The future of substance abuse in youth

0:00This is Stanford Engineering's The Future of Everything, and I'm your host Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics. Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. and it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody.

0:37In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here and that you'll share it with your friends, family, neighbors, co-workers as well. I don't think we're exaggerating the mental health issues. If anything, we are underplaying those right now and really not working with young people. I see a lot of, not parents directly or educators directly, but just society who's sort of blaming and shaming young people. Why are you depressed? Why are you on drugs? Things like that. If you step back and think about how the last few years have been, it's been really challenging.

1:12And so we really need to support young people and realize that the mental health crisis is real.

1:24This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. We're about to have a great show, and I want to encourage you that if during this show, someone you think of or somebody pops into your head, that's your cue to tell them about the show. Word of mouth is a great way to spread news about the show and to expand our listenership and also to impact more people. So if you think of somebody during the show, send them this message. Today, Bonnie Halpern-Felscher will tell us that the way adolescents and youth make health-related decisions, and this is not that surprising, is very different from how adults make these decisions.

2:02That can lead to misunderstandings about why they're doing things like substance abuse with nicotine products, alcohol, and cannabis. She'll tell us, however, that understanding their ways of thinking can lead to interventions to help improve their decision-making. It's the future of substance abuse in youth. Today, we're continuing our feature called The Future in a Minute. After my conversation with Bonnie, I'll ask her a few rapid questions and she'll give us a few rapid answers. And also, before we get started, a reminder that if during this show you think of somebody, send them a message about the podcast.

2:37That'll help grow our listenership.

2:45When we think about youth and their health, there's some good news. We've all heard that teenage pregnancies are down. We've also heard that drunk driving deaths are down among teenagers. However, there's also been bad news. Mental health and stress and anxiety for the youth is up. And this unfortunately can lead to substance abuse. I'm talking about nicotine in cigarettes or vaping, alcohol and cannabis use. So we'd like to get that under control because the way youth think about these decisions, we will learn is not about the future bad impacts. It's what about the here and now, what are my friends doing, what's going to help me fit in.

3:25Well, Bonnie Halpern-Felscher is a professor of pediatrics, epidemiology, and psychiatry at Stanford University, and she's an expert on adolescent psychology and adolescent health decision making. She'll tell us that the The way adolescents make decisions about using substances is not what you might expect. And understanding that is going to be key to helping them make better decisions. So, Bonnie, why have you decided to focus your work on adolescent issues, especially related to tobacco, alcohol, marijuana, and other substance uses? Well, hi, everyone. And hi, Russ. It's great to be here. So really, one of the things I'm a huge advocate of adolescents and adolescents, people think cannot make decisions.

4:12They do, but the decisions they make sometimes may not be what we adults want them to do. So my job and my goal has always been to help understand adolescent decision-making around all areas of health-related risk behaviors, sex, drugs, rock and roll, but then also to help them become empowered to make better decisions for themselves. So why substances in particular? You know, we hope adolescents grow up to a healthy sexual relationship, for example, in any way that they may have. Even alcohol in moderation as an adult. But there are some areas of substance use, tobacco, marijuana, fentanyl, that really no use is okay for an adolescent unless prescribed and stuff like that.

5:00But that we're really, really concerned about. And I'm really worried about brains and brain development, lungs and lung development. So that's why I've really focused on adolescent substance use. The other reason, quite frankly, is we're seeing so many ads and marketing and deception from the tobacco and cannabis industry that I just feel like that is a perfect area for advocacy, for really helping to change the environment for young people. So that's why I focus on those areas. Great. And I want to get into the details of that work because it's very exciting. But you said a bunch of things here that kind of lays the groundwork.

5:38And the two things I want to kind of talk about a little bit is the current status. A lot of us have heard that things are changing, like that driving deaths for teens are down and that even unexpected pregnancies and stuff like that are down. And so there's a sense that, oh, maybe things are getting better. But then we also hear about Internet usage and the phones and feelings of isolation. So the first thing I want to ask is what is the general state of adolescent health, mental health, and obviously these related issues of substance abuse? And especially since you've watched it for a couple of decades, and so you have kind of a sense of how things may have changed.

6:18And in particular, are people overstating the changes or are these real changes that you're noticing in shifts? So it depends on what behavior we're talking about and what health issue. So let's start with mental health. You're right. I mean, mental health has taken a huge toll right now, even before the pandemic. But with the COVID pandemic, we're seeing so many young people who are depressed, who are even suicidal and really committing suicide. And we're seeing that increase more and more. You know, adults are depressed and anxious, but we have more coping skills. Young people don't. So what they do is they turn to the Internet.

