Good evening, everyone, and welcome to the 2023-24 webinar series, Looking Beyond. My name is Dr. Regina James, and I am the Chief for the Division of Diversity and Health Equity and Deputy Medical Director here at the American Psychiatric Association. Before we get started with the webinar, I'd like to begin with the land acknowledgement. I humbly acknowledge that the land on which APA sits is where the Piscataway, Pamunkey, Nanticoke, Montapani, Chickahominy, and Powhatan cultures thrived. Together, we acknowledge the history of colonial genocide, forced assimilation practices of the boarding schools, and ongoing systemic inequities experienced by the Indigenous peoples of this homeland. We acknowledge that this is our collective obligation to support and pursue policies and practices that respect this land and its First Peoples. So, again, welcome to our series. The American Psychiatric Association is continuing an effort to promote justice, equity, diversity, inclusivity, and just a broader understanding of mental health inequities in marginalized and minoritized communities. In alignment with the goals of our President, Dr. Petrus Levinas, we will be focusing our series this year on substance use disorders. Our series is titled Voices for Change, Substance Use and Addiction in Minoritized and Marginalized Communities. This is an interdisciplinary series, as you know, where we bring together both clinical and research perspectives to tackle these questions and propose solutions. This series will focus on vaping, opioids, alcohol, and technology addiction, and hopefully shed light on the unique challenges that are experienced by marginalized and minoritized communities. Of the series, our President, Dr. Levinas, said, and I quote, we are living in a time of great challenges and greater opportunities in terms of the treatment of substance use disorders and the behavioral addictions in our country. So, tonight, our discussion will focus on a critical and emerging topic in mental health, vaping and its impact on our youth. We will focus the discussion on the intersection of race, ethnicity, and sexual orientation in minoritized youth that identify as LGBTQIA. Our moderator tonight is Dr. Tahid Zaman. He is an addiction psychiatrist, an associate clinical professor, and program director for the Addiction Psychiatry Fellowship at the University of California in San Francisco. He completed his addiction training at UCSF and his psychiatry residency at Harvard Medical School. Please welcome Dr. Zaman. Thank you so much, Dr. James. Hello and welcome. Today, we delve into a complex increasingly urgent issue that affects the well-being and future of our youth, particularly those belonging to minority and marginalized communities. It is my privilege as your moderator to set the stage today for this critical conversation and provide you with a bit of background on the topic before turning to our panel of experts for our Q&A. In recent years, vaping has emerged as a prevalent and often contentious public health concern, capturing the attention of healthcare professionals, policymakers, educators, and parents alike. Just between 2014 and 2021, the age of initiation of e-cigarette use has decreased, and the intensity of youth and rates of addiction have actually increased. While vaping transcends boundaries of age and identity, what makes this issue complex and compelling is the intersection of vaping with the unique sociocultural, economic, and psychological factors experienced by minority youth. We know, for example, that sexual minority youth with intersectional vulnerabilities are particularly at risk. Black, gay, lesbian, and bisexual adolescents experience significantly higher prevalence rates of vaping. Now, by minority youth, we're referring to racial and ethnic minorities, LGBTQ plus communities, and economically disadvantaged populations who encounter distinct stressors and disparities that can contribute to their risk of vaping. Understanding the dimensions of this crisis is essential for psychiatrists especially, as this problem challenges us to adopt a holistic and culturally sensitive approach to care. In this discussion, our panel of experts are going to explore the underlying factors that drive vaping in minority youth communities. We'll discuss some of the data demonstrating increased risk of cigarette initiation and use of cannabis, alcohol, and other substances among adolescents who vape and examine the psychological and public health impact of this new form of nicotine addiction. We'll touch upon the role of peer pressure and social influences and the importance of culturally competent and evidence-based intervention to protect the health of these vulnerable patients. So, let's begin our conversation by introducing our panelists. I'm going to get started with Dr. Azagba. Dr. Azagba is a health economist with postdoctoral training in substance use and mental health research. His academic interests encompass a broad spectrum, including substance use, tobacco control policy, public health policy, and health disparities. He is particularly interested in finding effective approaches to prevent and reduce tobacco and substance misuse and address health disparities, especially among vulnerable populations. He has extensive experience examining the impact of tobacco and other substance use-related policies on various behavioral and health outcomes. Welcome, Dr. Azagba. Thank you for having me. Thank you so much for joining us. We're also joined by Dr. Barrington-Tremis. Dr. Barrington-Tremis is a behavioral epidemiologist with training in tobacco regulatory science, whose research focuses on identifying behavioral and psychological factors associated with tobacco use, including vaping, in adolescence and in early adulthood, and the biobehavioral consequences of use. Her research has examined whether there are characteristics of e-cigarettes that increase risk of initiation and transition to combustible tobacco products that could be regulated to reduce the adverse public health consequences of e-cigarette use. Welcome, Dr. Barrington-Tremis. Thank you. Thanks for having me here. Thank you for being here. And finally, our third panelist is