The Role of the School Nurse in Creating a Vape- Free School - Kansas ...
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The Role of the School Nurse in Creating a Vape- Free School As published in NASN School Nurse, May 2020 Lisa Frey Blume, BA Shannon Lines, MPH Electronic, or “e”-cigarette use has been adopted by an alarming number of teens in recent years. T obacco prevention and control advocacy and shifting societal norms have significantly reduced epidemic has been challenging for the public health community and educational institutions because E-cigarettes are neither legal youth cigarette use over the past of the constantly evolving stream for youth nor considered safe 20 years. However, electronic of information and lack of specific for use by youth. E-cigarette cigarette (e-cigarette) use has youth vaping prevention resources. companies have targeted youth increased rapidly among youth. Although all school personnel have in their marketing strategies and In the United States in 2019, a role, the school nurse has unique developed appealing flavors with more than one in four high school expertise within school settings to high nicotine content to ensure students (27.5%) and one in ten help combat this challenging public dependence on their products. (10.5%) middle school students health issue. The role that school Schools lack adequate resources reported current use of e-cigarettes, nurses play in addressing youth and capacity to address e-cigarette compared to 11.7% and 3.3% in vaping relates directly to the skills use, relying mostly on punitive 2017 (Cullen et al., 2019; Wang outlined in the key principles of the sanctions for what is essentially et al., 2018). From 2017 to 2018, Framework for 21st Century School a health issue. School nurses the prevalence among high school Nursing Practice. can help their districts and students increased 78%. This E-cigarettes, also known as schools by navigating appropriate shocking increase prompted the vapes, have a variety of names, consequences for vaping, providing U.S. Surgeon General, Jerome shapes and sizes. Juul, a brand accurate information and education, Adams, to issue an advisory in widely used by youth in recent providing cessation resources, December 2018 to inform the years and with a considerable share advocating for student support, public of the risks of e-cigarettes of the e-cigarette market, resembles and informing stakeholders on and declare youth vaping to be a USB flash drive. These types population health strategies to an epidemic (U.S. Department of e-cigarettes are rechargeable prevent initiation and reduce youth of Health and Human Services, and have a disposable pod that e-cigarette use. [USDHHS], 2018). Addressing this snaps into an atomizer, creating an
aerosol. They are small, produce Nearly 90% of smokers (FDA) banned flavored tobacco in limited exhaled aerosol, and begin smoking before the age conventional cigarettes in 2009. generally have either no odor or a of 18 (USDHHS, 2012). Youth However, menthol was exempt as pleasant smell, making them easier exposure to conventional cigarette were flavored non-cigarette tobacco to conceal and use frequently advertising causes the initiation products such as e-cigarettes without detection (Truth Initiative, and continuation of smoking (Public Health Law Center, 2019a). 2019). The aerosol (not ‘water among youth (USDHHS, 2014). Many localities have taken matters vapor’) produced by e-cigarettes Similarly, researchers are finding into their own hands in the wake almost always contains nicotine, that youth who are exposed to more of the EVALI outbreak. Various flavorings and other chemicals. e-cigarette marketing are more jurisdictions have implemented Vaping devices can also be used to likely to use the product than youth e-cigarette flavor bans in an effort to inhale marijuana and other drugs. who are not exposed to e-cigarette reduce the availability and appeal of The Centers for Disease Control marketing (USDHHS, 2019). Unlike vape products to youth. and Prevention (CDC, 2019a) conventional cigarettes, vape E-cigarette companies have states that “the use of e-cigarettes products do not have many federal developed innovative ways of is unsafe for kids, teens and young regulations on their advertisement. delivering nicotine to users. Juul’s adults” (para. 1). According to USDHHS (2019): addictive formula uses nicotine E-cigarettes received increased In 2018, more than 5 in 10 salts, allowing its high level of national attention because of the middle school and high school nicotine to be inhaled more E-cigarette, or Vaping, product use students – more than 14 million efficiently and with less irritation Associated Lung Injury (EVALI) youth – said they had seen than the free-base nicotine used in outbreak first documented in March e-cigarette advertising. Retail stores most other e-cigarettes and tobacco 2019. This outbreak progressed to were the most frequent source products. Even more alarming is over 2,500 hospitalized cases in all of this advertising, followed by that many students and parents do 50 states, the District of Columbia, the internet, TV and movies, and not know that Juul always contains Puerto Rico, and the U.S. Virgin magazines and newspapers (para. nicotine. According to Juul Labs, Islands by December 27, 2019. 