUM AND INSTRUCTION Ellen Essick, Section Chief, Healthy Schools | [email protected] 6307 Mail Service Center, Raleigh, North Carolina 27699-6307 | (919) 807-3859 | Fax (919) 807-3823 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

DPI LETTER: FOR PARENTS & SCHOOLS

The following free resources are available to your school and community partners to address the surging use of e-cigarettes among youth.

Curricula. CATCH My Breath™ is a new evidence-based tobacco use prevention curriculum that addresses middle and high schoolers’ use of e-cigarettes. CATCH My Breath meets national and state educational standards. The curriculum is available free of charge to NC schools. More than 80 schools in NC have incorporated the curriculum this school year.

Plan an Awareness Event around New Updated Tobacco Free Schools Signs. This Spring the NC Tobacco Prevention and Control Branch and our Regional Tobacco Control Managers will deliver 2-3 new tobacco-free school signs per K-12 school to LEAs. The new signs clearly communicate that all tobacco products including e-cigarettes are always prohibited on campus by everyone. Installation of the new signs offers an opportunity to have an event to build tobacco-free policy awareness among students, staff, parents and visitors. It may be a good opportunity to invite media in for a positive story.

Engage Students and Parents in Solutions To engage students, teachers and parents in discussions about the dangers of e-cigarette use, the Food and Drug Administration (FDA), and Scholastic, developed free resources for teachers.

Help for teens to quit tobacco: • The Truth Initiative® has expanded its quit-smoking resources to include a first-of-its kind e- cigarette quit program. This innovative and free text message program: • Tailors content by age group to give teens and young adults appropriate recommendations about quitting. • Serves as a resource for parents looking to help their children who now vape. • Uses input from teens, college students, and young adults who have attempted to, or successfully, quit e-cigarettes. • To access the new e-cigarette quit program, users can text “QUIT” to (202) 804- 9884. • North Carolina provides a telephone and web-based tobacco treatment program free to our

PARENTS state’s residents, with a special five-call program for teens who are addicted to tobacco products, including e-cigarettes. Teens who call receive coaching from a dedicated Quit Coach, specially trained to work with adolescents. Students can access this program by calling 1-800-QuitNow (1-800-784-8669).

Teaching tools for Parents, Coaches and Teachers. The Stanford Medicine Tobacco Use Prevention Toolkit is a new, theory-based and evidence-informed educational resource created by educators and researchers aimed at preventing middle and high school students’ use of tobacco and nicotine products. The Tobacco Prevention Toolkit is committed to providing free tobacco/nicotine prevention materials to educators directly working with youth.

Finally, we do not recommend tobacco prevention and cessation programs being promoted by or funded by tobacco or e-cigarette companies.

SCHOOLS Additional Resources from NC Public Health: Prevention Programs and Resources here. VAPING: WHAT SCHOOLS NEED TO KNOW TO HELP TEENS

VAPING

What School Professionals Need to Know to Help Protect Children, Teens and Young Adults SCHOOLS VAPING: WHAT SCHOOLS NEED TO KNOW TO HELP TEENS

VAPING / What is vaping? Introduction

Vaping has become one of the most popular forms of substance use among young people, despite growing evidence of its health risks and harms. Vaping is the act of inhaling and exhaling the aerosol produced when using an electronic vapor device. Typically, the ingredients include nicotine, flavorings and other chemicals, many of which are toxic. Some vaping products contain marijuana or other drugs.

According to the U.S. Centers for Disease Control and Prevention (CDC), 27.5% of high school students and 10.5% of middle school students in 2019 reported using a vaping product (also known as an electronic or e-cigarette) in the past 30 days. These numbers represent a 32% increase among high school students and a staggering 114% increase among middle schools students since just the year before, despite growing awareness about the dangers of vaping.

As school professionals, we want to do all that we can to reduce the negative effects of vaping on our students’ developing brains, affecting their learning and future opportunities. Whether a child has not yet tried vaping, has already begun to vape or vapes regularly, this guide can help you. We break down what vaping is, why it appeals to youth, what the health risks are and what you can do to protect young people from its harms.

What Is in This Guide?

What is Vaping? ...... 3 What do vaping devices look like? ...... 3 What is being vaped? ...... 3 More than 1 in 4 What is vaping’s appeal? ...... 4 high school

What are the Health Effects of Vaping? ...... 5 students reported vaping in the Marijuana and Vaping ...... 8 past month.

What School Professionals Should Know and Do...... 9 CDC’s National Youth Materials and resources for schools ...... 11 Tobacco Survey, 2019

This guide was made possible by a grant from The Achelis & Bodman Foundation Teen using a JUUL SCHOOLS

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VAPING / What is vaping?

What is Vaping? Vaping is illegal for anyone under Vaping is the act of inhaling and exhaling the aerosol that is produced by an electronic vapor device when it heats up its liquid ingredients. Because of the the age of 21, rise in popularity of JUUL, currently the most popular brand of vaping device, according to many teens and young adults use the term “JUUL” (prounounced Jewel) or federal law and “JUULING” (pronounced Jeweling), instead of vaping, when referring to the many state and use of these products. More formally, these products are sometimes referred local laws. to as electronic cigarettes, or e-cigarettes. Less formally, some simply call The 21-age limit them “vapes.” The contents of most vaping liquids (e-liquids) include nicotine, applies to all flavoring chemicals and other chemicals. Some vaping products contain (or tobacco-nicotine are modified to contain) marijuana or THC, the psychoactive ingredient in marijuana. products and to all marijuana products in states where What do vaping devices look like? marijuana is legal. Vaping products, or vapes, come in many shapes and designs. Original devices intentionally looked like cigarettes, cigars or pipes so that they would feel familiar and appealing to smokers. Larger devices, known as tank systems or “mods,” do not look like cigarettes or other tobacco products but can be customized or modified by the consumer to have different flavors, nicotine doses or temperature limits. Today, vapes are small and discreet and resemble modern technology products, such as USB sticks/flash drives or cell phones, and other everyday objects like a pen, eraser or lipstick. Some are disposable while others can be reused by charging the device in the USB port of a computer or outlet charger and by replacing the e-liquid, either by filling the chamber or by using a replacement pre-filled pod or cartridge.

What is being vaped?

Although many substances can be vaped, teens and young adults most commonly vape flavored e-liquids with nicotine or marijuana (THC).

Thousands of flavoring chemicals. Vapes come in thousands of tasty, unmistakably child-friendly flavors, many with fun and enticing names. The flavors mask the harsh taste of nicotine and other chemicals contained in the Some vaping devices look like e-liquid, making it easier to inhale the aerosol. Sweet, fun flavors like gummy regular cigarettes, cigars or bear and cotton candy often remind teens of happy childhood experiences, pipes, while others resemble SCHOOLS USB sticks, guitar picks, small making them feel harmless. Recent crackdowns on flavors by federal, state cellphones, lipstick, watches or and local governments have begun to shift the landscape of preferred vaping other everyday items and tech devices. products among youth. Now that flavors, aside from menthol and tobacco, are

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VAPING / What is vaping?

generally banned in pod-based or closed-system devices like JUUL, loopholes in the regulations are driving kids to flavored disposable vapes that have even higher nicotine content and come in countless of enticing flavors.

High levels of nicotine. Nicotine doses can range from 2mg/ml to more than 59mg/ml, and some companies are engaging in “a nicotine arms race,” trying to raise the dose to levels that exceed those found in regular cigarettes or competing vapes. Currently, one of the most popular vapes, JUUL, contains 59mg/ml of nicotine in each pod in the United States – an amount equal to about 1-2 packs of cigarettes.

Other chemicals, metals and ultrafine particles. The aerosol, which many teens believe is harmless water vapor, actually consists of many chemicals, heavy metals and fine particles – many of which are toxic and dangerous – and seep deep into the lungs and bloodstream when vaping.