Dr. Lee. Dr. John Lee's interests are statistical methodologies and longitudinal research on youth substance use and tobacco regulatory policies. His current research focuses on epidemiology studies of youth substance use using the longitudinal U.S. national datasets, machine learning approach in big data, example, social media related to youth tobacco use, and reducing tobacco and other substance use related health disparities among sexual and gender minority populations. So, welcome, Dr. Lee. Thank you. Thank you for having me. Excellent. I neglected to mention all the affiliations of our esteemed guests, so let me go through that briefly, and please correct me if I'm incorrect. Dr. Azappa is an associate professor of the Consortium of Substance Use and Addiction at the Ross and Carol Neiss College of Nursing at Penn State University. Dr. Barrington-Tremis is an associate professor of population and public health sciences and director of the USC Epidemiology of Substance Use, or EOS, research group. And Dr. Lee is a postdoctoral associate at the Department of Psychiatry at Yale University School of Medicine. You all are busy folks, and so we appreciate you being here. With that, maybe we'll get started with some of the questions. And I'd love to start by just kind of understanding the scope of what we're up against here. And I might go to you first, Dr. Lee, with this initial question. And I wonder, could you provide just a brief overview of the current state of vaping prevalence amongst minority youth? What does that look like? Yeah, that's a great point. So yeah, according to the CDC, there's a U.S. national dataset, which is like a national youth tobacco survey, 2021 collected by CDC, indicate that e-cigarette use among, there's some like a disparity, race, ethnic disparity, and a sexual and gender minor disparity in vaping use. So for example, for e-cigarette, current e-cigarette use, which is like the past 30 days of e-cigarette use, among non-Hispanic white youth, they said that like a 9.6% for indicate them they use e-cigarette in the past 30 days. Among black, non-Hispanic, black or African-American youth reported that like a 4.3 of e-cigarette use, as well as 6.6% of the Hispanic youth reported that they use e-cigarette in the past 30 days. As I mentioned, the vaping, current use of vape is a little lower in non-Hispanic black youth and Hispanic youth than their white youth, but still they're using e-cigarette. Regarding to the e-cigarette use by sexual and gender minority, I could not find it's like exact like percentage for the e-cigarette use, but NYTS has any tobacco use estimate by sexual and gender minority. So for example, for the current use of any types of tobacco product, 7.9% of heterosexual reported that they use any types of tobacco product in the past 30 days, compared to 14% of gay, lesbian, or bisexual youth reported that they use any types of tobacco product, which represent approximately 490,000 youths, which is a lot of sexual and gender minority use using tobacco, including e-cigarette. So I want to highlight again, like there is some like disparity for tobacco use among certain like at-risk priority population. Excellent. Thank you so much, Dr. Lee. It's really helpful to hear those numbers for different minority populations and really kind of how they compare to the general population, right? So those numbers are really striking and kind of their discrepancies. I might go to Dr. Azagba for my next question, which is, you know, as Dr. Lee was saying, Dr. Azagba, we know that certain minority populations might be more at risk. That said, this kind of term minority population includes a broad range of people. So are there particular groups within kind of the minority youth category that you worry about the most, that you see kind of the most concerning outcomes among? Yes. Again, thanks for having me and I'm quite appreciative that APA is organizing something like this. It's very important to draw the lens of looking at disparities, particularly when it comes to vaping. If I may add a quick prevalence estimate regarding vaping among a minority population, data suggests that there are quite different data suggesting that minority population have higher prevalence. I've seen studies showing up to 15 percentage point difference between sexual minority youth versus non-sexual minority youth. So it's quite significant. Okay. Also, most times what studies don't do is looking at intersession with race and other ethnicity, because just looking at it in general, the population or by race may mask important differences between subgroups. So even our own research showed that amongst some specific population, the rates are different and particularly high for minority population. So, I think Dr. Azagba really kind of touches on an important point, which is that, and Dr. Lee too, that there really is not enough research out there, right? We should be able to say, okay, the population of kids who are this racial ethnic background and have this sexual identity and this gender identity and this socioeconomic status, and they're at substantially higher risk. But assessing intersectionality across all of these multiple identities becomes very challenging, right? For a number of different reasons, especially because there are so many other things that just come into the mix and impact patterns of tobacco use among young people. You know, one other thing that is really related to this, and maybe we'll get into this discussion a little bit more later on, is that in addition to the complications with being able to get accurate prevalence estimates across many, many different types of identities, which then gets your cell sizes very small, we also, in many national surveys, really don't have good measures of certain types, certain variables, right? So a really good example of that is how national surveys are assessing gender identity and how they're assessing sexual identity. We know from many conversations with young people lately that these identities are constantly changing, that there are more identities that become a part of the terminology that kids are using to describe themselves, and research has been quite slow to catch up to that. And so