Let’s Talk About Youth

Thanks to Sarah Jakes, a short two-page document from ASH Scotland found its way into my twitter timeline. As you can probably tell from the title of this post, it’s all about youth and e-cigs. I had a read. I had another read. I had a third read. They also have a short blog post on the subject. I read that too. Then I read it again.

There isn’t really much to the document in itself, page one is primarily background stuff, while page two gets to the heart of the matter. Or at least tries to. It is a masterclass in fence-sitting.

Now I have written about youth and e-cigs before and my position on the matter hasn’t really changed that much, if at all. But it did set me thinking about it again.

The first point is that while we don’t know everything about e-cigarettes and vaping, we do know enough to be getting on with. Organisations working with young people can and should be developing a response.

From the blog post, this snippet caught my attention. We do know enough to be getting on with. This isn’t just about the science of e-cigs, it’s about the people using them too, how and why they use them. Andy Morrison has been working with ASH Scotland – it’s not been easy for him in the slightest, but he has made significant progress and this latest publication highlights that his hard work is beneficial.

More from the blog:

Electronic cigarettes are neither safe nor harmless – but they are much less harmful than tobacco cigarettes, as well as being less expensive and less addictive. So while we do not welcome general use of e-cigs amongst young people, it is better for anyone using tobacco to move to using an e-cig instead.

This is where their opinion and my own differ greatly. As I’ve mentioned before, I have no problem with u18’s vaping if that is their choice. The bigger question here is are they using nicotine? To be fair, I have no real problem if they do choose to use nicotine, although there is still a lot of question marks surrounding the potential for dependency. I suspect, that outside of processed tobacco, nicotine by itself is not that dependency building. Most of the science surrounding nicotine has of course only really been done in the context of smoking.

On the whole electronic cigarettes reduce harm if young people vape when they would otherwise have smoked tobacco. They are problematic if they result in more young people using nicotine, who then go on to use tobacco.

I wondered if they would include mention of potential “gateway” theories, and I’m sadly not disappointed. Thus far in the UK, there is scant evidence to support the claim that vaping is a gateway to smoking – that doesn’t of course mean that it won’t happen, but the odds of it actually happening are tiny. But it does highlight the concern, and it is a concern, about the risk of youths becoming dependent on nicotine.

Taking a look at the “short e-cig guide for youth services” document, there are some plus points, some “meh” points and some negative points. For this part of the post, I asked Tom Pruen (blue), Sarah Jakes (red) and Lorien Jollye (purple) for their thoughts – remember these are individual opinions and thoughts. Starting with Tom.

Some of the highlights:

  • E-cigs are not tobacco products, and should be regulated and treated differently
  • Safer
  • Displacement of smoking behaviour, not just quitting- “young people vape when they would otherwise have smoked, or if they help young people stop using tobacco”
  • Points out that despite experimental vaping, smoking rates continue to fall
  • Warning about over-regulation
  • Extended advertising ban (inappropriate audience)
  • Discourage use in general – but alongside “making it clear to those already using tobacco that e-cig use brings less harm, financial cost and risk of addiction”
  • Despite outdoor use, these should be “separate to, and less restricted than, any areas where smoking is allowed”

The lowlights:

  • Smoking as addictive as heroin
  • Despite warning of over-regulation, vaping policy should be ‘coherent’ with tobacco policy – which suggests a total ban
  • Outdoor use
  • No guidance on how to ‘discourage’ – might encourage an overly heavy-handed approach

The “meh” (indifferent or irrelevant)

  • Gateway presented in an odd way “They can be problematic if they result in more young people using nicotine, who then go on to use tobacco.” Suggests a clear link between nicotine use and smoking – which is unproven (but obviously a legitimate concern)
  • Prospect of a medicinal ecig (which has no realistic prospect of appeal to target audience)

From the first page alone, in my view, there is significant emphasis on regulating e-cigs differently to tobacco – which I believe we can all agree on. To an extent anyway. From my point of view, regulation flows from implementing standards and not the other way around. The existing BSI PAS is in response to the TPD and is a classic case of trying to put something in place when there is already very little (if any) wiggle room.

I don’t know any smoker that “regrets” ever having started smoking, and while yes there is an increased chance of being diagnosed with – what public health refer to as – “smoking related diseases”, non-smokers and never smokers are also affected by them, despite the bans and legislation in place. On that point, the UK has had an age-restriction on sale of tobacco for years and yet there is still a portion of under 18s that smoke. Having legislation is fine and dandy, as long as it is enforced. The trouble is, enforcement is sorely lacking – and not just in the UK with regards to age-restricted sale.

In Scotland new legislation will come into force in late 2016/early 2017 making it illegal to sell e-cigarettes to under-18s, or to buy e-cigarettes on their behalf. It will not be illegal for a young person to possess, use or try to buy e-cigarettes.

The fact of the matter here is that the legislation referenced, is one that ASH Scotland wanted. From my point of view, it is fundamentally wrong. They have, at a stroke denied access to a harm reduction product and a viable choice to under-age smokers. I suspect that this guidance document is a way of backtracking on that legislation demand slightly while still maintaining it is a good thing – a masterclass in fence-sitting.