6:58They turn to social isolation. they turn to substances to self-medicate. So I don't think we're exaggerating the mental health issues. If anything, we are underplaying those right now and really not working with young people. I see a lot of, not parents directly or educators directly, but just society who's sort of blaming and shaming young people. Why are you depressed? Why are you on drugs? Things like that. When you step back and think about how the last few years have been, it's been really challenging. And so we really need to support young people and realize that the mental health crisis is real.

7:35In terms of substance, I mean, you're right. Unprotected sexual behaviors has gone down, which is great. Drunk driving and impaired driving has gone down, which is great. Young people have gotten the message about sober sitters or making sure that you're not driving drunk or we have Uber now and other. Right, right. Soon it'll be Waymo, so there's no humans involved. As soon as Waymo, which apparently is increasing now everywhere. So absolutely right. So I think they've gotten the message about that. But they've also heard, unfortunately, from people from the industry that tobacco and nicotine can help them feel better or cannabis can help them feel better or take a pill and you'll feel better.

8:15And I think they're hearing those messages and they're hearing the misperceptions of those rather than the real messages that they need to be hearing. And so we are seeing increases in substance use. Now, overall, substance use has gone down. But cannabis, fentanyl, and I would argue nicotine vaping, even though we see the national levels going down. I'm in schools, thousands of schools across the country, and I'm hearing 50, 60 percent of students vaping. So a lot of concern there. Great. Great. Thank you. That really sets the stage. And then the other thing, the other general comments that I want to address is you study, and you mentioned it right up front, health-related decision-making, perceptions of risk, and, like, communications about health.

9:01What should we who are not experts know about adolescents and how they do those things, how they think about health? Because it might inform the rest of our discussion. And I think a lot of us don't have a good feeling for what's going inside those heads. Absolutely. So adolescents, when they're thinking about and making decisions, they're more attuned to the here and now, and they're more attuned to social issues. But when we talk about, you know, as physicians or psychologists or health care folks or health communication, we tend to focus on the risks. In 30 years, you're going to get lung cancer.

9:38In 20 years, you're going to have heart issues, whatever it might be. Kids don't care about that. They care about today. They care about, you know, I used to, when I was talking more about cigarettes, which aren't an issue, thankfully, with teens, but with cigarettes, I'd look at a middle school boy and just go point and say, it's harder to have sex if you smoke. And immediately that you can see the light go, I'm never going to smoke, never. Or it's going to be harder to kiss your partner or something. Kids care about today. So talking to them about, you know, that you might have bad breath or talking to them about it's harder to do sports.

10:17It's harder to run if you vape. Or you might think that it's easier to concentrate with cannabis, but it's actually harder to concentrate, harder to sleep. And also realize that we harp on the physical aspects. Kids care about the social aspects, the positive, the benefits. So when we say, you know, I always say, you know, the lung cancer, or you're going to turn green and grow a horn. And teens are saying, but wait a second, that didn't happen to me. I smoked the other day, and I was the life of the party. And I didn't crash and all these things. We look like idiots as adults. And they tell us, we don't trust you when you're hyperbolic, when you're talking about things we don't care about.

11:02So as communicators, we need to hone in on what they care about today. and it's the social aspects, the physical and emotional and the social benefits, not the risks as much. Great. Thank you. So that really is a great tutorial on how to think about this. And now let's go into your work, which is why you're here. And you've really been an advocate and you've been out there. So people think about professors sometimes as up in an ivory tower, we're not in touch with the real world. This is not a claim that I'm guessing you're accused of very frequently. So tell me how you've taken your academic interests and turned it into kind of an action plan.

11:42Absolutely. So two areas that we have action, well, three, if you think about, we also try to train the next generation to do this work because I'm not going to be doing it forever. Although I hope I will. So one is translating to advocacy. So I've taken the research showing, for example, that teens are using nicotine e-cigarettes and cannabis because the flavors, you know, they come in unicorn poop and honey doo doo and banana butt and all these crazy flavors. That's why teens are using. So I've taken that to testify at the city, county, and state levels across the country to really help advocate for banning e-cigarettes and tobacco that have flavors and, you know, claim to fame of really helping with that bill.

12:28And those flavors are pretty much entirely there for the youth audience. Is that true? Or do we have a lot of 30 and 40-year-olds who love the flavors? Yeah, I mean, 30 and 40-year-olds might like the flavors, but think about it for us. I don't like the syrupy flavors anymore. They really are for kids. And they originally, the e-cigarette companies, for example, claim that adults needed the flavors to help adults quit smoking cigarettes and turn to e-cigarettes, which there really isn't evidence that adults quit smoking through e-cigarettes. We've got other ways to help adults. But more importantly, adults don't need those flavors.