while in some local studies we can say that the asexual population have very high rates of vaping, the pansexual population of kids in our studies have very high rates of vaping, most national surveys are not assessing sexual identity to that point. They're just not assessing the percentage of kids who are identifying as pansexual or omnisexual or asexual or any of these other identities that a lot of young people are using to describe themselves. Right, that's such an excellent point, and I appreciate you mentioning that. And yes, Dr. Ozagwe, did you want to add something? Yeah, yes, that's a good point. I mean, I understand probably we might, if the time permits, might be able to talk about some of the challenges in this area, but consistently, a number of studies, particularly among youth, points to higher prevalence of this broad among sexual minority youth. I just wanted to let the audience know that. Right, right. Now, that's really helpful, and I appreciate the nuance that each of you have added to kind of my pretty broad question, you know, so it sounds like putting this all together, we're saying that there are compelling studies showing that minority youth, youth of intersectional identities might, or not just might, but are at increased risk when it comes to kind of prevalence, are more likely to vape or to, you know, transition to smoking. That said, there's a lot more work to be done. I think this is maybe to your point, Dr. Barrington-Trimmis, that more research is needed on kind of intersectional factors, predictive models, things like that, and that's complicated, right? That's complicated by even some of the definitions we're using around sexual orientation, gender, which are rapidly shifting. So, I really appreciate both the highlighting the need, and then also the need for more research. So, thank you all. I want to ask a little bit about, on your perspective, about why this is a problem. Why should we worry about this? Are there particular health outcomes that we're worried about amongst minority youth if they vape and, or if they vape and smoke? And maybe I'll start with you, Dr. Lee, on this particular question. Yes, I think there are some like negative health outcomes reported, especially like vaping, e-cigarette use among youth, especially for this like at-risk population. So, as you know, vaping is related to exposure to like nicotine, still related to exposure to nicotine, nicotine exposure, either toxic or chemical, which is like, which might relate to like brain maldevelopment, especially when they're using tobacco, which is including like an e-cigarette in early age. That's why when I, when I mention this, like this number of, striking number of youth, like a race, ethnic minority youth, or sexual and gender minority youth still using like an e-cigarette, which might relate to like tobacco-related health disparity for their health outcome. So, this is something like clinicians should know about, or, and kind of like being worried about, like, there should be some like a negative health outcomes, especially minority youth who use, who vaping, who's vaping. That's really helpful. So it sounds like really, and I might kind of ask you to comment a little bit about this in a minute, Dr. Barrington-Tremis, but it really sounds like, you know, part of the issue is this exposure is happening at a vulnerable time. It's happening during adolescence, during this period of kind of, I guess, neurologic vulnerability is what we might say. And so we really do need to worry about kind of those longer term, you know, neurological, psychiatric, other health outcomes as you're alluding to Dr. Lee. Dr. Barrington-Tremis, did you want to add anything more to that? Yeah, yeah. So, you know, I think when we think about why is this a problem? Why should we be devoting time via webinar? Why are you all here? When we think about, you know, what are the key issues? You know, I think there are two. One, you know, as Dr. Lee mentioned, the use of any nicotine products for young people is problematic, especially given that in many places, not very many of young people, not very many of these young people are using cigarettes or smoking to the extent that they used to. But a lot of people are vaping. A lot of people, a lot of young people are vaping. And the use of nicotine at such a young age is very problematic in terms of all the things that Dr. Lee mentioned. When we think about these marginalized populations, the first thing is that when they are vaping at a higher prevalence, all else being equal, assuming that the effects of vaping are equal across the population, they will experience higher rates of adverse effects just by nature of having a higher prevalence of initiation and continued use. But I think that we need to go a step further. Some of the cigarette literature has looked at how when two people of different racial and ethnic backgrounds smoke the same, there are different effects that happen in these different populations. With e-cigarettes, I don't think that we know much. We don't know enough yet about whether there are differential effects of similar levels of vaping in different populations. If there are, there's the potential for that to really compound the effect. So if these marginalized populations are not only vaping at a higher prevalence or at a higher level, they're more likely to vape. But if once they vape, they're also more likely to keep vaping, to vape more frequently and to experience adverse effects of vaping, then the problem becomes bigger and bigger, right? And I think we just absolutely cannot sort of take this approach of, well, let's just look at the population overall, take the average of everything and make sure we're okay. We really, really need to be sure that we are reaching those populations that sort of are at greatest risk because of lots of different things, including a very long history of targeted marketing. Absolutely. And that's an issue we'll come back to, but I wonder, Dr. Azagba, did you want to add anything more to Dr. Barrington-Tremez's comments? Right. I mean, I agree with all the points they made, but just to reemphasize, there is no risk-free level of tobacco use. There's no safe level