Marijuana or other drugs. Increasingly, marijuana ingredients are found in vapes, including THC (the psychoactive compound in marijuana that creates a sense of being high), the leaf form of marijuana or CBD. Vapes also are sometimes used to inhale other drugs as well.

What is vaping’s appeal?

Most vapes are discreet, easy to hide and generally seen as cool and relatively harmless. They come in thousands of tasty flavors that help cover the harsh taste of the chemicals and override the sense that these products might be harmful. They also produce a brief positive sensation or ‘head rush’ that some people like.

Most also have very high doses of nicotine, which can rapidly make those who Vaping tricks, such as “The Dragon,” shown above, are another major vape develop an addiction or become dependent on the product. Some young attraction of vaping. people are also drawn to the “vape tricks” and “cloud competitions,” where they form cloud-like shapes or patterns when exhaling the vape’s aerosol. These tricks are usually performed with modifiable devices, or ‘mod’ style vapes. People will breathe aerosol deep into their lungs and then exhale it through their ears, eyes or nose.

Teens say they vape for many reasons. Curiosity is one, and peer pressure is another. They see friends or family members vaping and they are drawn to the appealing flavors. For others, it’s to do vape tricks. Some also say they do it because they feel it is less harmful than other tobacco products and it’s also discreet. SCHOOLS

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VAPING / What are the health effects of vaping?

What are the Health Effects of Vaping? Although some It is now widely recognized that vaping is unhealthy and dangerous, even of the flavoring if it might not be quite as unhealthy and dangerous as smoking traditional, combustible cigarettes. chemicals have been deemed The more immediate health effects include coughing and wheezing, safe when eating behavioral and mood changes, headaches, seizures, vomiting and potential or drinking, once severe lung injury. Vaping also negatively affects teens’ attention, learning, and impulse control in a way that can affect them in school, sports and social they are heated situations. to produce an aerosol, they Nearly all vapes contain nicotine, one of the most addictive substances, and form additional in many cases as much as or more than in traditional cigarettes. Nicotine harmful negatively affects the cardiovascular system (increasing heart rate and blood pressure and the risk of heart attack and stroke), respiratory/lung functioning compounds (including inflammation, asthma and wheezing) and reproductive organs. that have been People who vape can quickly become addicted and are at increased risk of found to cause starting to smoke cigarettes or use other addictive products. Taking in high lung damage. doses of nicotine can lead to nicotine toxicity, which in severe cases can give rise to seizures as well as nausea, vomiting, diarrhea, excessive salivation, dizziness, respiratory failure, coma and paralysis.

The other ingredients in vapes, including the flavorings, are harmful as well. Most contain cancer-causing and other toxic chemicals, heavy metals and tiny particles that go deep into the lungs and cause lung damage, cell damage and reduced ability to fight off infections.

! Exposure to Nicotine

Nicotine is a stimulant that makes the nervous system prepare the body for physical and mental activity. It causes breathing to become more rapid and shallow, as well as increases heart rate and blood pressure. Nicotine exposure from vaping varies considerably depending upon the contents of the e-liquid, the type of device used and how it is used.

Vaping exposes young people to nicotine at a time when the human brain is SCHOOLS most at risk for addiction. Because the brain continues to develop until early adulthood, roughly age 25-30, use of any addictive substance prior to these years is especially risky. Young people who vape are affected more intensely than are adults by nicotine.

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VAPING / What are the health effects of vaping?

! Exposure to toxic chemicals and other harmful ingredients

Vapes contain a number of chemicals, metals and ultrafine particles that are poisonous when they are heated to form an aerosol and then inhaled. Because of their chemical makeup, certain popular flavors – such as cinnamon, vanilla, butter, and mint – are especially harmful. Although some of the flavoring chemicals have been deemed safe when eating or drinking, once they are heated to produce an aerosol, they form additional harmful compounds that have been found to cause lung damage. There also is evidence that some metals and other components of vape can seep into the e-liquid and enter the lungs during the heating and inhalation process, causing lung damage ranging from mild to severe.

! Addiction Many people who are able to Nicotine is a highly addictive substance. People who vape can quickly become stop smoking addicted to the nicotine that is in nearly all vapes, and are at increased risk of cigarettes by starting to smoke cigarettes or use other addictive substances. When a person switching to stops vaping, even for a short period, they can experience withdrawal including vaping find it strong cravings, irritability, fatigue, headache, sleeplessness and difficulty extremely concentrating. These symptoms can be quite intense, driving them right back difficult to quit to the nicotine product, even when they want to quit. In fact, many people who are able to stop smoking cigarettes by switching to vaping find it extremely vaping due to difficult to quit vaping due to the very high doses of nicotine and the ease of the very high consuming it through vapes. doses of nicotine and ! Cigarette smoking the ease of consuming it Teens and young adults who vape are significantly more likely than those through vapes. who do not vape – about four times as likely – to end up smoking traditional cigarettes. This is true of young people who never smoked cigarettes and had no intention of, likelihood to or interest in doing so. Strong and consistent research also shows that vaping is not a safe or reliable way to quit smoking. For many people, vaping can actually make it more difficult to quit smoking.

! Multiple tobacco product use

Young people who vape have five times the likelihood of those who do not

SCHOOLS vape to use tobacco products such as cigarettes, hookah, cigars or pipes. The

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VAPING / What are the health effects of vaping?

majority of people who vape to help them quit smoking end up becoming ‘dual users,’ smoking in places and situations where they can and vaping in places and situations where smoking is impossible. Dual users, therefore, actually take in more nicotine and other potentially toxic chemicals than people who only vape or only use other tobacco products. Dual users actually take in ! Injuries and poisonings more nicotine and other Vaping devices, especially those with poor quality batteries that have been potentially stored improperly or have been modified by the user, can malfunction or toxic chemicals explode. This results in burns and other injuries. Young people exposed to than people who e-liquids through the mouth, eye or skin contact can experience nicotine only vape or poisoning, resulting in vomiting, seizures, brain injury or death. only use other tobacco products. ! Cardiovascular, respiratory, reproductive and immunity effects

More and more, nicotine and other chemicals in vapes are being tied to increasing heart rate and blood pressure and the risk of heart attack and stroke, as well as inflammation, asthma and wheezing. They also can cause inflammatory processes and depress immune function in lungs, and are associated with chronic bronchitis and reduced ability to fight off bacterial and viral infections including COVID-19.

Vaping poses a significant risk to young people when it comes to contracting, transmitting and experiencing the health effects of COVID-19. A recent national survey of adolescents and young adults found that young people who have vaped were 5 times more likely than those who haven’t vaped to be diagnosed with the virus and the risk of being diagnosed and experiencing its symptoms was even higher among those who both vaped and smoked cigarettes. The risk of contracting (and transmitting) the virus might be higher simply because of the need to remove masks to vape and because of repeated contact between one’s hand, the device and one’s mouth while vaping. Perhaps most importantly, because vaping weakens the cardiovascular, respiratory and immune systems, one’s vulnerability to contracting the virus and experiencing its symptoms is elevated among those who vape. SCHOOLS

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VAPING / Marijuana and vaping

Marijuana and Vaping

The practice of using vaping devices to consume marijuana or cannabis products is becoming increasingly widespread. Recent data show that many youth who vape, especially older teens, are not just vaping nicotine. Many are vaping THC, the psychoactive ingredient in marijuana that produces a high. National data from 2019 show that 21% of 12th graders, 19% of 10th graders and 7% of 8th graders reported vaping marijuana in the past year, each a significant increase over the previous year. Other national data show that 15% The level of of middle and high school students, and 43% of those who ever used vapes, THC in marijuana have vaped marijuana. vapes can be far Different from most plant-based marijuana, the level of THC in marijuana vapes higher. Therefore, can be far higher. Therefore, vaped marijuana tends to be much more potent vaped marijuana than smoked marijuana. tends to be much more potent Some marijuana vapes look like nicotine vaping devices (e.g., PAX brand, which resembles JUUL products); come in loose leaf, concentrate or extract forms; are than smoked available in youth-friendly flavors and names; and are virtually odorless. The THC marijuana. inhaled when vaping enters the bloodstream quickly and can lead to overuse, addiction and other negative health consequences. Vaping marijuana can cause bloodshot eyes, dry mouth, increased appetite, mood swings and can increase the risk of depression, psychosis and suicidality. Marijuana vaping has also been implicated in the recent spate of vaping-related lung injuries and deaths known as EVALI (E-cigarette, or Vaping, product use Associated Lung Injury).