While it is illegal to smoke tobacco in an enclosed public space, there are no such restrictions on using e-cigarettes and this remains at the discretion of individual premises. Many have chosen to restrict use of e-cigarettes in enclosed public spaces to ease communication and enforcement of their smoke-free policy.

I found this section of the guidance document particularly illuminating – especially as it refers to, in part at least, a discussion held on VTTV recently and a recent post – especially the discretion of individual premises comment. How do those premises view vapers?

Moving on to the section in the guidance document entitled Developing a policy response for youth settings, the very first line raise alarm bells for me:

In order to support their role as health educators and positive life choice influencers for young people, youth organisations should go beyond basic legal requirements

Now that there are legal requirements, they want to go further. Wonderful. Of course it is difficult to put together guidance on this particular topic – and it is one that will continue to rage on for a very long time, it’ll also be incredibly difficult to “get it right” – while this may be a start, it isn’t necessarily the best of starts. There’s some good, some bad and some “meh” in this document – Tom and I agree on the majority of those.

However, statements such as:

At the same time, and recognising the far greater harm arising from tobacco use, staff should take opportunities to provide good information to help young people build their understanding of electronic cigarettes, and to engage young people in discussions on tobacco and health more widely – making it clear to those already using tobacco that e-cig use brings less harm, financial cost and risk of addiction.

Aren’t at all helpful. The key issue I have with this one is what kind of information are they going to provide? This is where information from NICE, NCSCT, PHE and RCP would be the most beneficial. Clear, simple documentation either as short infographics, or some kind of presentation – the key thing would be to make it easy to digest for the intended audience. In order to do that, first they need to understand two key things – the audience themselves, get them engaged and asking questions. Secondly, and this relates specifically to the smoking youth – understand why they smoke.

Then there’s this:

With regards to use by staff or young people over 18, youth services may wish to enhance the appeal of e-cigarettes as an alternative to smoking by allowing their use in discrete outdoor areas which are separate to, and less restricted than, any areas where smoking is allowed.

If they really want to “enhance the appeal” of e-cigarettes as an alternative to smoking, why not allow their use inside as well as outside? A suitable indoor location for instance – especially if they agree that the devices are not covered by the smoke-free legislation.

As you have probably figured out from various posts on my blog, I am more liberal in my views on youth and e-cigs, while there are concerns surrounding this topic, the data from the UK by and large doesn’t lead toward youth and e-cigs being that much of a problem. If there is one thing I learned as a teenager is that if something was not allowed I wanted to go ahead and do it anyway, that’s just part and parcel of growing up in my view. True things are significantly different now than they were 20 years ago, but look at what was prevalent 20 years ago – smoking. It was accepted by society. Smokers were by and large were also accepted. Unspoken rules governed where and when folk could light up. Vaping is a long way from being at that point, but drafting guidance like this isn’t really going to help the overall acceptance of vaping – because it still imposes limitations, and leaves scope to impose more.

Is there an ideal solution? Not really no. We know that genuine uptake of youth vaping in the UK is minimal, and generally restricted to smoking youths. This would therefore suggest that vaping isn’t at all attractive to non-smoking youths. It is likely that this may not always be the case, especially if vaping in general reaches the same level of acceptance that smoking once did – even if it did, I find it unlikely that youths will take to vaping as the youths of yesteryear took to smoking.

It is however, long past time that youth services are allowed to present the relevant information (correct and factual) about vaping, without all the ludicrous headlines getting in the way. Engagement is key, talk to the youths – not at them.

The whole thing reads to me like a) it was written by an anti & a reasonable stepped in or b) the exact opposite.

Given that some of the youth links they are talking about are considered vulnerable & most at risk of smoking then the idea of requesting that staff hide their vaping & discourage vaping in those groups makes me really uncomfortable. They are the very teens that will not respond to bullying & negative messaging re smoking & are likely to go in the exact opposite direction. As such they are the ones that need most exposure & the most frank conversation about relative harms.

There is a fine line between accepting & passively encouraging a behaviour & actively encouraging it. To me this document reads like actively discouraging.

On the other hand, I think it’s outstanding that this actually exists. There seems to be a wider move to actually acknowledge the place of vaping in teens beyond just experimentation.

Maybe I’m being impatient but the way this is written just frustrates me because it’s so close & yet that little bit of distance to perfect could actually be damaging. Which is what makes me think the person who edited it had a very different position to the person that wrote it.

Not many people would disagree that young people initiating smoking is not a good thing. When it comes to vaping, the concern among many in public health is that vaping will lead to nicotine dependency, which in turn could lead to smoking for young people who would not otherwise have smoked.

So far in the UK this does not appear to be happening. Young people who vape appear to be almost completely confined to those who smoke. However, it is almost certain that this will not always be the case. At some point we will see never smoking young people initiate nicotine use through vaping, and whilst most of them could be expected to be people who were likely to start smoking, some of them would never have done so.