of use. I mean, kids out there, you'd think there should be a way of the risk associated with smoking, right? What worries me the most regarding vaping is the fact that social norms, right? It is so easy for folks to engage in vaping in an environment where typically traditional cigarettes are not allowed. I was just having a conversation today with a young lady who was coming from school. Somebody was vaping in the school bus. And she went on to complain to the driver. The driver said, nothing can be done. Basically, all the folks were exposed, right? This is a problem, and it's particularly more in some certain locations. Yes, absolutely. So it's around social norms that worries me that folks are thinking it's just cool to vape. Go ahead, Dr. Barrington. Oh, sorry. I was just gonna add to that. I mean, I think one thing that's really important to mention in this discussion of social norms and the fact that they're just everywhere, on the bus everywhere, is the role that the industry has played in this, right? If you look at the kinds of vaping products that are on the market right now, it's just absolutely unbelievable. There was recently a brand called Highlight, right? This vaping product that looks identical to a highlighter. And so when the industry is putting things out like that, that just make it so easy for kids to use and for other people around them to not be able, like not really understand, not really know that they're using and thus be unable to kind of do anything about it. And then all the kids know, and now it is the social norm. Yes, the bathrooms are places where kids go to vape, right? Like, yes, kids vape on campus all the time. And so we have to, I think we would be remiss not to hold the industry accountable for contributing to this change in societal norms overall. Right, I really appreciate that point about kind of the extrinsic factors, which are really considerable, including economic pressures, marketing, all of these things that actually come together to put minority youth at risk, right? It's not just intrinsic factors by any means whatsoever. So I really appreciate all of you highlighting that point. I also wanted to mention we have a couple of very relevant audience questions about this, and we're going to take questions at the end. So just wanted to let our listeners know. I guess I'm wondering a little bit about why. I'm wondering why minority youth might be vaping or smoking kind of at higher rates. Now, there are some good reasons you all have mentioned already. Perhaps, say I am a high school kid and I'm being targeted by Big Tobacco to smoke. They're the highlighter vaporizers. There's so many extrinsic factors. Are there intrinsic factors? Are there pressures that minority youth experience or other factors that just kind of make them or push them more towards using that nicotine product? And I actually want to start with Dr. Lee, if that's okay. Yeah, so that's a great point. So for the intrinsic factor, I might be, I think a lot of like a minority youth, especially as a LGBTQ tobacco researcher, a lot of sexual and gender minority youth use tobacco to cope with their stress, such as like a stress from structural marginalization or like a social stigma or discrimination, or they always like being afraid of being a victim of the violence. So for example, these days it's a sad situation, but some of the state has like an anti-LGBTQ law is still happening, which might be related to like a negative mental health for younger people, especially like for youth because they feel, probably they feel, oh, I'm not, I don't belong here. I don't accept it in this environment. And this kind of like a negative feeling themselves about themselves might be related to tobacco use, especially e-cigarette use. So that's something could be a, that's something that I speculate part of reason for minority youth to use e-cigarette. Right, you know, that makes a lot of sense to me, Dr. Lee, and, you know, it makes me think of kind of what we learn about minority stress and the fact that there's this minority stress model studied amongst sexual minorities, which kind of accounts for a number of poor health outcomes, mental health outcomes. And then I think the point you're making is an excellent one, which is that level of stress, that level of, you know, pressure, all of that is really enhanced by external factors, including the laws that are being passed, right? We know that anti-LGBTQ plus laws really affect the mental health of folks who identify that way in a particular state or a particular region. So there are the intrinsic factors and there are also the really kind of large extrinsic factors like the marketing, like the laws, all of which really come together to enhance that minority stress. So I appreciate you all mentioning that. I'm wondering, Dr. Azagba, when you think about the stress that kind of intersectional, you know, and that's a very large term, but kind of intersectionally identified youth might be under, what ameliorates that? Are there any studies of something that kind of reduces rates of vaping or e-cigarettes, any interventions that are effective for minority youth that you've come across? Oh, you're muted, Dr. Azagba. Yes, I'm sorry, I was muted. There's no one size fits all approach regarding substance use or tobacco or any of the substances. It has to be a comprehensive strategy, right, to address this problem. For example, I mean, existing laws. Let me point to some existing laws. Typically, some states are very good at passing laws. Fortunately, little is done in terms of enforcing those laws, okay? For example, majority of long-term smokers initiated smoking before the legal age, access age of accessing these products. So what is this suggesting? It's suggesting that we have a long way to go regarding existing laws enforcement, right? So it is very important that resources need to be put to us enforcing the existing laws. Right. Where there are loopholes, make the laws as close as, I mean, as tight as possible. Let me give you one example regarding even typical cigarettes, conventional cigarettes. For example, the question typically folks ask me, why do we have menthol cigarettes? What is it doing? What is the benefit of menthol and mentholated cigarettes? Well, we know why, through digesting. The industry basically targeted particular sub-population. For example, data suggests almost 80% of daily users of current users of cigarettes, right? 