6). each 5% pod is manufactured Among the 2,159 hospitalized E-cigarette brands use the to contain the same amount of patients with data on age (as of same marketing techniques as nicotine as a pack of conventional December 3, 2019), 16% of patients conventional cigarette advertising cigarettes or 200 puffs (Truth are under 18 years old, and 78% did in its heyday: sexual imagery, Initiative, 2019). It is the nicotine of patients are under 35 years old. implied harm reduction claims that keeps youth dependent on There is a median age of 24 years and customer satisfaction vape products even when they with ages ranging from 13 to 77 (USDHHS, 2016). E-cigarette face multiple consequences or years. In addition to these cases, companies, experiencing increasing punishments. Lastly, it is important 55 deaths are confirmed in 27 investments from the traditional to note that nicotine is harmful to states and the District of Columbia global tobacco companies, employ the developing brain. Nicotine can as of December 27, 2019 (CDC, extensive use of social media, impact attention, learning, memory, 2019b). Parents, school staff, and sponsor music festivals and related and other cognitive functions as teens themselves have become events, and even provide student the brain continues to develop into more aware that vaping is a risky scholarships (Truth Initiative, 2018). young adulthood (USDHHS, 2016). behavior because of this media These marketing practices have FDA was granted regulatory attention. been criticized in recent months authority over all deemed tobacco Many ask, how did we get and the most obvious ones have products in 2016, including back to this point of youth tobacco disappeared. Juul and its imitators e-cigarettes, but there are currently use? Although there are several have found success focusing on no enforced regulations on contributing factors, the short product design and packaging e-cigarettes. FDA has stated that answer is marketing, appealing that appeals to the youth market all tobacco products authorized flavors, and the creation of a (USDHHS, 2019). for the market will only receive more efficient vehicle for nicotine Most notably, vape approval after undergoing thorough addiction. manufacturers have marketed scientific review (Sharpless, 2019). candy, fruity, and similarly appealing In September 2019, the Secretary The Ingredients to flavors to youth (USDHHS 2019). of Health and Human Services, Flavoring in products can mask Secretary Alex Azar, announced the Vaping Epidemic: inhalation harshness and make that FDA would finalize a guidance Marketing, Flavors and the vapor seem less harmful. The document to ban all flavors, other Nicotine Food and Drug Administration than natural tobacco flavor (Trump,
Azar, & Sharpless, 2019). In these types of violations. As the for young people who want to December 2019, federal legislation school’s health professional, nurses quit tobacco and vaping have was signed raising the federal have an opportunity to educate not been established by medical minimum age of sale of tobacco administrators that addiction is a professionals because there has products from 18 to 21 years. It complex disease and compulsion not been sufficient study. The is now illegal for a retailer to sell to use a substance is not a willful American Academy of Pediatrics any tobacco product, including defiance of school rules. If a student (2015) strongly recommends cigarettes, cigars and e-cigarettes, is dependent on nicotine or another tobacco dependence treatment in to anyone under 21 years (U.S. substance, they need treatment the form of behavioral counseling, Food and Drug Administration, interventions, not further isolation including quitline referral (para. 2020). Upon implementation, these with the increased opportunity to 3) for adolescents who want to regulations could potentially limit engage in unhealthy behaviors stop using tobacco. The school the number of vape products and (Public Health Law Center, 2019b). nurse can ensure that whoever is flavors sold in the U.S. in the future. This is in line with