Marijuana, e-cigarettes and teens

In the past year, my staff and I have seen a dramatic increase in use of both marijuana and electronic cigarettes among our patients, consistent with nationwide trends.  As a result, we now include very specific questions about their use on our intake forms as well as in our patient interviews.

Marijuana use has been on the rise among adolescents for many years. In 2010 the Office of National Drug Control Policy estimated that from 2008 to 2009, the rate of current illicit drug use among young adults aged 18 to 25 climbed 8 percent, from 19.6% to 21.2%, driven largely by a 10 percent rise in marijuana use (from 16.5% to 18.1%). At the time of that survey 16.7 million people aged 12 and over had used marijuana in the past month. ¹ Generally, when speaking to my own patients, I find that adolescents (and adults) in my practice regard marijuana use as equivalent to alcohol use in their daily lives; this underestimation of harm is echoed in national surveys as well. However, marijuana has evolved since it first gained wide popularity in the US in the 1960’s; through genetic manipulation, the potency of marijuana has doubled from 1998-2008¹.

Marijuana is now a very different drug than it once was with a much higher potential for addiction and harm. Studies have suggested an association between chronic marijuana use and increased rates of anxiety, depression, suicidal thoughts, and schizophrenia. Other research has shown marijuana smoke to contain carcinogens and to be an irritant to the lungs. In a prospective birth cohort study, Meier et al showed that, among adolescent initiators of marijuana use in New Zealand, persistent cannabis use was associated “with neuropsychological decline broadly across domains of functioning, even after controlling for years of education, suggesting a neurotoxic effect of cannabis on the adolescent brain”²

Use of electronic cigarettes is also on the rise. E-cigarettes, also known as vaping pens or hooka pens, are being aggressively marketed to younger users. “Electronic cigarettes, or e-cigarettes, are battery-powered devices that provide doses of nicotine and other additives to the user in an aerosol. Depending on the brand, e-cigarette cartridges typically contain nicotine, a component to produce the aerosol (e.g., propylene glycol or glycerol), and flavorings (e.g., fruit, mint, or chocolate”³ The MMWR Weekly from November 15, 2013 reports that the percentage of high school students who reported ever using an e-cigarette rose from 4.7 percent in 2011 to 10.0 percent in 2012.  Altogether, in 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes. ⁴

It is well known that early addiction to nicotine, regardless of the delivery system, is more likely to produce addictive behavior. The effects of nicotine on the adolescent brain are quite different than those in adults, according to Dr. Theodore Slotkin. “Adolescence represents a unique period of vulnerability for nicotine-induced mis-programming of brain cell development and synaptic function. Effects of nicotine on critical components of reward pathways and circuits involved in learning, memory and mood are likely to contribute to increased addictive properties and long term behavioral problems seen in adolescent smokers.”⁵

Currently, E-cigarettes are not regulated by the FDA. As a result, manufacturers are not accountable for the accuracy/ consistency of the dose of nicotine nor are they limited by the laws prohibiting the marketing of tobacco products to teens. Testing of e-cigarette cartridges has shown highly variable and inconsistent nicotine content, often higher than indicated by the label. In addition, a significant percentage of teens believe that flavored vaping pens do not contain nicotine and many also believe that vaping is good for you. While cigarette companies say they don’t market to kids, e-cigarettes flavored with cherry, strawberry, vanilla and cookies and cream milkshake are clearly not aimed at adult users. In addition advertisements like the,which appeared in sports illustrated’s swimsuit edition, are clearly aimed at making the use of these devices sexy to younger users. In targeting younger consumers, e-cigarette manufacturers (often subdivisions of “big tobacco”) are actively recruiting a new generation of nicotine addicts.

Not only are teens are using more marijuana and more e cigarettes; there is a growing use of vaping pens for smoking marijuana. Many “vaping” devices are able to accept alternatives to nicotine cartridges, including marijuana, dried herbs, and essential oils. Because there is no ash or smoke produced by e cigarettes, there is little to no smell. That makes marijuana use via these devices almost undetectable. There are a remarkable number of articles in the press in which comments are made to the effect that vaping marijuana makes it possible to get high almost anywhere, including in school.

In short we are facing a new era in teen drug use and accessibility. Clearly, increases nicotine and marijuana use are not as worrisome as the heroin epidemic sweeping the US, but they are significant. While we are gynecologists, not pediatricians or family doctors, we, nonetheless, care for the whole patient. In the case of adolescents, drug use, school performance, psychological state, and sexual activity are all intricately related. We can’t confine ourselves to “just” the gynecologic issues and have an obligation to address these more global issues with our teen patients as well.

References:

¹Office of National Drug Control Policy: Marijuana: Know the Facts October 2010

²Persistent cannabis users show neuropsychological decline from childhood to midlife.  Madeline H. Meier et al. Proceedings of the National Academy of Sciences of the United States of America Edited by Michael I. Posner, University of Oregon, Eugene, OR, and approved July 30, 2012 (received for review April 23, 2012)

³MMWR Weekly: Notes from the Field: Electronic Cigarette Use Among Middle and High School Students — United States, 2011–2012

September 6, 2013 / 62(35);729-73

⁴MMWR weekly: Tobacco Product Use Among Middle and High School Students — United States, 2011 and 2012 November 15, 2013 / 62(45);893-897

⁵Theodore A. Slotkin: Nicotine and the adolescent brain: Insights from an animal model. Neurotoxicology and Teratology 24 (2002) 369-384

National Public Radio: E-Cigarette Critics Worry New Ads Will Make ‘Vaping’ Cool For Kids by DEBBIE ELLIOTT March 03, 2014 3:35 AM