The difficulty for policy makers is how do we ensure that young smokers and those who would take up smoking are aware of, and can obtain, safer nicotine delivery methods whilst avoiding uptake by those who would never have smoked? This is an impossible question to answer, not least because accurately defining, let alone separating the two groups is also pretty much impossible. The ideal solution simply doesn’t exist.

Much of the above relies on the assumptions that a) young people are using liquid which contains nicotine, b) that vaped nicotine is addictive, c) that being dependant on nicotine will eventually lead to smoking or that d) being dependant on nicotine is in itself a ‘bad thing’.

A recent large-scale US study showed that 60% (Monitoring The Future survey) of young people did not use nicotine containing liquid when they vaped. It is likely (but we do not have sufficient data) that vaping carries a much lower risk of dependency on nicotine for never smokers than smoking tobacco. If vapour products were freely available it is difficult to see why young people would progress from vaping to smoking, given that vaping is cheaper and less harmful. That leaves us with the ‘bad thing’.

Assuming that there is a significant risk of becoming dependant on nicotine for never smokers via vaping there are two issues to balance against the benefits of vaping on a population level. Possible harm to developing brains, and the social and other costs of dependency itself. A study released today has estimated that despite these concerns the net benefit to public health of vapour products being available will be to cut smoking related deaths by 21%. Other studies have shown firstly that youth smoking is continuing to decline, but that the decline is slowed in areas where there are restrictions on youth purchasing of e-cigarettes.

So it seems that a blanket policy which bans the sale of harm reduced products to young people is not the optimal solution, and those working with young people should avoid discouraging the use of vapour products by those who do, or would otherwise smoke. It’s a difficult line to tread and I applaud ASH Scotland for their attempt to do so, even if I don’t completely agree with their position.

Finally, my thanks to Tom Pruen, Lorien Jollye and Sarah Jakes for taking the time to outline their thoughts on this, and surprisingly I find myself in partial agreement with all three.

As always, I’d be delighted to hear your thoughts in the comments. Do you think ASH Scotland have it right or wrong? Could (or specifically should) they do more? Or should they leave well enough alone?

(Image credit Dawn Gilfillan/shutterstock.com)

  • EKeller

    I believe Sarah Jakes hit the nail on the head in her discussion of assumptions about nicotine. We know from the Monitoring the Future survey that assumption a) (at least in the U.S.) is false. Liquids containing nicotine are mostly used by youth who already smoke, or presumably by youth who would have smoked instead of vaping. As for assumption b), smoking may well be “addictive” (if we can ever come up with a reasonable definition of that adjective), probably due to additional chemicals not found in vapor such as MAO inhibitors and/or minor tobacco alkaloids that have an effect on cognition. But the evidence on nicotine per se being addictive is weak. If it were so, then how do we explain the fact that when non-smokers are provided with nicotine from pharmaceutical sources (e.g., the patch, nicotine gum), they do not suffer withdrawal when the nicotine is stopped. These clinical trials of nicotine, by the way, were to test whether the beneficial effects of nicotine could help people suffering from memory problems, attention deficits, and Parkinsons, to name a few. And nicotine did help. But only mildly, presumably because of lacking the additional help of the MAO inhibitors and minor tobacco alkaloids. So if word ever got out that there were possible additional benefits to tobacco use, it is possible that assumption c) could come true — vapers might proceed to smoking. But on the other hand, if that word got out, it might also get out that these additional chemicals can be obtained from use of smokeless tobacco products, without necessitating exposure to the hazardous properties of smoke. [ASIDE: The ANTZ have told so many lies about the health hazards of smokeless tobacco products, that this alternative would have a long way to go.] Nicotine itself has scientifically verified positive effects on both mood (relief from depression and anxiety) and cognition (ability to concentrate, pay attention, and retrieve memories.) And, on the other hand, there are very few negative effects. People on nicotine are not prone to the negative behaviors seen in those using alcohol and psychoactive drugs such as heroin, cocaine, and methamphetamine. So this begs the question of whether assumption d) is true–whether dependence on nicotine is such a bad thing. Maybe the strength of the dependence on nicotine is directly related to an individual’s need for the beneficial effects. If your mood and cognition are both fine without nicotine, maybe it just isn’t all that attractive to you. And if the need for those beneficial effects is the driver, why would we begrudge someone the ability to pay attention, remember what they need to, and avoid depression and anxiety? No, no. You must not enjoy those benefits because nicotine is bad for you. [NOTE: The opinions expressed here are my personal opinions, based on years of library research trying to figure out why going without nicotine makes me so very, very ill. They do not necessarily reflect the opinions or policies of any organization that I am, or have been, associated with.]

    • Indeed. Though, as a side note, many studies into the “addictiveness” of nicotine (a fact which I don’t subscribe to btw) have primarily been in conjunction with tobacco – i.e. cigarettes – and not into nicotine on its own.

      Fortune has it that I have (thanks to Tom Pruen) some papers that look at nicotine on its own – this one in particular looks at “pure” nicotine along with nicotine + MAO -http://www.ncbi.nlm.nih.gov/pubmed/19366487 – which I found most illuminating. Sadly, as previously noted, direct nicotine research is few and far between.