schools shifting dealing with student violations has to whole child approaches and the state’s quitline materials and How Do School Nurses trauma-informed schools. information about locally available Vaping is a long-term issue counseling options. It is best to Contribute to a Vape- which will not be solved by a contact local organizations first to Free School? one-time presentation. The school ask if they have the capacity for nurse should deliver, or coordinate potential school referrals. There are There is no doubt that schools vape education to staff and parents emerging no-cost programs for text- have been burdened by the on a regular basis. This practice based cessation help as well (Table e-cigarette epidemic. Many districts is essential in elementary and 1). Cessation referrals should also have strengthened their tobacco middle schools when most kids be made for parents and staff who policies to include e-cigarettes and start experimenting and should use tobacco products and want to expanded policies to encompass not be limited to just high schools. quit. all school grounds and school- In addition, nurses can participate School culture is strengthened sponsored events. School in reviewing current curriculum by students developing positive districts are also examining their content about alcohol, tobacco social norms. If students perceive policies for addressing violations. and other drugs and determine that most of their peers do not use Appropriate violation procedures what updates need to be made. tobacco or vape, then they are should include product confiscation, Many expensive vaping curricula less likely to initiate tobacco use parent notification, information are currently being marketed to (USDHHS, 2012). School nurses for parents and students (Public schools, but credible free resources can encourage coaches and other Health Law Center, 2019b), and are also available. Curriculum sets influential school personnel to at the very least, a referral to the should always be evidence-based. discuss the harms of tobacco and state quitline, 1-800-QUIT-NOW. Table 1 lists vaping prevention and vaping with teams and classes. Quitlines are telephone and web- cessation resources for schools to Nurses can also sponsor or support based counseling services available consider. clubs and peer leadership programs for free to U.S. residents who are As the school administration that seek to raise awareness trying to quit using tobacco products considers internal procedures for around the dangers of tobacco (CDC, n.d.). All state quitlines offer addressing policy violations, the and substance use and work to specific services for youth. school nurse should advocate change school norms. The majority School districts often have for screening, brief intervention, of students do not use tobacco existing alcohol, tobacco, and and treatment referral as an products and often welcome other drug policies which have evidence-based practice to support in resisting target marketing suspension, expulsion and referral identify, reduce and prevent and daily peer pressure. to law enforcement as disciplinary student e-cigarette and other Finally, all school staff, including measures. There is evidence substance use (National Research school nurses, can advocate for that these punitive measures Council, 2001). If possible, state initiatives and local policies are applied disproportionately to students who have violated the that have been shown to prevent minority students and have long- tobacco or other substance use and reduce youth tobacco use. term negative consequences policies should be referred to the These include increasing taxation (Public Health Law Center, school nurse or another licensed on tobacco products, prohibiting 2019b). The school nurse can professional within the school smoking in public places, and exercise leadership by advocating who has training in motivational enforcing the minimum age of sale for non-punitive procedures for interviewing. Treatment guidelines for tobacco products to 21 years
