1. Understanding the Impact on Adolescent Students of Combined Nicotine and Marijuana Use Selena Morresi, MPH, CTTS, CHES Mallory Henry, BS PASAP Conference 2016

2. Objectives 1.After completing this workshop, the learner will be able to understand the impact of students who use both marijuana and nicotine together. 2.After completing this workshop, the learner should understand the prevalence of students who use marijuana and nicotine together.

3. Objectives 3. After completing this workshop, the learner will be able to understand the current trends in nicotine and marijuana. 4. After completing this workshop, the learner will be able to recognize potential risks faced by students who combine nicotine and marijuana.

4. Current Trends in Nicotine and Marijuana Use

5. Nicotine

6. Nicotine Delivery Products Cigarettes: Smokeless tobacco & snus: Hookahs: Cigars & cigarillos: Vaping devices: Dissolvables:

7. Cigar Types

8. Cigars/Little Cigars/ Cigarillos Unlike cigarettes, cigars can be marketed with candy, fruit and chocolate flavors Cigars are also taxed less and can be sold as singles, unlike cigarettes that must be sold in packs of 20 Cigars are marketed more heavily in black neighborhoods than in others Used for smoking blunts

9. Vaping Devices: Electronic Cigarettes What is it called? “e-cig”, “an e-cigarette”, “a personal vaporizer”, a “PV”, a “nicotine vaporizer”, etc. How does it work? A rechargeable battery powers a heating element called an atomizer which touches a cartridge holding e- liquid. The atomizer heats (steams) the liquid turning it into a vapor which is inhaled and delivers nicotine to the bloodstream What does the e-liquid (e-juice) consist of? Varying amounts of nicotine (also available without nicotine), flavoring (also available without flavoring) and propylene glycol and/or vegetable glycerin

10. Other Vaping Devices Called by various names: “hookah pens”, “hookah sticks, “e-hookahs”, “vape pipes”, “vape pens” Similar in construction to an e-cigarette They’re all about the flavor Some are disposable; some are rechargeable/refillable Some are nicotine-free; many have nicotine

11. What are the dangers of vaping? No medical studies have been conducted on the long-term effects of inhaling glycerin, propylene glycol, or any kind of flavoring Not regulated; no consistency in what is added Certain e-cigarette devices may also release metals as well as other impurities known to be toxic and/or carcinogenic

12. Substances Vaporized 12

13. Hookah Hookah is a water pipe used by indirectly heating the tobacco, usually with burning embers or charcoal Hookah smoke can be served in a variety of flavors like strawberry, mint, and chocolate The device has been used for centuries in the Middle East and Asia to smoke tobacco 19.8% of 12 th graders smoked hookah at least once in the past year (MTF, 2015)

14. Comparison of Hookah & Cigarette Smoke A 45-60 minute session of hookah smoking could be the same as chain smoking 15 cigarettes, meaning: 5 xs more cancer causing agents than cigarettes 100 xs more tar 11 xs more carbon monoxide

15. Marijuana

16. Marijuana: How is it Used?

17. Dabbing New concentrated form Made with most potent part of plant and butane Ear wax, canna wax, honey oil, dabs 80% THC reported Overdose potential

18. Types of Dabs Butane honey oil Shatter Earwax Honeycomb

19. Combined Nicotine and Marijuana Use

20. How are they used together? Little Cigar/cigarillo wraps “blunts” Vaporizers/vape pens Hookah “Chaser” Spliffs

21. Blunts Cigars or cigarillos are emptied of their tobacco products and filled with marijuana.

22. Spliffs Rolled in similar paper to joints, filled with a combination of loose tobacco and marijuana. Often include a paper filter.

23. How Many Students are Using?

24. MTF 2015 24

25. MTF 2015 percentages Cigarette Usage 8 th Grade10 th Grade12 th Grade Lifetime13.3%19.9%31.1% Past 30- Days 3.6%6.3%11.4% Daily1.3%3.0%5.5% ½ pack or more daily 0.4%1.0%2.1%

26. How Prevalent is Adolescent Marijuana Use? 8 th Grade10 th Grade12 th Grade Past Year Use11.8%25.4%34.9% 26 8 th Grade10 th grade12 th Grade Past 30 Day Use6.5%14.8%21.3% 8 th Grade10 th grade12 th Grade Daily Use1.1%3.0%6.0% Source: 2015 Monitoring the Future Study 8 th Grade10 th Grade12 th Grade Lifetime Use15.5%31.1%44.7%

27. MTF 2015 27

28. Our Data: Nationally 2,530 students across 8 states Identified for Nicotine Cessation Support Group Tobacco Products Used: – Cigarettes: 27.9% – Cigars and Little Cigars: 51.9% – Hookah: 34.3% – Chewing Tobacco: 6.7% – Electronic Cigarettes/Vape Pens: 20.4% Project Connect 2014

29. Our Data: Pennsylvania Percentage Roll own cigarettes16.5Hookahs32.5 Regular cigarettes40.5Snus9.0 Light cigarettes13.5Cigars or little cigars28.5 Menthol cigarettes45.5Chewing tobacco/Dip20.5 Flavored cigarettes/Cloves 6.5Electronic cigarettes31.0 Dissolvable tobacco products 1.5 Project Connect 2015

30. Prevalence of Marijuana Use among Adolescents Who Use Both Tobacco and Marijuana Past 30-Day Marijuana Use (Alone) Males: 19% Females: 16% Percentage of Days Using Tobacco or Marijuana in which Both Substances Were Used Males: 49% Females: 42%