13:07Kids do. And kids tell us that that's why they're vaping. So, yeah, one of the claims to fame is really helping to pass bills at the city and state levels to be able to get flavors off the market. To reduce the nicotine levels is another thing I'm trying to do to change the marketing and so on. So my lab really does a lot of work in the advocacy or action there. And the other that I'm probably most known for are substance use prevention and intervention curriculums. We're in thousands of schools. We've reached 5 million kids across the country and globe. were used in 12 countries as well. So we've got free, I'm not selling anybody anything, free substance use prevention, school-based curriculums.

13:50And we do free trainings and teach people how to use these. So that's - What age groups are, are we talking about multiple programs for different age groups? Because of course, I remember as a parent of kids in the 90s, there was this thing called D.A.R.E. And my kids still remember their D.A.R.E. classes and with mixed reviews, to be honest. But tell me, what are the target demographics of these programs? Yeah, and it's funny. We say that we're the new dare, and people look at me and say, no, no, better, better. But in terms of sort of becoming a household name, I've had parents who have emailed me the permission slip from their schools.

14:25Bonnie, they're using your curriculum. I'm like, oh, so cool. So we have elementary, middle, and high school programs, separate programs. And we have cannabis, nicotine, e-cigarettes, fentanyl, all drugs, alcohol, and so on. And all demographics. We even have a set of curriculums specifically for our trans and queer youth as well. So because they are facing particular stressors right now and using substances. We've got specific curriculums for Hawaii, for example, and other cultures. And we do have Spanish as well. So we reach every youth who is out there as much as possible. And how do you measure the success?

15:06Yeah, how do you measure the success? Because it's a tough one and you can look at societal trends, but you would really like to know in that school where my curriculum was used, do I have better outcomes than if my curriculum hadn't been used? Absolutely. So we do that a few ways in brief. One is we have embedded pre-post curriculum, excuse me, embedded pre-post surveys in the curriculums that classes can just register. They don't have to, but they can register on our data dashboard for the curriculums. And then in doing that, they get a pre and a post survey, and then they can see and we can see that they've changed the needle on knowledge, attitudes, and intentions.

15:49But we also do formal pre-post evaluations. And thankfully, we've been funded by the NIH and other funders to do randomized control trials. It's hard because we've had the problem with schools saying, I don't want to be part of the randomized control trial because I don't want to risk being the control group. Right, right. I don't want to use the curriculum, which is, I joke with my program officers, isn't that enough to show that it works? Right, right. Classes want to use it, teachers. But thankfully, we've said, because teachers say, how do I know it's effective? And I say, well, help me evaluate it.

16:21And so we've had some success. So we are evidence-based. We are seeing changes in knowledge, attitudes, intentions, and behaviors, which is wonderful. And we also are seeing changes with our cessation curriculum, Healthy Futures, in young people quitting, which is really ultimately what we are hoping to do. Yeah. On that note, I wanted to ask before, do kids realize that they're addicted and do they say, I want to quit? Or is that just a thing that happens when you're an older adult? Yeah, it's a great question. I was just thinking about that. So teens don't always realize that they're addicted, but there's been some change where teens are now starting to recognize that they're addicted and parents are starting to recognize.

17:04When I first started this work, particularly around cannabis and e-cigarettes, nicotine e-cigarettes, I got even colleagues who said, oh, you can't become addicted to those. You can. And we have science to prove it. And we have just kids telling us. so the hardest part though russ to be honest is helping young people to quit we don't have nicotine replacement therapy the patch for example approve anybody under 18 a big area for advocates oh i didn't realize that yeah it's all now plenty of health care providers prescribe it they just prescribe it off label which is fine to use but we don't have any science telling us how many patches, how often.

17:47These e-cigarettes have as much as one to multiple packs of cigarettes worth of nicotine in there. And we don't have many ways to help kids quit cannabis either. So that is an area that we really need to work on. And again, that's why we can't blame or shame these young people. They start because of the ads and the flavors, and then they are hooked pretty quickly because of the amount of nicotine or TNC. Now, another thing that you said in a previous comment was, I think you referred to Hawaii. I know you referred to Hawaii. And that led me to wonder, is there a geographic differences, even in the United States or even globally, like how exportable are these methods?

18:33And do you have to, I guess you do because you referred to the Spanish language, do you have to refine them for different subcultures, even within the United States? Yeah, so yes and no. The pedagogy, no scare tactics. We really talk about instead of just say no, N-O, which is what Dara did, to just say K-N-O-W. And to really meet young people where they're at, no matter where they are on the spectrum of use. No use to substance use disorders. Not talking down to young people. The thing we started at the beginning talking about balancing the perceptions of benefits and risks and addressing those.