Marijuana use, regardless of how it is ingested, can have long-lasting effects on the developing teen brain. Negative effects include:

▶ Impaired attention, learning, problem-solving skills, memory and other cognitive functions

▶ Impaired reaction time and coordination, especially related to driving

▶ Academic or job difficulties, school dropout

▶ Increased risk of mental health issues including depression, anxiety and, in some cases, psychosis and suicidal thoughts

▶ Marijuana use disorder (addiction) and other substance use and addiction

The likelihood of developing a marijuana use disorder, or addiction to marijuana, SCHOOLS is about twice as high among teens than among adults who use marijuana.

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VAPING / What health care professionals should know and do

What School Professionals Should Know and Do

The following are some indicators that a student may be vaping nicotine or marijuana:

▶ Frequent trips to the bathroom

▶ Mood changes before and after leaving the classroom (may be irritable before leaving and seem less stressed upon return)

▶ Hanging out in bathroom stalls with other students

▶ Returning to class smelling of minty or sweet scents

▶ Putting what appear to be thick markers or pens in the mouth

▶ Using colorful USB-like devices

▶ Using lanyards or hoodies to hide vaping devices

▶ Unexplained shifts in mood, behavior, academics

Help, Don’t Punish, Students Who Are Vaping

▶ Recognize that vaping is a health issue, not just a behavioral problem

▶ Focus on health and safety, not punishment

▶ Ensure that students have accurate facts: offer a research-based anti-vaping curriculum to students

▶ Incorporate vaping-related facts and content into the general academic curriculum (e.g., biology, chemistry, psychology courses)

▶ Challenge students’ perceived norms (it’s not true that ‘everyone’ vapes)

▶ Appeal to students’ desire for independence by demonstrating industry marketing tactics that target youth and make students dependent on SCHOOLS their products

▶ Sponsor student-led anti-vaping campaigns

▶ Offer alternative, safer means of having fun, reducing stress and taking risks

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VAPING / What health care professionals should know and do

▶ Be vigilant about places on campus where students vape (e.g., check pop-up ceilings in bathrooms where vaping devices may be hidden; school parking lots) so that it becomes difficult for students to vape on campus

▶ Educate staff, parents/caregivers on the harms of vaping and on how to respond effectively

▶ Share community and professional resources that can provide assistance

Get Help for Students with Addiction

▶ Get students’ perspectives on why they vape, acknowledge the appeal, but help them weigh risks against benefits

▶ Recognize that addiction is serious and usually too hard for a teen to overcome alone

▶ Encourage professional help to cut back and quit

▶ Interventions should address mental health problems, social concerns

▶ Connect students with self-help online and text messaging programs that can support students trying to quit (e.g., truthinitiative.org/thisisquitting)

▶ There is no simple treatment for teen vaping; some tobacco cessation methods can work but counseling is often needed to address cravings and triggers

Collect Data

Collecting data on the types of addictive substances students are using can help inform education and intervention efforts and decisions about school policies. Tracking trends in reported use of vaping products can help schools address emerging trends and adjust policies and practices to meet student needs. SCHOOLS

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VAPING / What health care professionals should know and do

Materials and resources for schools

▶ Juuling, Dripping, Dabbing and More: What School Professionals Need to Know About Vaping. A companion PowerPoint presentation to this guide by Partnership to End Addiction tailored to school professionals to help to reduce the negative effects of vaping on students’ developing brains.

▶ CATCH My Breath – CATCH (Coordinated Approach to Child Health). A youth e-cigarette prevention program targeting ages 11-18. The program is divided into four sessions lasting 35-40 minutes each and uses a variety of educational strategies. These include cooperative learning groups, group discussions, goal setting, interviews and analysis of mass media.

▶ The Tobacco Prevention Toolkit – Stanford University School of Medicine. A toolkit for teachers with in-classroom units and lesson plans on e-cigarettes, tobacco and nicotine. The toolkit includes PowerPoints, discussion guides, worksheets and activities.

▶ ASPIRE – MD Anderson Center. ASPIRE is a free, bilingual and online tool that helps middle and high school teens learn about being tobacco free.

▶ The Real Cost of Vaping: Understanding the Dangers of Teen E-cigarette Use – For grades 9-12, information and a single lesson plan from a collaboration between the U.S. Food and Drug Administration and Scholastic.

▶ Know the Risks: A Youth Guide to E-cigarettes – A presentation from the Centers for Disease Control and Prevention’s Office on Smoking and Health to educate youth on e-cigarettes. This resource is intended for adults who educate or serve youth ages 11–18 and includes a document with talking points. SCHOOLS

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trial trial “Stand with CATCH , webinars and offer hassle-free DELIVERED IN PARTNERSHIP WITH IN PARTNERSHIP DELIVERED & JUUL PREVENTION PROGRAM PREVENTION & JUUL CATCH MY BREATH: YOUTH E-CIGARETTE E-CIGARETTE YOUTH BREATH: MY CATCH

Online curriculum tools & evaluation resources Teacher materials Parent posters My Breath CATCH Printable Implementation support from team My Breath the CATCH • • • • •

You’ll be emailed an Access Code to unlock the unlock to Code be emailed an Access You’ll including: and resources, curriculum Receive program materials. program Receive Fill out enrollment form. Fill Let us know where and when the program will be taught and when the program where us know Let at www.catchmybreath.org/enroll. parent parent presentation and resource , page host FEATURED BY FEATURED BUILDING SUPPORT www.catchmybreath.org [email protected] 500-0050 x803 (855) periods to review the curriculum in its entirety. We’ve also created a My Breath” where grassroots parents, team (catchinfo.org/supportcmb) teachers, public informed. can stay citizens and concerned professionals, health To help build administration and community support for e-cigarette education, we include include we education, e-cigarette for support community and administration build help To a 1

2 GETTING STARTED SCHOOLS BUILDING COMMUNITYSUPPORT: ADDRESSINGYOUTH BUILDING COMMUNITY BUILDING Addressing Youth E-Cigarette Use andVaping in Schools E-CIGARETTE USEANDVAPING INSCHOOL A Roadmap for School Administrators School for Roadmap A SUPPORT SCHOOLS - cigarette Youth Activation More information can based resources as we QuitLying Ensuring thatparents Ensuring and . We have alsolaunched the # 14 high school in students are vaping,