Figure 1. Roles of the School Nurse in a Vape-Free School (National Academies of Sciences, targeted youth in their marketing Engineering, and Medicine, 2015; strategies and developed appealing Lisa Frey Blume, BA USDHHS, 2012). Often, someone flavors with high nicotine content Training and Outreach from the district is a member of a to ensure dependence on their Coordinator local health coalition which can be products. Schools are concerned KDHE, Wichita, KS consulted on local policy initiatives. but overwhelmed, and many rely Lisa has provided training and In addition, the district’s federally on excessive punishment for assistance to substance abuse mandated student wellness what is a health issue. School prevention coalitions and grantees committee may be a source of nurses can help their districts and for 7 years. Before moving to information. schools by navigating appropriate Kansas and entering the public consequences for vaping, providing health field, she was a teacher. Conclusion accurate information and health education, providing cessation We all have a part to play in resources, advocating for student Shannon Lines, MPH curbing the youth e-cigarette support, and educating others Advanced Epidemiologist epidemic and it will not happen with about population health strategies KDHE, Topeka, KS public health outcry or legislation to prevent initiation and reduce Shannon has been a tobacco and alone. Schools, and especially youth tobacco use. ● physical activity and nutrition school nurses, are integral to epidemiologist for more than 2 reversing the alarming increases Acknowledgements years in Kansas. in overall youth tobacco use. As the licensed health professional The authors wish to thank in the school setting, school Kansas Department of Health Frey Blume, L & Lines, S. The Role nurses can provide the leadership and Environment staff for their of the School Nurse in Creating a that is needed to create a vape- help in preparation of this article, Vape-Free School. NASN School free school. See Figure 1 for an and NASN School Nurse for their Nurse, vol. 35, no. 3. May 2020, pp. overview of the outlined leadership interest in sharing this information. 166–172. © 2020 The Author(s). roles. DOI: 10.1177/1942602X20913261 E-cigarette companies have
Table 1. Vaping Prevention and Cessation Resources for Schools CDC Office on Smoking and Health (CDC/OSH) e-cigarette resources E-Cigarettes: Talk to Youth About the Evidence based messaging about https://www.cdc.gov/tobacco/features/ Risks e-cigarettes. Includes a presentation back-to-school/e-cigarettes-talk-to- for youth. youth-about-risks/index.html Quick Facts on the Risks of Includes resources for learning more https://www.cdc.gov/tobacco/basic_ E-cigarettes for Kids, Teens, and about the youth vaping epidemic, information/e-cigarettes/Quick-Facts- Young Adults including a toolkit for partners. on-the-Risks-of-E-cigarettes-for-Kids- Teens-and-Young-Adults.html E-cigarette focused curriculum The Real Cost of Vaping school-based Free, evidence-based curriculum for www.scholastic.com/youthvapingrisks curriculum Grades 6-12 developed by Scholastic and the FDA. The University of Texas Health Free program that uses a peer-led https://catchinfo.org/ Science Center at Houston Catch My teaching approach for ages 10-18 Breath Youth E-Cigarette and JUUL and meets National and State Health Prevention Program Education Standards. The Stanford Medical School Tobacco Free, evidence-based resources, https://med.stanford.edu/ Prevention Toolkit including an Alternative-to-Suspension tobaccopreventiontoolkit.html Curriculum. The American Lung Association Free training/curriculum offers an https://www.lung.org/stop-smoking/ INDEPTH™: Intervention for Nicotine alternative to suspension or citation helping-teens-quit/indepth.html Dependence: Education, Prevention, for infractions of school tobacco-free Tobacco and Health policies. Tobacco-free school policy The Public Health Law Center Model policies and other resources https://www.publichealthlawcenter.org/ on addressing student commercial tobacco use as part of school tobacco- Student Commercial Tobacco Use in free policies. Schools: Alternative Measures Commercial Tobacco-Free K-12 School Model Policy Kansas Department of Health & Contains information and resources http://www.kdheks.gov/tobacco/ Environment to help schools effectively implement, download/Vape_Free_Schools_ clearly communicate, regularly enforce Toolkit.pdf Kansas Vape-Free Schools Toolkit and support a tobacco-free and e-cigarette-free campus. E-cigarette cessation for youth State Tobacco Quitline All states have free, evidence-based Call this number to connect directly to quitlines with trained counselors. your state’s quitline. Hours of operation and services vary from state to state. 1-800-QUIT-NOW (1-800-784-8669) The Truth Initiative “This is Quitting” A youth/young-adult focused Youth and young adults can access E-cigarette Quit Program that uses the e-cigarette quit program by texting text messaging. "DITCHJUUL" to 88709. Parents and other adults looking to help young people quit should text "QUIT" to (202) 899-7550. https://truthinitiative.org/thisisquitting The National Cancer Institute’s Includes information on how to quit https://teen.smokefree.gov/quit-vaping SmokefreeTeen vaping.
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