80% of a particular population, menthol is their preferred brand. So I mean, the industry understand this. They do their own marketing, right? So they understand this is a specific product targeting a particular sub-population. So the right way to go is comprehensive strategies. There's no one size fits all. It's comprehensive strategies, educational campaigns. It's just not enough, it's just not cool to vape, for example, right? So there need to be multiple policies in place and this law should be enforced. Right, right. I really appreciate the point about this needing to be something comprehensive, right? So it can't just be enforcement. It can't just be education and outreach. It can't just be kind of policy, kind of maybe limiting what tobacco marketing can accomplish or not. It needs to be kind of comprehensive. And to that end, I just wonder, Dr. Barrington-Tremas, if you might comment on, who are the other players here? Who are the other stakeholders? Certainly, I think in this group and amongst this audience of psychiatrists and mental health folks, we would say we're probably one of the stakeholders, but who are the other stakeholders that really need to be brought on board to address this issue of vaping amongst minority youth? Yeah, I mean, this is an excellent question. I think if we think about the universe of people who impact whether an individual child, and I will call them a child even when they are crazy teenagers that are 14, when a child begins to vape, there are just so many different people that impact so many different things that all can contribute to whether that individual child will begin vaping or not, and importantly, whether they will continue to vape or not. And so when we think about this, I mean, I think Dr. Zagba is completely correct in that we need a totally comprehensive strategy to really help make a dent overall. So we need to change social norms. How are we gonna change social norms? Well, we need to pass laws that are gonna make products less available and less accessible to young people. Not only do we need to pass these laws, we also need to enforce them. California has a statewide ban on flavored tobacco products right now. And if you ask any child or college student or young adult whether they can, if they want to, purchase a flavored tobacco product, all of them will tell you, yeah, absolutely. Like the store does it, the store does it. Like there's a billion places to do it, right? And so there's no enforcement there from just enforcement against the sale of these products. In addition, like why are companies allowed to make a vape that looks like a highlighter? That's crazy, right? And then we need, you know, and then there's the marketing of all of this stuff, both the marketing on social media, the marketing that kids are getting on a daily basis when they are looking through the internet and even the marketing that they see when they are in stores, in convenience stores, walking by vape shops, many of which are, you know, are on like a part of kids' daily lives because they are close to schools and they see these places regularly, right? So all of these are like the external stakeholders. So like stop marketing, make these products harder for kids to get across the board. And then I think there's also this point that you brought up which is the intrinsic piece of all of this. You know, when you're thinking about a child who is in school and experiences some stress, right? What are the sources of stress? So one, systemic inequality, right? That is a huge stressor for a lot of kids and a lot of kids who experience, who identify as belonging to multiple marginalized populations, right? But there's also, you know, in addition to those kinds of stressors, there's also like the stressors at the school and stressors based on family and stressors based on their own desire to fit in and be a part of whatever crowd, right? This is a really strong desire among young people to fit in, right? And so a lot of times kids that belong to marginalized populations and especially if they belong to multiple marginalized populations, that desire, you know, is even stronger. One of the interesting findings, like just within the LGBTQ community and looking at the different rates of use is that individuals, young people who identify as gay or lesbian do not actually have rates of use that are that much higher than individuals who identify as being heterosexual. But the kids who identify as bisexual or pansexual or queer or some other group, right? That doesn't have sort of a clear, like supportive network, right? Then that group is sort of, again, in this place where they're trying to find themselves, they're trying to figure out who they are, they're experiencing stress due to all these external factors, they're experiencing internal stress because they're trying to find their identity and their adolescents growing up in 2023, which is a difficult time to be an adolescent across the board for many reasons, right? And so in addition to kind of addressing the e-cigarette issue, and sorry, I keep, I'm like rambling and going on and on, but in addition to addressing sort of the accessibility, like how easy is it for kids to get these products? I think we also need to address the stress issues because oftentimes I think that vaping is really a symptom of something deeper, right? These kids are experiencing all of this stress and turmoil and challenges with identity. And so they're looking to try and make themselves feel better. And the ways that they're, when a kid is sitting here, like, oh my God, I'm really stressed out, I'm really anxious, I need to feel better, how am I gonna feel better? I don't have any friends, I don't know, dah, dah, dah. Right, what are they turning to? And when e-cigarettes are so easily available, kids are turning to e-cigarettes, right? But I think that the deeper issue is all of the internal stuff that a lot of kids are struggling with. And so we, especially