E-CIGARETTE USE AND VAPING IN SCHOOL IN VAPING USE AND E-CIGARETTE www.QuitLying.org cigarette use. peer industry.strategiesvaping that counter the

andthe number of teens vapewhomore than doubled 2 years.in to- - We are investing in research to identify more effective strategies to support community leaders understand what you and your students are dealing will with provide POWERFUL examples thisof how epidemicis disrupting our schools, addicting children and damaging of the lives youngthe people have beenwho duped into using these dangerous and deadly products. willIn the weeks to come, the AHA share evidence new - identify them, will working and bediligently we city with government and statehousesprotect Vape. to students your from Big Pleasecontact your local office AHA anywith questions. This briefThis toolkit to supportis designed your school(s) holding a solutionsin parentswith focusedcommunities. and dialogue The AmericanThe Heart Associationcommitted is to supporting schools in addressing the devastating youth vaping epidemic. We are working aggressively at local, state and federal levelsto pass policies that protect youth by banning the saleof all flavored tobacco/e- products that appeal to kids and raising the age to purchase these products to 21. your students in breaking their addiction to nicotine and prevent them from starting e- Campaign designed to empower youth to stand up against Big Vape and to use peer be found at BUILDING COMMUNITY SUPPORT: ADDRESSING YOUTH YOUTH ADDRESSING SUPPORT: COMMUNITY BUILDING SCHOOLS OBJECTIVE = OBJECTIVE BUILDING COMMUNITYSUPPORT: ADDRESSINGYOUTH        GOALS LEADERSHIP + ACTION + LEADERSHIP enforcement strategy. enforcement ofan consequences unintended Consider partners. local other and Association Heart American the and partners local from Receive support stakeholders. your for resources and tools Provide stand. a to take students empower and Activate e- and vaping of the topic around language common Establish the body. to harm nicotine that is Educate and addictive causes locally facilitate and communities school Educate Superintendent - - owned, solution -by step a simple outlines information The following issue. proven solutionsthathelp combat willthe and partnerships synergistic to crisis identify vaping and the smoking and nicotine addiction togetherleaders to raise awarenessabout boards,youth andother regionaland local designedto bring parents, educators,school School- tracks. its in epidemic this stop cigaretteepidemic.isYour leadership critical to Schools “groundforarezero” the youth e- cigarettes. addressing the vaping and e and vaping the addressing t o successfullyo conductschool a Based Community Dialogues should should Dialogues Community Based step plan for you to follow. to you for plan -step E-CIGARETTE USEANDVAPING INSCHOOL based action plans. action based - Led School Dialogue Action Plan - cigarette youth crisis.    ENDGAME  - based dialogue dialogue based be be and e vaping end to effectively resources and tools daily the have will personnel School addiction. their end effectively provided age are with dependency nicotine Students free. nicotine become students and schools e- and Vaping school events. events. school hazards of e hazards and unknown risks the known and about learn will and educators parents Students, - cigarette use on campus and at at and use on campus cigarette 1 INTEENS1 4ARE - - cigarette use and vaping. and use cigarette relevant resources to resources relevant cigarettes are eliminated at at eliminated are cigarettes 2019 VAPING SCHOOLS based community dialogue. community based - Secondary Campus Principals, Teachers, Teachers, Principals, Campus Secondary Counselors and Support Staff Members of the School Health Advisory Council Leaders PTA/PTO Student Council, NJHS/NHS Members, HOSA Members Body Student      -up work of buildingand implementingaction an plan tocurb vaping action. - to - in your district relies on your ability to encourage and facilitate the efforts of efforts the and facilitate encourage to on ability your relies district in your The follow The your champions, includingencouraging your studentstaketoa stand andlead. based Leaders based - E-CIGARETTE USE AND VAPING IN SCHOOL IN VAPING USE AND E-CIGARETTE School Board Members Board School Members Council and City Mayor Leaders Commerce of Chamber Leaders Provider Health Parents Faith Officers Law Enforcement School Staff Department Health Local SET THE MEETING SET your it making by meeting the of importance and urgency the Elevate where. and when Decide priority. THEDESIGN AGENDA your from directly hearing as as important just is epidemic vaping the of issue the Framing A is important. elements these of balance The questions. answer experts having and community led a student Engage needed. as modify to toolkit this of end at the included is agenda sample call a with End panel. ALIGN YOUR PEOPLE school and members community of list the brainstorm to team your with work and Lead school the for table the at be to need that personnel encouraged: is groups strongly stakeholder of these each from Representation         FIND AND ALIGN YOUR CHAMPIONS FOR ACTION FOR CHAMPIONS YOUR AND ALIGN FIND to out toolkit this in included resources the send assistant your have meeting the after day The identify you help and created have you momentum the will sustain This stakeholders. your to desire that you for working individuals those identify and partners community for opportunities in a role this cause. lead take

4 1 3 2

ACTION PLAN Our Growth Success: BUILDING COMMUNITY SUPPORT: ADDRESSING YOUTH YOUTH ADDRESSING SUPPORT: COMMUNITY BUILDING SCHOOLS BUILDING COMMUNITYSUPPORT: ADDRESSINGYOUTH  CLOSING         QUESTIONS    ISSUE THE FRAMING  INTRODUCTION [90 minutes] on Meeting Youth E Community Action to Call Superintendent Superintendent Conclusion vaping? of hazards on the children their educate to What resourcesare there for parents and what shouldparents be doing cigarettes? e- using and starting teenagers to contributing see you do factors What Does your district relyon a particularintervention or cessationprogram? community? medical the including What supportthedoes school district from theneed community, Whatthe district areand campuspoliciesyou follow? Hasthere been a community response of any kind? What are the major concerns of parents? How has the youth e youth the hasHow cigarettes. e and vaping of perspective student the shares leader student A adolescents.by nicotine use professionalA medicalthedescribes known andunknown healthrisksof community. the within and campuses on occurring is what discuss Administrators Campus and Officer) Enforcement or Law Psychologist Behavioral Health Expert (i.e. School Counselor, Social Worker, Superintendent Welcome E-CIGARETTE USEANDVAPING INSCHOOL SAMPLE AGENDA SAMPLE - cigarette epidemiccigaretteimpactedyour district? -cigarette and Vaping Epidemic - SCHOOLS peer peer - to - 12 - cigarette cessation cessation cigarette - - skill prevention tobacco based - School – Cigarettes - /ANTIVAPING Cigarettes and Vaping Addressing Schools: Use in Tobacco Addressing Student - Cigarette Model Cigarette – - cigarette use - RESOURCES Cigarette Prevention Program for Grades 5 Grades for Program Prevention Cigarette HEART.ORG - Cigarette Policy Recommendations Schools for Recommendations Cigarette Policy - Truth Initiative’s Initiative’s Truth text-based e AHA youth activation campaign peer campaign supporting activation youth AHA – – Cigarette and Vaping ResolutionBoardMeeting (For Adoption) -

Cigarette and Vaping FactSheet Cigarette and Vaping FactSheet Athlete Toolkits Athlete E-CIGARETTE USE AND VAPING IN SCHOOL IN VAPING USE AND E-CIGARETTE - - Resources Addressing E My Breath E My Breath Lesson Plans for Middle School and High School High and School Middle for Plans Lesson

How to KeeptoHow Kids and Teens from Smokingand Vaping forTips Talking Kids About to E Alternate Measures Measures Alternate QuitLying.org This is Quitting Student Tobacco Prevention Toolkit, E Toolkit, Prevention Tobacco Truth Initiative Initiative Truth Public Service Announcements An Alternative to Suspension Tobacco/E Model Parent Youth E Cessation Programs and Resources AHA AHA Youth E Youth E AHA Catch   intervention strategies addressing e building programs PEER TO PEER         TEACHERS & STAFF  COUNSELORS & HEALTH PROFESSIONALS  SCHOOL BOARD SCHOOL     ADMINISTRATORS PARENTS BUILDING COMMUNITY SUPPORT: ADDRESSING YOUTH YOUTH ADDRESSING SUPPORT: COMMUNITY BUILDING SCHOOLS K-12 SCHOOL MODEL POLICY COMMERCIAL TOBACCO-FREE www.publichealthlawcenter.org cover outdoor schoolgrounds. law andmany state laws donot are used intheschool. the age of18years iffederal funds or library servingchildren under elementary, orsecondary school prohibited inany kindergarten, Under federal law, smokingis tobacco products of commercial The use or promotion K–12 schools. electronic cigarettes, inpublic commercial tobacco use,including states alsohave laws thatrestrict staff, and visitors. safety of students, to health the and events is detrimental school‑sponsored and at off‑campus on school grounds 3 However, federal 2 Many 1

COMMERCIAL TOBACCO FREESCHOOLS SCHOOLS TOBACCO-FREE November 2019 COMMERCIAL TOBACCO FREE SCHOOLS

November 2019

To promote an environment free of commercial tobacco in primary and secondary schools, the Public Health Law Center has prepared a comprehensive model policy that school districts and schools may adopt. The policy:

{ Provides a definition of commercial tobacco products to include current and future tobacco products;

{ Prohibits the following items on campus (inside and outside buildings) and at off-campus, school-sponsored events:

] Tobacco products and tobacco-related devices, including electronic cigarettes,

] Imitation tobacco products (such as candy cigarettes), and

] Lighters;

{ Prohibits accepting any donations or curriculum from any tobacco-related industry;

{ Prohibits any promotion of tobacco products, including electronic cigarette products; and

{ Includes effective and holistic enforcement options for student violations beyond suspension and expulsion.

