Since funding for North Carolina's teen smoking cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes.
Since funding for North Carolina's teen smoking cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes. Photo courtesy Nerissa's Ring, flickr creative commons

By Liz Schlemmer

The good news is that fewer kids are smoking. The bad news is that many of them are still using nicotine.

According to new surveys, as many as one in three teens is starting on nicotine without lighting up.

Since funding for North Carolina's teen smoking cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes.
Since funding for North Carolina’s teen smoking-cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes. Photo courtesy Nerissa’s Ring, flickr creative commons

Every other year, North Carolina schools administer the Youth Risk Behavior Survey designed by the Centers for Disease Control to monitor risky health behaviors among middle- and high-schoolers. In 2015, the survey included a new set of questions to gauge students’ use of electronic vapor products, or e-cigarettes, and local educators are concerned by their students’ responses.

Statewide results from the survey have yet to be released, but school health officials in Chapel Hill-Carrboro City Schools have seen their local results, which suggest e-cigarette use among high-schoolers is still on the rise.

According to the survey results, 37 percent of students in the CHCCS district surveyed had tried an electronic vapor product and 18 percent reported vaping in the last 30 days. Those numbers are substantially higher than previously recorded state averages for e-cigarette use.

The numbers are particularly surprising coming from the CHCCS school district, which has ranked well below state averages for tobacco use in recent years.

The 2013 North Carolina Youth Tobacco Survey showed 7.7 percent of high school students had used electronic cigarettes, and the most recent NC Child Health Report Card reported 24 percent of the state’s middle- and high-schoolers used an emerging tobacco product in 2014.

Meanwhile, traditional cigarette use among North Carolina teens has been on a downward trend for at least 15 years. That’s offset by rising local and statewide trends for overall teen tobacco use, including electronic cigarettes and hookahs, which are on the upswing. This is after the state saw all-time lows in tobacco use from 2009 to 2011.

For Chapel Hill-Carrboro schools, the 2015 YRBS concluded that e-cigarette use is contributing to an overall increase in nicotine use among its students. The total number of the district’s students using any tobacco product rose for high school students from 11 percent in 2013 to 21 percent in 2015.

Jim Wise, Chapel Hill High School’s student assistance specialist, said the numbers are concerning. “I was expecting it to be up, but I was definitely surprised,” Wise said.

Challenges of education on e-cigarettes

Wise said schools face challenges in educating students about the potential risks of vaping.

He said one of the biggest setbacks for health educators is a lack of evidence-based curriculum. Longitudinal studies on the health effects of vaping are lacking. The products entered American markets in 2007.

infographic reading 7 out of 10 middle and high school students who have currently used tobacco have used a flavored product
Infographic courtesy Centers for Disease Control and Prevention

Another issue for educators is that e-cigarettes are unregulated by the U.S. Food and Drug Administration. No reliable information is available on the ingredients in e-liquids, the fuel and flavor for e-cigarettes. The products’ nicotine levels are also not reliably known or advertised.

The uncertainty and lack of product information on e-cigarettes complicates the job of local health educators.

Coby Austin, senior public health educator for Orange County, manages tobacco initiatives for her county health department, including support of cessation policies and offering technical assistance to public schools.

Austin said Orange County has had to develop some its own resources regarding e-cigarettes because it is no longer connected into a network, referring to state funding diverted from the Tobacco Reality Unfiltered, or TRU, program.

The former statewide tobacco-education program was originally funded by master settlement dollars from tobacco companies. The program had its state funding eliminated in 2012, but Orange County built on the legacy of TRU to continue programming in CHCCS high schools.

When it comes to programming around e-cigarettes, Austin said, the products are so new that it’s difficult to provide teens with accurate information about the risks of vaping.

“The research is still coming out, which means all the policies and materials on that research are also still evolving,” Austin said.

The battle against marketing

Educators also have to combat marketing campaigns that suggest e-cigarettes are less harmful than traditional tobacco products.

According to Austin, e-cigarettes may provide a way to reduce the harm associated with combustion for current smokers of traditional tobacco products.

Some of the e-cigarette liquids for sale in N.C. today. Flavors from left to right: watermelon, Irish Cream and appletini.
Some of the e-cigarette liquids for sale in N.C. today. Flavors, from left to right: watermelon, Irish Cream and appletini. Photo credit: Rose Hoban

Many students appear to accept this message. At Chapel Hill High, only a third of students surveyed said electronic vapor products posed a risk and believed their friends would agree.

But the devices are not without risk.

A 2014 Surgeon General’s report concluded that the health impact of electronic nicotine device systems is “more likely to be beneficial only in an environment where the appeal, accessibility, promotion and use of cigarettes and other combusted tobacco products are being rapidly reduced.”

Critics claim e-cigarettes are largely marketed to youth, using colorful packaging and flavors ranging from mock cereals that mimic the likes of Cap’n Crunch to dessert flavors like rocky road and cherry cheesecake. The appeal of electronic gadgets might also affect young adults considering e-cigarettes.

In Wise’s opinion, e-cigarettes are deliberately not marketed to adults, and he says there is a business incentive to that.

“Very seldom do established smokers change their brand. They’re in a habit. Companies are looking for new users.” he said.

Harder for schools to regulate

Schools also must deal with students’ lack of knowledge about campus policies on e-cigarettes. Wise recalled a situation earlier in the school year in which a school administrator encountered a freshman vaping in front of the school.

“The assistant principal said, ‘You were aware you can’t have that here,’ and the student was not aware that e-cigarettes are covered under our tobacco-free school rules,” he said.

e-cigarette next to a mobile phone
E-cigarette image, courtesy Terry Ozon, flickr creative commons

In 2008, state law mandated that all North Carolina schools have a 100 percent tobacco-free policy applicable to all students, staff and visitors to school campuses and school-related events.

Superintendent of Public Instruction June St. Clair Atkinson sent a letter to all public schools in February 2014 clarifying that electronic cigarette products are included in the statewide tobacco-free mandate.

According to Wise, the policy can be difficult to enforce because parents and teachers are generally undereducated about e-cigarettes. Adults may not know how to recognize e-cigarette paraphernalia, which includes not only cigarette look-alikes but also vaping chambers that sometimes resemble pens.

New statistics in time for summer vacation

Wise said Chapel Hill High will use the information from the YRBS as soon as possible. The survey report will go before the district’s school board later in April for approval of distribution of the full report.

Summertime is a prime time for students to begin drug use or experiment with new substances, and Wise said he hopes to send out information about the most recent survey to staff and students before vacation. He also said he looks forward to the day when more developed curriculum is available to address teen e-cigarette use.

“We continue to believe that good information is going to lead to better choices,” Wise said.

“Kids are good at consuming good information. Any time we can attach evidence-based and clinical information, most of them absorb that information and hold on to that.”

Author Elizabeth Schlemmer is in the master’s program at the UNC School of Media and Journalism.

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