31. Cycle of Addiction and The Impact of Co Use on the Brain

32. Activity

33. The Spiral into Addiction Use Misuse Abuse Addiction/Chemical Dependency

34. CYCLE OF NICOTINE ADDICTION NICOTINE (Use of tobacco product) EFFECT (Release of Chemical) TOLERANCE (Nicotine needed to function normally) INCREASED DOSE (imbalance of chemicals in the brain causes person to use more) WITHDRAWAL Craving and Withdraw Symptoms

35. Health Effects of Nicotine and Marijuana Use

36. The Blunt Truth Cardiovascular problems associated with cigarettes are caused by nicotine Increases respiratory symptoms and aggravates COPD

37. Health Effects According to the American Lung Association, smoke from marijuana combustion has been shown to contain many of the same toxins, irritants and carcinogens as tobacco smoke. Typically marijuana users inhale more deeply and hold their breath longer than cigarette smokers, which leads to a greater exposure per breath to tar.

38. Health Effects Weakened immune system Marijuana affects brain development Marijuana use that begins in their teens and continues into adulthood can cause IQ to lower by 8 points.

39. Impact on Adolescents Who Use Both Marijuana and Nicotine Together

40. Cigarillos as a Marijuana Delivery System The percentage of adolescents who smoked tobacco in the past 30 days increased by more than half when cigarillos - small cigars or little cigars - are included with regular cigarettes as a form of tobacco use (MTF 2015). A contributing factor to this percentage is due to many users emptying the cigarillos of tobacco and replacing it with marijuana. 40

41. Chasing the High “Chasing” is when an individual follows up smoking marijuana with tobacco use. Claims to “boost the high.” However, this combination can lead to unexpected outcomes.

42. Impact of Combined Use Frequent marijuana use can lead to greater nicotine addiction in adolescent smokers. We also observe that smoking tobacco along with marijuana can increase dependence of cannabis. Using tobacco with marijuana – smoking blunts and “chasing” marijuana with tobacco – contributes to cannabis dependence symptoms. Treatment for cannabis dependence may be more effective if it addresses the issue of concurrent tobacco use. (Ream, Geoffrey L. et al. 2008)

43. Neurotransmitters New memories Learning Receptors Sets off new chemical reactions New Proteins Activates Genes New desires cravings

44. Survival Brain (Limbic Area) Rewards/Instincts Food/Water Fight or Flight Social Sex Drugs emotions Limbic

45. Drugs of abuse trigger reward area Alcohol Marijuana Opioids Benzodiazepines Barbiturates Cocaine Amphetamines Nicotine Anabolic steroids Ketamine “Bath salts”

46. Impact of Combined Use Marijuana also reduces nicotine withdrawal symptoms. This can lead to lower success rates in tobacco cessation. Balerio et al., 2004; Cohen et al.,2005a,b

47. Impact of Combined Use Daily cigarette smoking in adolescence is associated with marijuana and other substance use in young adulthood (Patton et al., 2006).

48. Exposure to drugs of abuse during adolescence could have profound effects on Brain Development

49. Individuals who begin drinking before age 15 are 4 times more likely to develop alcohol dependence during their lifetimes than those who begin drinking at age 21. (Grant & Dawson 1997; Journal of Substance Abuse 9:103-110) Same applies for combined use of marijuana and nicotine. Earlier use increases risk

50. The Blunt Truth What are some common comments you get in defense of using nicotine or smoking marijuana?

51. Myth: “It Helps Me Relax” This is one of the most common defenses for using nicotine or smoking marijuana. Nicotine actually increases your stress level! Nicotine keeps you trapped in a cycle of addiction because of the withdrawal.

52. Myth: “It Helps Me Relax” U.S. researchers found the brains of users were less able to react to dopamine - the feel- good chemical. This can lead to an increase in anxiety and depression in marijuana users.

53. So … What do we do about it?

54. What can we do about it? Nicotine Cessation Programs Marijuana Awareness/Intervention Groups Programs that address co-use Education on the risks of co-use

55. Resources

56. http://legacy.nreppadmin.net/ViewInterventio n.aspx?id=340 http://legacy.nreppadmin.net/ViewInterventio n.aspx?id=340 http://nrepp.samhsa.gov/ProgramProfile.aspx ?id=10 http://nrepp.samhsa.gov/ProgramProfile.aspx ?id=10

57. References Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2015). Monitoring the Future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. Ream, G. L., Benoit, E., Johnson, B. D., & Dunlap, E. (2008). Smoking tobacco along with marijuana increases symptoms of cannabis dependence. Drug and Alcohol Dependence, 95(3), 199–208. http://doi.org/10.1016/j.drugalcdep.2008.01.011http://doi.org/10.1016/j.drugalcdep.2008.01.011 Rubinstein. Mark L., Rait, Michelle A, Prochaska, Judith J. (2014). Frequent marijuana use is associated with greater nicotine addiction in adolescent smokers. Drug and Alcohol Dependence, 114, 159–162. Meiera,Caspia,Amblere,Harringtonb, Houts, Keefed, McDonaldf,Wardf, Poultonf,and Mof!tta.(2012). Persistent cannabis users show neuropsychological decline from childhood to midlife. www.pnas.org/cgi/doi/10.1073/pnas.1206820109.www.pnas.org/cgi/doi/10.1073/pnas.1206820109 Ramo, D. Prochaska, J. (2012). Prevalence and co-use of marijuana among young adult cigarette smokers: an anonymous online national survey. Addiction Science & Clinical Practice. 7:5 http://www.ascpjournal.org/content/7/1/5http://www.ascpjournal.org/content/7/1/5

58. Thank you!