Both this publication and Commercial Tobacco-Free K-12 School Model Policy: Questions & Answers reflect this policy.

Free Legal Technical Assistance

As with all policy drafting, this K–12 Model Policy is only to be used as a guide. Each school district or school may consider modifications that reflect local needs, resources, and situations. You should review your policy with a legal technical assistance provider to ensure internal consistency, especially if you change terms or delete provisions.

The Public Health Law Center may be able to review the draft of your school or school district’s commercial tobacco-free policy. The Center also offers trainings on drafting effective policies. Please check our website at www.publichealthlawcenter.org for more information about policy drafting and other model policies and resources. To request assistance, e-mail [email protected]. SCHOOLS

www.publichealthlawcenter.org Commercial Tobacco-Free K-12 School Model Policy 2 SCHOOLS www.publichealthlawcenter.org (D) (G) (B) (F) (E) (A) I. PolicyModel Questions &Answers K (C)

‑ 12 Schools, Commercial Tobacco

children andadults. disease ofconsiderable proportions thatresults innew generations ofnicotine-dependent The useofcommercial tobacco products by children intheUnited States isapediatric addiction andharmthedeveloping brain. devices asanepidemicamongyoung people. people. In2018, the U.S.Surgeon General declared useofelectronic delivery smoking Electronic delivery smokingdevices create andincrease nicotine addictionamongyoung Findings nearly $170 billioninexcess medicalcare costs. In theUnited States, smokingcauses480,000 deathsannuallyandisresponsible for likely to beginto usecommercial tobacco. overestimate theprevalence andunderminethehealthharmsof, and(3)become more marketing andadvertising thatleadsyoung peopleto (1)holdfavorable beliefs about,(2) Children are exposed to tailored, targeted, substantial,andunavoidable tobacco industry Juul), whichrose 78 percent during2017–2018. was driven by theuseofelectronic smokingdevices (alsoknown ase-cigarettes, vapes, recent declinesincommercial tobacco useby youth in theUnited States. This increase students increased intheUnited States by 38percent during2017–2018, whichreversed tobacco products, totaling 4million.Overall commercial tobacco useby highschool In 2018, 27.1 percent ofU.S.highschoolstudentswere current users ofcommercial Commercial devices. Nicotine isfound inallcommercial tobacco products, includingelectronic smoking users ofe-cigarettes, themajority (67.8 percent) ofwhomuseflavored e-cigarettes. percent) ofhighschooland 570,000 (5.7 percent) ofmiddleschoolstudentswere current to premature death. youth to try other combustible tobacco products that are known to cause disease and lead 7 Exposure to nicotine duringadolescence andyoung adulthoodcancause 4

tobacco useisthesinglemostpreventable causeofdeathintheUnited States. 9 COMMERCIAL TOBACCO FREESCHOOLS 8 12

13 ‑

Using theseproducts may alsoencourage 10 Free: Free: 6 By 2018, anestimated 3.05 million(20.8

Commercial Tobacco-Free K-12 School ModelPolicy

11 November 2019 5

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November 2019 November [ board/

14 Commercial Tobacco-Free K-12 School Model Policy K-12 Tobacco-Free Commercial

15 COMMERCIAL TOBACCO FREE SCHOOLS FREE TOBACCO COMMERCIAL means any person who has disciplinary and managerial authority to to authority who has disciplinary and managerial person means any “Administrator” principals, to name ], including but not limited school policies in [ district/school enforce personnel. and office vice-principals, a year. 365 days a week, days seven a day, hours means 24 time” “Any believes that the use or promotion of commercial tobacco products, including products, tobacco of commercial that the use or promotion school ] believes school-sponsored and at off-campus on school grounds smoking devices, electronic and visitors. staff, of students, safety the health and is detrimental to events industry the tobacco gifts from or materials accepting ] also believes [ board/school The and visitors. students, staff, to message will send an inconsistent embraces that adult staff and visitors serve as role models for models for as role serve that adult staff and visitors ] embraces [ board/school The models in schools and to role positive promote to its obligation embraces board students. The unwanted from and free healthy, that is safe, and working learning for an environment provide and visitors. the students, staff, use for tobacco commercial and other or aerosol smoke recognizes that the use of that / [ school name ] recognizes of Education] [ district name ] Board [ The safety, is a health, smoking devices, electronic including products, tobacco commercial is board The and school facilities. visitors, students, staff, for hazard and environmental tobacco with the use of commercial associated of the serious health risks aware acutely The and non-users. users to smoking devices, including electronic products, Imitation tobacco products, such as candy cigarettes and smokeless chew, may lead may chew, and smokeless such as candy cigarettes products, Imitation tobacco and by of tobacco dangers the desensitizing them to by tobacco use commercial to youth use is socially acceptable. tobacco idea that commercial the advancing Purpose Evidence has shown anti-tobacco use campaigns sponsored by the tobacco industry the tobacco by use campaigns sponsored anti-tobacco has shown Evidence youth do not prevent and retailers) manufacturers smoking device (including electronic and create smoke to youth encourage may and products tobacco commercial using from industry. with the tobacco associations positive

(A) III. Definitions (B) (B) (C) policy: tobacco-free commercial ] adopts the following the [ board/school THEREFORE, This is a comprehensive policy designed to ensure a safe learning and work environment free free environment learning and work a safe ensure policy designed to is a comprehensive This tobacco. of commercial (A) II. (H) (I) www.publichealthlawcenter.org SCHOOLS www.publichealthlawcenter.org (K) (J) (I) (H) (G) (F) (E) (D) (C)

cigarette, orpipe,any otherlighted orheated product containing, made,orderived “Smoking” meansinhaling,exhaling, burning,orcarryingany lighted orheated cigar, tobacco-free. “Signage” meanssignsdeclaringthatall[district/school name ]schoolproperty is staff, orvisitors. contracted for, orcontrolled by [district/school name]usedfor transporting students, rented, orleasedby [district/school name ],andallvehicles owned, leased,rented, “School property” meansallfacilities andproperty, includingland,whetherowned, center oradulteducationcenter ]operated underthecontrol of[districtname]. program,Head Start elementary, kindergarten, secondary school,alternative learning “School” means[nameofschool/any publicnursery, day care center, childcare facility, day camps,fieldtrips,dances, ortheatrical productions. school districtthatisnotonproperty, includingbutnotlimited to, events, sporting “Off-campus, school-sponsored event” meansany event sponsored by theschoolor products. “Lighter” meansamechanicalorelectricaldevice typically usedfor lighting tobacco packaged similarto snus,andshredded beefjerky incontainers resembling snufftins. bubble gumresembling chewing tobacco, pouchescontaining flavored substances includes, butisnotlimited to, candyorchocolate cigarettes, bubblegumcigars, shredded tobacco product andintended to beusedby children asatoy. “Imitationtobacco product” a tobacco product, orany non-ediblenon-tobacco product designedto resemble a “Imitation tobacco product” meansany ediblenon-tobacco product designedto resemble orpods. cartridges, whether ornotmarketed orsoldseparately, includingbutnotlimited to e-liquids,e-juice, or descriptor. “Electronic smokingdevice” includesany componentofaproduct, part e-pipes, vape pens,mods,tanksystems, Juul,Suorin,orunderany otherproduct name but isnotlimited to, devices manufactured, marketed, orsoldase-cigarettes, e-cigars, the inhalationofaerosol orvapor from theproduct. “Electronic smokingdevice” includes, other substance, whethernatural orsynthetic, intended for humanconsumption through “Electronic smokingdevice” meansany product containing ordelivering nicotine, orany enrolled in[district/school name]. “Parent/Guardian” meansany person thathaslegal guardian statusover astudent COMMERCIAL TOBACCO FREESCHOOLS Commercial Tobacco-Free K-12 School ModelPolicy November 2019

