The Role of the School Nurse in Creating a Vape- Free School - Kansas ...

The Role of the School Nurse in Creating a Vape- Free School - Kansas ...
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 
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
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-

E-cigarette focused curriculum
The Real Cost of Vaping school-based Free, evidence-based curriculum for 
curriculum                           Grades 6-12 developed by Scholastic
                                     and the FDA.
The University of Texas Health            Free program that uses a peer-led
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,
Prevention Toolkit                        including an Alternative-to-Suspension tobaccopreventiontoolkit.html
The American Lung Association             Free training/curriculum offers an
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
                                          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
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)
The National Cancer Institute’s           Includes information on how to quit
SmokefreeTeen                             vaping.
References                              Public Health Law Center. (2019a).      U.S. Department of Health and
                                        Flavored Products. https://www.         Human Services. (2014). The
American Academy of Pediatrics.       Health Consequences of Smoking
(2015). Clinical Practice Policy to     commercial-tobacco-control/sales-       - 50 Years of Progress: A Report of
Protect Children from Tobacco,          restrictions/flavored-products          the Surgeon General. Atlanta, GA:
Nicotine, and Tobacco Smoke.                                                    Centers for Disease Control and
https://pediatrics.aappublications.     Public Health Law Center. (2019b).      Prevention.
org/content/136/5/1008                  Student Commercial Tobacco Use
                                        in Schools: Alternative Measures.       U.S. Department of Health
Centers for Disease Control and         https://www.publichealthlawcenter.      and Human Services. (2016).
Prevention. (2019a). Quick Facts        org/sites/default/files/resources/      E-cigarette Use Among Youth
on the Risks of E-cigarettes for        Addressing-Student-Commercial-          and Young Adults: A Report of the
Young People. https://www.cdc.          Tobacco-Use-in-Schools-                 Surgeon General. Rockville, MD:
gov/tobacco/basic_information/e-        Alternative-Measures-2019.pdf           Centers for Disease Control and
cigarettes/Quick-Facts-on-the-                                                  Prevention.
Risks-of-E-cigarettes-for-Kids-         Sharpless, N. (2019). How FDA
Teens-and-Young-Adults.html             is Regulating E-cigarettes. https://    U.S. Department of Health and
                                          Human Services. (2018). Surgeon
Centers for Disease Control and         voices-perspectives-fda-leadership-     General’s Advisory on E-cigarette
Prevention. (2019b). Outbreak of        and-experts/how-fda-regulating-e-       Use Among Youth. https://www.cdc.
Lung Injury Associated with the Use     cigarettes                              gov/tobacco/basic_information/e-
of E-cigarette, or Vaping, Products.                                            cigarettes/surgeon-general-      Trump, D. J., Azar, A., & Sharpless,    advisory/index.html
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lung-disease.html                       Trump in Meeting on E-cigarettes.       U.S. Department of Health and
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NOW and the National Network                                                    html
of Tobacco Cessation Quitlines.         Truth Initiative. (2018). 4 Marketing            Tactics E-cigarette Companies           U.S. Food and Drug Administration.
quit_smoking/cessation/pdfs/faq_        Use to Target Youth. https://           (2020). Newly Signed Legislation
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Cullen, K. A., Gentzke, A. S.,          marketing/4-marketing-tactics-e-        to 21.
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