19:12That is uniform across the globe. But things like Hawaii, we built for them because they have different lengths of classes. And the flavors, for example, it's more mango and poi and other different flavors. The marketing is different there. And the products they have available are a little bit different. So we didn't do a huge 180 on the curriculums, but we did revise them. We're doing a little bit of differences in New York, for example, a little shorter classes, making sure that the images are relevant across the globe or across the country. We have a Northern Ireland curriculum, and that was very different, for example, because their marketing is different and their policies are different.

19:55Vietnam did one, but they just changed the language. Same thing with Spanish, it's just the language. So it's kind of a yes-no on that question. This is the Future of Everything. I'm Russ Altman, and we'll have more with Bonnie Halpern-Felsher next.

20:24Welcome back to The Future of Everything. I'm Russ Altman, and I'm speaking with Bonnie Halpern-Felsher from Stanford University. In the last segment, we got a great introduction to how adolescents think about health decisions, why they're using these substances that we talked about, and what are some of the methods that Bonnie and her colleagues have developed to intervene. In this segment, I want to ask about the marketing of both vaping products and also cannabis products. What kind of extreme reactions are we seeing in cannabis use? And finally, what are things that you can do if you're worried about an adolescent or a youth in your life?

21:00Bonnie, you made reference to flavors, especially for flavors in vaping, but basically there is this industry behind nicotine. It's either cigarettes or vaping products and they have marketing strategies. What are those strategies and how do you manage all of that as part of your research and your interventions? Absolutely. One of them is what we talked about, which is flavors. Clearly those flavors are there to attract young people. Unicorn poop, sugar booger, honey doo doo, those are not attracting people our age, whatever age you are, certainly not attracting my age. Those are squarely attracting our young people.

21:39But also the ads, the ads show those flavors. The ads talk about freedom, which is something that teens want to have, right? Freedom, do what you want, use where you want, use under your circumstances. They show a lot of skateboards or bling or dancing models that look young, whether they are underage or not, that they look young. The other is that we really worry about are the actual products themselves that we haven't really talked about. You know, e-cigarettes or vapes look like USBs. They look like pens. They look like highlighters. In fact, we're starting to see something happen for a while.

22:21One is a highlighter that's a highlighter, writes like one, actually writes like one, but it's a vape device. So if you're a parent or a healthcare provider, you wouldn't know. It looks like the kid's studying. It looks like the kid's studying. They're highlighting their history book. Exactly. And then taking a hit. There are some that look like McDonald's Happy Meal toys. And then more recently, we've seen these that are video game vapes. And if you don't inhale, you lose the game. Oh, my goodness. And there's one, like when we were kids, the Tamagotchi idea, the little thing that we would have.

22:55If you don't take a hit off of the vape, your Tamagotchi character dies. This is really... I had no idea. I had no idea the level that this reaches. It is awful. And with cannabis, we're seeing similar things. We're seeing gummies that, yes, adults are using, but kids are. And kids don't realize that maybe a dose or a serving size is one gummy. So how many times have you been able to eat one candy? Yeah, right. They eat multiple and they're getting really sick. So we're very worried about the marketing of cannabis as well, the flavors, the blame, the styles. And none of this is regulated or it is, but not enforced.

23:37Yeah, so I wanted to get to cannabis because that seems to me to be like a newer market. Like we've been having cigarettes, of course, forever and then vaping. But the legalized cannabis market is relatively new. And I'm sure that that creates a dynamic situation for you in your research and in your interventions because it's a very rapidly evolving thing. So tell me, what are the specific risks and what are the specific things you're seeing in cannabis use that people may not be aware of? Yeah, so one of the things that people may not be aware of is the amount of THC that's in these cannabis products.

24:10When I was a kid, they were more like 5 % THC. Today, they're upwards of 15 % to 20%. So just to be clear, THC is one of the active ingredients in cannabis that gives you all of the symptoms associated with cannabis use or many of those symptoms. Right, right. It's the psychoactive component. It makes you high, gives you that buzz. Absolutely. Thank you for clarifying that. Absolutely. And so it used to be about 5%. So it would still give you the buzz high, but was not going to cause some of the problems we're seeing today. Today we're seeing upwards of 20%. So just to explain that, today's one joint, which is like a cigarette style of a cannabis, one joint that you burn and inhale is equivalent to 10 joints when I was a kid.

24:57Wow. So at least 10 fold. Is this through like basically bioengineering the cannabis to have higher levels of making these chemicals inside the plant? Correct. Correct. And then we have something called dabbing that's about 80 to 90%. And what they're doing there is they're taking all the plant material out and just keeping the psychoactive component and enhancing that component within the bud, within the flower of that cannabis. So you're getting highly concentrated amounts of THC. So this is causing young people to wind up in the emergency room. We're seeing cannabis hyperemesis, so vomiting, cyclical.