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November 2019 November Commercial Tobacco-Free K-12 School Model Policy K-12 Tobacco-Free Commercial as full or part-time, or any any or part-time, or full as name ] [ district/school COMMERCIAL TOBACCO FREE SCHOOLS FREE TOBACCO COMMERCIAL position contracted for or otherwise employed, with direct or indirect monetary wages monetary wages or indirect with direct or otherwise employed, for position contracted on a volunteer working name ], or anyone [ district/school paid by or compensation volunteers, personnel, service faculty, to, is not limited includes, but term basis. This aides, and other adults working or student adult classroom student teachers, chaperones, name ]. [ district/school for educational system. name ]’s in [ district/school enrolled person “Student” means any of tobacco or wholesalers distributors means manufacturers, industry” “Tobacco companies includes parent Juul, Altria). This (e.g., devices or tobacco-related products and subsidiaries. motto, symbol, logo, name, trademark, corporate ” means any brand industry “Tobacco other indication of product or any of colors, pattern recognizable selling message, product, tobacco of brand for any to those used identification identical or similar products. of tobacco or manufacturer company, or that tobacco from made, or derived containing, product means any product” “Tobacco human consumption, for that is intended or natural, whether synthetic nicotine, contains by or ingested inhaled, snorted, sniffed, absorbed, dissolved, smoked, whether chewed, including product, of a tobacco part, or accessory component, other means, or any any cheroots; little cigars; cigars; smoking devices; electronic cigarettes; to: but not limited rubbed, and other smoking plug cut, crimp cut, ready periques; granulated, stogies; fine-cut and other chewing tobacco; twist plug and snuff; snuff flour; cavendish; tobacco; and other of tobacco; clippings, cuttings and sweepings scraps, shorts; refuse tobacco; of tobacco. kinds and forms than 90 percent more establishment that derives means a retail shop” products “Tobacco as defined in this policy. products, the sale of tobacco from revenue of its gross smoking or pipes for wraps, papers, rolling means ashtrays, devices” “Tobacco-related smoking devices. of electronic parts, components, or accessories and any or policy that is not a student, staff, this to subject person means any “Visitor” as defined above. administrator from nicotine, tobacco, marijuana, or other plant, whether natural or synthetic, that is or synthetic, natural marijuana, or other plant, whether tobacco, nicotine, from electronic includes carrying or using an activated inhalation. “Smoking” also for intended smoking device. by “Staff”employed person any means

(M) (N) (O) (P) (Q) (R) (S) (L) www.publichealthlawcenter.org SCHOOLS www.publichealthlawcenter.org (F) (E) (D) (C) (B) (A) IV.

General StatementGeneral of Policy clothing, any personal signs,structures, articles, vehicles, flyers orany othermaterials. events. This includespromotion oftheseproducts viagear, technology accessories, bags, imitation tobacco products ontheschoolproperty oratoff-campus, school-sponsored name ]to promote orallow promotion oftobacco products, tobacco-related devices, or It shallbeaviolationofthispolicyfor any person to promote, orfor will notbepaidfor ordeveloped by the tobacco industryoritssubsidiaries. effectively deliver theeducationprogram asplanned. The curriculumfor thisinstruction have adequate training inongoing andparticipate professional development activitiesto provided for allstudents. Staffresponsible for teaching tobacco useprevention shall Instruction to discourage theuseoftobacco products shallbeincludedintheeducation policy. against any student,staff, administrator, orvisitor whoisfound to have violated this [ district/school name]shallactto enforce thispolicyandto take appropriate action while inthescope ofemployment for [district/school name]. inanyviolation ofthispolicyto participate type ofservice fundedby thetobacco industry foror support equipment,uniforms,and/or andsports training facilities. Itshallalsobea sponsorship, advertising, alleged educationalmaterials, promotions, loans,scholarships, any tobacco products shop. This includes,butisnotlimited to, donations,moniesfor contributions, money, gifts, curricula, ormaterials from thetobacco industryorfrom It shallbeaviolationofthispolicyfor [district/school name]to solicitoraccept any displaying tobacco industrybrands. or atany off-campus, school-sponsored events. This includesproducts orparaphernalia related devices, imitationtobacco products, orlighters atany timeonschoolproperty consuming, displaying, activating, promoting, orsellingany tobacco products, tobacco- Administrators, staff, orvisitors of[district/school name]are prohibited from using, sponsored event. tobacco products, orlighters atany timeon schoolproperty oratany off-campus, school- displaying, promoting, orsellingany tobacco products, tobacco-related devices, imitation [ district/school name]studentsare prohibited from possessing, using,consuming, COMMERCIAL TOBACCO FREESCHOOLS Commercial Tobacco-Free K-12 SchoolModel Policy [ district/school November 2019

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November 2019 November Commercial Tobacco-Free K-12 School Model Policy K-12 Tobacco-Free Commercial COMMERCIAL TOBACCO FREE SCHOOLS FREE TOBACCO COMMERCIAL Administrators shall consult with the local public health department or other appropriate department with the local public health or other appropriate shall consult Administrators and students, staff, provide to organizations health and allied community-based to and services programs, support to systems, and access information with administrators products. the use of tobacco abstain from them to encourage staff for and services programs evidence-based and offer shall identify Administrators support with this policy. to them in complying products that use tobacco It shall not be a violation of this policy for a person to possess or provide tobacco, tobacco, or provide possess to person a of this policy for It shall not be a violation as other person any to or lighters products, imitation tobacco devices, tobacco-related spiritual, or cultural religious, recognized or a lawfully part practice indigenous of an or tobacco- use tobacco of this policy to It shall not be a violation or practice. ceremony tobacco indigenous to related as part of an educational experience devices related administrators. by that has been approved practices devices, tobacco-related products, tobacco for It shall not be a violation of this policy included in an instructional or work-related be to or lighters products, imitation tobacco a staff by is conducted name ] school buildings if the activity in [ district/school activity or include smoking, chewing, does not and the activity visitor member or an approved the product. otherwise ingesting It shall not be a violation of this policy for non-students 18 years and older to use or and older to non-students 18 years for It shall not be a violation of this policy and Drug Administration the U.S. Food by that has been approved a product possess other or for product, dependence as a tobacco product, cessation a tobacco sale as for purpose. such an approved and sold solely for medical purposes, and is being marketed Enforcement Opportunities for Cessation Programs Cessation for Opportunities Exceptions

VII. and cooperation consideration, of this policy depends upon the thoughtfulness, success The including on school premises, All individuals name ] community. of the whole [ district/school this and enforcing adhering to for responsible are and visitors administrators, students, staff, communicate to encouraged are name ] community of the [ district/school Members policy. violation of this policy will be acting in person Any and diplomacy. this policy with courtesy comply. to of the policy and asked or reminded informed VI. (A) (B) V. (A) (B) (C) www.publichealthlawcenter.org SCHOOLS www.publichealthlawcenter.org (B) (A)