when we talk about psychiatrists, right, and the community of healthcare providers who are helping with mental health concerns that these populations and these kids are really facing at much higher levels, that there's a real change to address those, a real chance to address those. If we can address that underlying mental health issue, then hopefully we can get kids to a point where even if e-cigarettes are available, they're making the choice not to use them. Right, right. I really appreciate that point. And in a minute, I may ask you to comment a little bit about this, Dr. Ozogban-Lee, too. But I think what you're mentioning, Dr. Barrington-Tremas, makes me think about the fact that even though these kids or these youth, we should say, are under such pressures, right, including kind of pressures that arise from identity, from kind of in and out group kind of dynamics, you know, all of these things, right? One of the key things that psychiatrists can do is really try and understand those pressures, those identities, but also treat any comorbid diagnoses, right? So we know that across the board, across age groups, including in youth, treating the comorbid diagnosis, if it's that's depression, anxiety, whatever, reduces the rates of substances, including vaping and smoking. So I really appreciate you bringing up that point, that, you know, there's something actionable here, and part of it might come from treating kind of what's underlying the vaping. So I really appreciate that point. Dr. Zappa, I wonder if you might have any comments about that in terms of, you know, say I'm a psychiatrist, you know, I don't have the time to go and lobby my, you know, state legislature to change laws and have little hope of doing that as an individual person, maybe as an organization like the APA. But if I'm a psychiatrist trying to make a difference, looking at comorbidities, you know, what are interventions that work that actually help reduce rates of vaping in minority youth? That's an interesting question. In fact, I was going to say something regarding that issue. Yes. I think the first step is clinicians have a crucial role to play. One thing, one pattern that seems common is that even when you have contact with clinicians at any setting, sometimes they remember to ask you, do you smoke any cigarettes? But you know, you know, what is not typically asked? They don't ask you, do you vape? It's an important question. For example, I have my daughter, I have a teenage daughter, right? She goes to the doctor and they ask her, do you smoke cigarettes? Never once has she been asked, do you vape? So language matters, right? And we need, even at the care setting, these questions need to be asked because it provides opportunity to also provide opportunity for intervention, to be able to educate some of this population about the risk of using this product. Right. If at the level of the clinician, the clinician at the level of contact, you don't even know if the person vapes or not. It becomes more difficult to even find ways to help that person quit smoking. Absolutely. I really appreciate this very fundamental kind of point you're making Dr. Ozagba, which is fundamental, but also incredibly important, which is that many times we're not trained to actually ask the right questions, the right questions about current forms of use, right? You know, I did my fellowship nearly 10 years ago. Now the questions then are not the questions that are best now. And so we need to be asking about vaping. We need to be asking about, you know, the different forms of use, whether it's, you know, Zen pouches, you know, whatever it is, we need to ask specifically about that rather than just doing broad tobacco screening, which I think is what you're alluding to and can happen. And I might extend that to say that we need to, if we're talking about minority youth, we need to ask questions about identity. We need to ask questions about, you know, what groups these youth might kind of be affiliated with, see themselves as a part of, come from. We need to understand the broader kind of community and context. We're not really trained necessarily as clinicians to ask great questions about that. So part of this starts with us and it starts with educating mental health professionals. I wonder kind of Dr. Lee, and then maybe we'll turn to some great questions from the audience after this comment. Dr. Lee, any thoughts about, you know, what psychiatrists can do, you know, in our practice to really affect change? You know, maybe if, you know, everyone who listens to this webinar makes one change, maybe we could affect kind of a bit of a movement, you know, what would that be? Yeah, I want to chime in, ask about it. So I want to specifically indicate that 5A model, like for US task force, like for guideline to assess. So 5As are like, probably you already know that, ask, advise, assess, assist, and arrange. So whenever in your clinical setting, when you meet your patient, you just could ask like about like a vaping status, then advise, vaping is bad, like vaping is bad, there is some like a potential harm of the e-cigarette use, you can advise and assess their like a frequency of vaping use and why they're using vaping, why they're vaping, and assist to help them to quit if they already start, if use patient already started their vaping, you can ask, you can assist them to quit. And arrange part is a little difficult, but like you can try arrange the appointment follow up appointment to help their quit vaping. So that kind of like asking, just being aware of this situation to the patient, I think that's a really good, good starting point. And yeah, I think that's a really good starting point. But regarding the sexual sexual and sexual orientation, I'm still learning about this. But first, do not assume their sexual orientation. And the most accurate way to know their sexual orientation is just ask them. But sometimes, some patient, especially like underage patient might feel uncomfortable to disclose their sexual orientation, right. So one of the I think is a little different setting, but one of the American Cancer Society recommend was just put like a rainbow flag or a rainbow badge or whatever the