(1) (3) (2) (1) Staff Students (ii) (ii) (iii) (ii) (i) (i) (i) and anoffer ofareferral to cessation services. The first violation ofthispolicyshall result ina verbal warning to thestaffmember and atleastoneofthefollowing: available cessation programs; inatobacco studentparticipation educationprogram; of parents and/or guardians; theprovision ofinformation to thestudentabout products, tobacco-related devices, imitationtobacco products, orlighters; notification The third andany subsequentviolationshallresult inconfiscation of tobacco programs; andatleastoneofthefollowing: or guardians; theprovision ofinformation to thestudentabout available cessation related devices, imitationtobacco products, orlighters; notificationofparents and/ The second violationshallresult inconfiscation of tobacco products, tobacco- guardians; andatleastoneofthefollowing: devices, imitationtobacco products, orlighters; notificationofparents and/or The first violationshall result in confiscation of tobacco products, tobacco-related Educational community service. tobacco useandschoolpolicy. educator or designated staff with parents and/or guardians to discuss commercial A studentmeetingandindividualassessment withachemicalhealth inatobaccoStudent participation educationprogram. tobacco useandschoolpolicy. educator or designated staff with parents and/or guardians to discuss commercial A studentmeetingandindividualassessment withachemicalhealth resources. Provision ofinformation to studentaboutavailable cessation programs and inatobaccoStudent participation educationprogram. educator ordesignated staffto discuss commercial tobacco useandtheschoolpolicy. A studentmeetingandindividualassessment withachemicalhealth COMMERCIAL TOBACCO FREESCHOOLS Commercial Tobacco-Free K-12 School ModelPolicy November 2019

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November 2019 November district/school [ district/school Commercial Tobacco-Free K-12 School Model Policy K-12 Tobacco-Free Commercial COMMERCIAL TOBACCO FREE SCHOOLS FREE TOBACCO COMMERCIAL The second violation shall result in a written warning to the staff member with a the staff to warning in a written violation shall result second The to referral of file, and an offer district personnel in the staff member’s placed copy services. cessation dealt with and shall be insubordination violation shall be considered third The suspension and/or for and procedures based on established policies accordingly of staff. dismissal with comply to violating this policy shall be asked observed Visitors policy. tobacco-free name ]’s to be referred may this policy violation with the request, comply to fails If a visitor The personnel. school district supervisory the building principal or other available that the visitor include a directive supervisor shall decide on furthermay action that a school-sponsored to admission for charged fee any and forfeit school property leave event. prohibit that the superintendent in a recommendation result violations may Repeated a specified period for property name ]’s [ district/school entering the individual from of time. Dissemination Policy of Visitors Appropriate signage shall be posted throughout the district at building entrances and entrances the district at building throughout be posted shall signage Appropriate vehicular vehicles, buildings, building entrances, other highly visible locations on all school indicating that athletic facilities and all indoor and outdoor school grounds, to entrances tobacco. of commercial free an environment name ] requires [ district/school of this policy through ] shall notify students and parents/guardians [ school/district The and orientations. student handbooks through of this policy in staff handbooks, notice ] shall provide [ school/district The employment. and when offering or staff trainings, orientations and employee tobacco- of its commercial announcements reminder ] shall make [ school/district The the events, throughout intervals at appropriate ] events policy at [ school/district free when possible.

(3) (1) (2) (3) (2)

(C) (B) (C) (D) VIII. (A) www.publichealthlawcenter.org SCHOOLS www.publichealthlawcenter.org 7 6 5 4 3 2 1 Endnotes The Center doesnotprovide legal representation oradvice. This documentshouldnotbeconsidered legal advice. The Public HealthLaw Center provides information andlegal technical assistance onissues related to publichealth. and donotnecessarily represent theofficialviews ofthe Centers for Disease Control and Prevention. funded by theCenters for DiseaseControl andPrevention. Itscontents are solelytheresponsibility oftheauthors Tobacco Prevention andControl Program andby Cooperative Agreement Number5NU58DP006263-02-00, Minnesota, andmadepossible by aTobacco-Free Communities Grant from ofHealth theMinnesotaDepartment This publicationwas prepared by thePublic HealthLaw Center atMitchell HamlineSchoolofLaw, St.Paul, X. IX. General (2016), https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf U.S. Dep’t Health &HumanServices, E-CigaretteUseAmongYouth andYoung Adults: AReport oftheSurgeon Id. of theSurgeon General (2014), https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm U.S. Dep’t ofHealth andHumanServices, The Health Consequences ofSmoking—50 Years ofProgress: AReport document, except for theindigenous practice provision, acommercial context isimpliedandintended. death. For more information, visithttp://www.keepitsacred.itcmi.org. Whentheword “tobacco” isusedthroughout this commercial tobacco is manufactured withchemicaladditives for recreational useandprofit, resulting indiseaseand al tobacco isand has beenusedinsacred ways by Indigenous communities andtribes for centuries. Comparatively, Traditional andcommercial tobacco are different intheways they are planted, grown, harvested, andused.Tradition- categories/physical-environment/tobacco-free-environments. National Association ofState Boards ofEducation, Tobacco-Free Environments , https://statepolicies.nasbe.org/health/ 20 U.S.C. §6083(a),https://www.law.cornell.edu/uscode/text/20/6083. When theword “tobacco” isusedthroughout thisdocument,acommercial context isimpliedandintended. ational useandprofit, resulting indisease anddeath. For more information, visit:http://www.keepitsacred.itcmi.org. ties andtribesfor centuries. Comparatively, commercial tobacco ismanufactured withchemicaladditives for recre- planted, grown, harvested, andused.Traditional tobacco isandhasbeenusedinsacred ways by Indigenous communi- The Public HealthLaw Center recognizes thattraditional andcommercial tobacco are different intheways they are

Effective Date Effective Program Evaluation This policyshalltake date effect ]. infullon[insert effective. Policies andprograms shallbeupdated andrevised accordingly. enforcement, communication, education,stafftraining, andcessation programs are at regular intervals, butatleastonce ayear, to determine whetherpolicies,policy The tobacco-free policyshallbeassessed by theschool districtoritsdesigneeevaluator COMMERCIAL TOBACCO FREESCHOOLS Commercial Tobacco-Free K-12 SchoolModel Policy . . November 2019

11 SCHOOLS 12

November 2019 November , 68 ; U.S. . , 117 Prev. , 45 Prev. - https://e-cig (2018), . Commercial Tobacco-Free K-12 School Model Policy K-12 Tobacco-Free Commercial . . COMMERCIAL TOBACCO FREE SCHOOLS FREE TOBACCO COMMERCIAL . rettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf Vital Signs: Tobacco Product Use Among Middle and High School Students — U.S., 2011–2018 Product Signs: Tobacco et al., Vital S. Gentzke Andrea U.S. Dep’t Health & Human Services, E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon the Surgeon of Report A Adults: and Young Use Among Youth E-Cigarette & Human Services, Health U.S. Dep’t https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_ (2016), Summary General — Executive Summ_508.pdf of the A Report Adults: Young and Use Among Youth Tobacco Preventing and Human Services, of Health Dep’t . https://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm General (2012), Surgeon Middle and High Among Product Tobacco and Any Cigarettes of Electronic Use Field: the from et al., Notes A. Cullen Karen https://www.cdc.gov/ (2018), 1276 Rep. Wkly. & Mortality , Morbidity 2011–2018 States, School Students — United mmwr/volumes/67/wr/pdfs/mm6745a5-H.pdf . https://www.cdc.gov/mmwr/volumes/68/wr/mm6806e1.htm (2019), Rep. 157-64 Wkly. & Mortality Morbidity Causality for the Evidence Use: Assessing and the Initiation of Tobacco Promotion et al., Tobacco Joseph R. DiFranza (2006), http://pediatrics.aappublications.org/cgi/reprint/117/6/e1237 e1237 Pediatrics a U.S. Dep’t of Health And Human Services, The Health Consequences of Smoking — 50 Years of Progress: A Report A Report of Progress: Years of Smoking — 50 Consequences Health The And Human Services, of Health U.S. Dep’t https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm General (2014), of the Surgeon Use Among Youth on E-Cigarette Advisory General’s , Surgeon and Human Services of Health U.S. Dep’t Do Candy Cigarettes Do Candy Cigarettes St. Clair, Klein & Steve . Jonathan D. https://doi.org/10.1016/j.ypmed.2007.04.006 (2007), Med. 26 . http://www.bmj.com/cgi/content/full/321/7257/362 (2000), 362 Med . J. , 321 Brit. Smoke? to People Young Encourage Tobacco and Reducing of the Media in Promoting Role 19: The No. Monograph Control Tobacco Institute, National Cancer et al., C. Farrelly ; Matthew Use (2008), https://cancercontrol.cancer.gov/brp/tcrb/monographs/19/m19_complete.pdf https:// (2002), 92 Public Health Campaigns, Am. J. Countermarketing National Tobacco Evaluating the Truth: Getting to www.ncbi.nlm.nih.gov/pmc/articles/PMC1447480/pdf/0920901.pdf History of Childhood Candy Cigarette Use is Associated with Tobacco Smoking by Adults Smoking by Tobacco with Use is Associated of Childhood Candy Cigarette Klein et al., History Jonathan D. 11 8 10 12 9 13 15 14 www.publichealthlawcenter.org