label flag, just give them impression that you're safe person to talk about their sexual orientation, you are open to talk about their sexual orientation and potential issue derived from their sexual orientation. I think ask and, and being on the same page with your patient about their sexual orientation and substance use might be the like, might be the easy way to prevent and assist them prevent the substance use among this population and treat their comorbidity of their like, depression or anxiety, distress. Yes, I really appreciate that point. And we're going to move to audience questions after this. But I promise I'll come to each of you with those because there are some great questions. But Dr. Lee, I appreciate that framework. And you're just kind of highlighting the importance of safety of creating an atmosphere of safety, where those kind of questions can be asked and responded to by minority youth in kind of a transparent and honest way. Now, I want to mention this given the political times we live in and because we're a national organization, that for some clinicians in some states, and for some youth in some states, there might be real kind of consequences of disclosing issues of gender identity or sexual orientation. So we also want to keep that in mind as we're kind of creating these kind of, you know, these environments of safety. So really appreciate those points. With that, I would like to turn to some of our excellent audience questions. And the first one, I'm actually going to send your way Dr. Barrington-Tremis. And this is a question I was going to ask if no one else did, which is, you know, what impact do you think COVID has had on on vaping and particularly vaping and behavioral issues amongst minority youth? And this is a big question, but we'd love your thoughts. Yeah, yeah. That is a wonderful question. We have we have begun. So I have two sort of things that I'll talk a little bit about what we've seen in the data and sort of what we've heard from our interactions with with youth and and another folks at schools. So on the one hand, when we look at the data, a lot of what we're seeing is sort of divergent patterns, right? So when we went into lockdown, and a lot of kids were home all day, kids sort of fell into two categories. Kids that were home with their parents all day, their parents were there, they were not ever away from their parents. And then kids who were home alone all day, and their parents were working as essential workers in some way or another. We saw that there were some kids who greatly increased the amount that they were vaping and drinking over the lockdown period and kind of leading into the post lockdown period. And then other kids who just completely they're like, yeah, I always, you know, I vape with my friends, and I didn't see my friends anymore. And so I didn't vape anymore. And so, you know, I think the pandemic sort of had like, different effects on different people, depending on what their individual circumstances were. We know we found some young people experienced much higher levels of stress during the pandemic as a result of things like their parents getting laid off that could have, or struggles with money, right, that that led to either not vaping, because they didn't have money, or not smoking or drinking or whatever, because they didn't have money or for other kids using these substances as a as a stress relieving mechanism. And so the overall, like what is happening? You know, I don't think we have a straight answer for that, because the impact of COVID just was so different across different individuals in the population. In talking with, with school principals and teachers and other individuals at the schools, and I should just clarify, so we, I'm an epidemiologist, we have a couple of cohort studies that we actually started during the pandemic, when kids were in remote school, as their first wave or two waves of data collection, and then went back to school and actually surveyed some kids in school in the following years. And now everybody's back in school. And so our data collection are all in schools right now. And what we heard from from principals and teachers is that really, the kids are having a lot of struggles with mental health, a lot of struggles with things like stress and anxiety and depression. And, and, and just like general acting out. And so I think from the school's perspectives, they would tell you like, yeah, there's a lot more kids that are vaping, like, you know, I don't know, I don't know what's going on, that kids are acting crazy, like, I don't know, it's like, they forgot how to be human beings in this in this post lockdown world. And so so I think, you know, this isn't a satisfying answer. But, but it depends is really the answer kind of across the board. You know, in terms of the impact that the pandemic has had on on young people. Right now, I appreciate that kind of, you kind of pointing out the differences that different different youth might be affected. And I imagine that actually, minority kind of minority communities might face issues around, like, you know, different rates of kind of people being laid off different abilities of parents to have been able to work from home versus have to go in, you know, all of which kind of, you know, adds to this complex picture. And I wanted to go to you, Dr. Azaiba to ask if maybe you had any comments or any observations of kind of how COVID has had an impact on vaping among minority youth. In general, I mean, the mode of delivery, it's huge on the age use, we're taking advantage of the loop, some of the existing mechanisms to assess this product. During COVID, what we actually saw was that kids were able to get this product through e-delivery was so easy for them to assess this for two different mechanisms, right? In the past, I mean, before COVID was first going to your typical store, right on social sources, but it was so easy for kids to be able to assess this product. Multiple forms of delivery was going on electronic delivery methods. So it became easier for kids to actually assess this product to the extent that even some of this big male organization had to come off and basically say they were not going to start doing interstate shipping anymore, handling tobacco products, right? So it was an opportunity for kids to have access to this product in different ways. Right, right. Access changed in a different way. Perhaps ironically, because we were in the midst of dealing with that respiratory virus, and then with this proliferation of kind of these ways that youth could get a hold of these agents, right? These different devices to actually vape, including online and app-based delivery services. We're focusing on nicotine here, but I think we all know that cannabis is another kind of issue when it comes to inhaled use, and there's certainly a proliferation of delivery methods around that. So really appreciate those points around COVID. The next question might be something I'd throw to you first, Dr. Lee, and this is kind of based on a couple of comments in the chat, saying that it's so important to advocate for policies to decrease targeted marketing, but also there's an importance in awareness amongst kids about the immediate difficulties that vaping can pose, difficulties concentrating, remembering, decision-making, right? And I think the person asking the question might be alluding to some executive function issues, right, that might come up. And I know that you've looked at kind of social media data, so I guess my overall question might be, are there ways of reaching youth, minority youth directly that have been effective? Have there been campaigns, social media, or otherwise to educate them about some of these risks that have actually had an impact? Yeah, so I think a federal government and like, for example, like tourist campaign or tourist campaign, a lot of like federal campaigns are doing a great job to prevent, to contribute to preventing like a youth vaping. Specifically, some of the campaigns are tailored for the sexual and gender minority youth or racist, racist, ethnic minority youth. So I think that they're doing a great job, but still, still a lot of tobacco marketing and user-generated content are still on social media. It's pretty common. And still, still youth still can access to those content, even though social media are doing their best to restrict this, to put the age restrict for those types of like tobacco-related content. But still, one of many of our study, like our team, my, our study found that those types of content are still assessed by youth, underage youth. So having said that, I think developing and implementing counter-messaging for the like e-cigarette use prevention on social media could be like a one potential way to reach out to youth and educate them, educate them about a potential harm of e-cigarette use. Specifically, in 2022, over 95% of youth, like US youth in the United States reported that they're using social media, which like a social media is a pretty, it's very common, like a channel to share information, to hanging out with your friend and to learn something. Like it could be like a, their hobby, but it could be like some substance use or e-cigarette use might be the one. So I think targeting social media, developing, developing counter-messaging, like a prevention strategy, specifically directed at social media and minor, minor direct, directed at like a minor, minor ties like youth could be a good solution for, for this situation. Right. I really appreciate that, Dr. Lee. And we're almost out of time, but how about Dr. Barrington-Tremis, any last words? Yeah. Yeah. Let me just, let me, let me just jump in there. So, so, you know, I think it's important. It is definitely important for us to make sure that kids have information regarding the, the impact of nicotine and cannabis on the developing brain. That said the vast majority of young people, the first time that they use a product, it's not because they've looked at it and said, Oh, well, you know, even though the cigarette is likely to cause lung cancer, I'm going to decide that I'm okay with getting lung cancer and, and actually smoke the cigarette. You know, the majority of young people, the very first time that they use their product, it's because somebody handed it to them. Right. And they said, okay. Right. And, and even when kids know that e-cigarettes or cigarettes are bad for them and they shouldn't do it, their brains are like really incapable of kind of attributing potential consequences associated with the behavior back to themselves. Right. They're very young people are very self-focused. The world revolves around them, but also if you ask them, you know, like the likelihood that they'll die in a car accident or, but, you know, they're also, they also have this invincibility mentality. Right. So, so educating regarding the potential consequences of substance use only goes so far. So it's important. We shouldn't neglect that altogether, but there are many other things that we need to make sure are part of this tobacco controlled package so that we're not just relying on young people to make educated decisions regarding substance use. That's an excellent point. And I really appreciate it. We're going to wrap up there, but I want to say we are up against a huge problem, but I feel so much better that folks like you are working on it. So thank you, Dr. Lee of the Agba Barrington Tremas. It's been a pleasure to be able to chat with you today and learn from you. I'm going to turn it over to our APA staff in just a second, but I wanted to just appreciate our APA staff for all of their hard work, getting us organized for this panel and APA leadership, including our presidential work group, working on a number of substance use issues, including vaping for their work on this matter. And with that, I'll turn it over to Ms. Reynolds. Thank you. Thank you, Dr. Salman. And thank you all for joining us this evening and a very special thank you to all our panelists. You've shared some valuable insights and please, we'd like to invite all our participants to complete our survey and as well to register for our next webinar, which will be December 7th. It will be on opioids. And thank you all and have a great night.

vaping

marginalized youth

minoritized youth

race

ethnicity

sexual orientation

health risks

comprehensive strategies

existing laws