COMMUNITIES

CESSATION AND MORE HELP YOUTHS for Communities, Youths, Parents, and Schools

Please visit poehealth.org for more information and resources, as well as any links you see written in this booklet. PARENTS SCHOOLS RESOURCE GRID Program/Resource Title Description Website/Phone Number The Mission of the Poe Center for Health Education is to educate and empower NC children, youth and their families to make choices that increase positive health www.poehealth.org behaviors. The Poe Center provides a number 919-231-4006 of tobacco education programs for youth and COMMUNITIES adults. Young people who are interested in health communities and prevention efforts can join Poe’s Youth Empowerment teams.

A message from the Office of the U.S. Surgeon General, https://e-cigarettes.surgeongeneral. facts on e-cigarettes gov/ The Risks: E-Cigarettes and Young People

www.heart.org The American Heart Association is committed to fighting heart disease and stroke and https://www2.heart.org/site/ raising awareness of these diseases. As part SPageServer?pagename=ahc_ of our mission, we focus on specific causes resources_ designed to help people achieve a heart-

YOUTHS vapingandecigarettesresources healthy lifestyle including tobacco prevention.

What: One-hour tobacco 101 training on the www.tobaccofreekids.org toll of tobacco Who: Youth new to tobacco prevention www.takingdowntobacco.org Why: To educate and engage youth to #BeTheFirst tobacco-free generation Go online and register to unlock Where: Meeting or class room with Take Down Tobacco training options audiovisual equipment capabilities

The Food and Drug Administration’s “The Real Cost” peer-to-peer campaigns are designed to educate at-risk youth aged 12-17 about the https://www.fda.gov/ harms of tobacco use. TobaccoProducts/ PublicHealthEducation/ See several campaigns with different target PublicEducationCampaigns/ audiences – middle school youth; rural TheRealCostCampaign/default.htm youth using smokeless tobacco; electronic

PARENTS cigarettes; LGBT youth (This Free Life - see https://therealcost.betobaccofree. below) hhs.gov/?g=t – interactive youth site See videos on YouTube: https://www.youtube.com/user/ KnowTheRealCost/videos?disable_polymer=1

Fresh Empire promotes a tobacco-free life by educating youth through Hip Hop-inspired events, videos and contests. The public https://freshempire.betobaccofree. education campaign is designed to prevent hhs.gov and reduce tobacco use among at-risk multicultural youth ages 12-17.

Dedicated to defending teens from tobacco companies lies and deceptions. “truth” produces television and digital content to en- https://www.thetruth.com courage teens to reject tobacco and to unite

SCHOOLS against the tobacco industry. Requires flash plugin. RESOURCE GRID COMMUNITIES Program/Resource Title Description Website/Phone Number National Institute on Drug Abuse for Teens – click on drug facts and then “tobacco, nicotine & e-cigarettes”; see infographic https://teens.drugabuse.gov/ on teens and e-cigarettes https://teens.drugabuse.gov/drug-facts/ tobacco-nicotine-e-cigarettes

See a variety of tools and tips ranging from smokefree texting to quitSTART App designed to help teens who are trying to quit. https://teen.smokefree.gov/ Sponsored by National Cancer Institute – part of the Smokefree.gov series Truth Tobacco Industry Documents -Provides permanent access to tobacco industry internal corporate documents produced https://www. TRUTH Tobacco Industry during litigation between US States and the industrydocumentslibrary.ucsf.edu/

Documents seven major tobacco industry organizations YOUTHS tobacco/ and other sources. These internal documents give a view into the workings of the Tobacco Industry

NC laws provide limited immunity from prosecution if a person seeks medical assistance for individual experiencing www.safetocall.org/NC an alcohol or drug related emergency by contacting 911, law enforcement or emergency medical personnel.

CRISIS LINE If you are in crisis or would like to speak to someone immediately, please call or text: 919-231-4525 or 877-235-4525

919-231-4525 or 877-235-4525 PARENTS FDA is aware of explosion events and is collecting data to help address this problem. Please report a vape explosion, or any other unexpected health or safety issue with a vape, to the FDA through the Safety Reporting www.safetyreporting.hhs.gov Portal. When you fill out the form, please be sure to include: www.fda.org

Other information about e-cigarettes and tobacco www.fda.org

Dedicated to defending teens from tobacco companies lies and deceptions. “truth” produces television and digital content to en- www.quitlinenc.com courage teens to reject tobacco and to unite SCHOOLS against the tobacco industry. Requires flash plugin. QUITLINE COMMUNITIES

YOUTHS . PARENTS N.C. Tobacco Use Quitline Talk with an expert Quit Coach 1-800-784-8669

24 hours a day, 7 days a week Quit Coaching available in many languages. All calls are free and confidential. TTY 1-877-777-6534

Call us. You can quit. SCHOOLS We can help. COMMON MYTHS COMMUNITIES

Many teens have dangerous misperceptions that lead them to believe that vaping is harmless.

“It’s just Common myths water But believed about vaping, along with the facts. vapor.” it’s not. Vaping can expose the user’s “It’s just lungs to harmful chemicals YOUTHS Vapes get their flavors from chemicals. While these like formaldehyde, diacetyl flavoring.” flavorings are safe to eat in food, they’re not safe to and acrolein, as well as toxic inhale. Inhaling flavor chemicals can harm your lungs.11 metal particles like nickel, tin and lead.4,8-10,11-13 Want an example? Some buttery-flavored vapes like caramel contain diacetyl and acetoin. Inhaling diacetyl has been linked to popcorn lung, a lung disease that doesn’t have a cure.11 “I don’t have an addictive personality —I won’t get hooked “My vape says Vaping delivers nicotine on vapes.” Some vapes that to the brain in as little claim they are it’s nicotine-free. as 10 seconds.14,15 nicotine-free are There’s no way not.8,17-22 I’ll become A teen’s brain is still developing, making it more vulnerable to nicotine addiction.16 addicted.” PARENTS

Nicotine exposure during “Just because Research “Nicotine the teen years can disrupt I vape doesn’t mean shows teens normal brain development. It who vape are isn’t that bad can have long-lasting effects, I’m going to smoke more likely to for me.” like increased impulsivity and cigarettes.” try smoking mood disorders.23-25 cigarettes.26

FDA’s FDA is committed to protecting youth from Share This Information the dangers of e-cigarettes. In addition to Efforts to our national peer-to-peer public education Please share this infographic with other teachers and campaign called “The Real Cost,” we’re school administrators. In addition, if you’d like to learn Curb Youth joining forces with Scholastic to provide more about e-cigarettes, check out these resources: teachers and school administrators with E-Cigarette » Surgeon General Fact Sheet – E-cigarette use among the resources they need to educate their youth and young adults Use students about e-cigarettes. » Parent Tip Sheet – How parents can talk with their SCHOOLS teen about vaping Together, we’ve created a free lesson plan and » CDC Infographic – E-cigarette ads and youth infographics research activity for teachers to educate their students on the health risks of e-cigarette use. Please visit the » Smokefree Teen – If you know a teen who is addicted to Scholastic youth-vaping-risks site to access these resources. any tobacco product, including cigarettes and e-cigarettes, there are resources to help them quit NOTES ______NOTES ______

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