Dr. Bonnie Halpern-Felsher: Teen nicotine use
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Nicotine pouches, particularly the “Zyn” brand, are increasingly popular among young people. Meanwhile, nearly 8 percent of high schoolers (1.2 million teens) report that they use e-cigarettes.
On January 22, 2025, SciLine interviewed: Dr. Bonnie Halpern-Felsher, a professor of pediatrics at Stanford University. See the footage and transcript from the interview below, or select ‘Contents’ on the left to skip to specific questions.
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Introduction
[0:00:20]
BONNIE HALPERN-FELSHER: Hi. My name is Bonnie Halpern-Felsher and I’m a professor of pediatrics in the Division of Adolescent Medicine at Stanford University. In my research—which is I developed and direct the REACH lab—our REACH lab, first and foremost, does research—we study adolescent and young adult drug use, substance use, and try to really understand patterns of use, why adolescents and young adults are using various drugs, and then ultimately, with an eye towards prevention and policy. So, we translate the research findings that we have into our really internationally used prevention and intervention programs, as well as into policies at the city, state, and federal level to make sure that we’re regulating tobacco, cannabis, and other drugs to ensure that we’re keeping our young people safe.
Interview with SciLine
What are the trends in nicotine use among young people in recent decades?
[0:01:20]
BONNIE HALPERN-FELSHER: So, the good news about tobacco/nicotine use is that for cigarettes, we’ve seen a dramatic decrease in about the past 20-25, years in youth use of cigarettes, conventional combustible cigarettes. So that’s the good news. We’re now in most states across the country, really well below 10% and often well below 5% of adolescents and young adults who are initiating and continuing to use cigarettes. What hasn’t been the good news is what we’re seeing with electronic cigarettes—some people call it vapes—electronic cigarettes, that use has gone up pretty dramatically over the past 10, 15 years. Now, we started seeing some increase around 2012, 2013, 2014 a little bit of increase in use to around 11%, and that dipped and went up and down until about 2017 where between 2017- 2018 saw dramatic increase in the percentage of adolescents using electronic cigarettes. We saw about 28 to 30% of adolescents reporting past 30-day use, which was a 48% increase amongst middle school students and a 78% increase amongst high school students just in that one, one-and-a-half-year period. Now since the pandemic, the rates are going down, and that is the good news, but I will tell you that while the rates of initiation have gone down, or at least appear to and the reason why I give that caveat is despite some of the national data suggesting it’s around 7 to 10% of use, I’m still seeing schools and parents and teachers contact me daily to use our curriculums because they’re still finding a number of young people using. But what’s more concerning is among those who are using, they’re much more likely to be using frequently, daily, and to be addicted. And we’re not just worried about electronic cigarettes, worried about Zyn, the new nicotine pouches that have been on the market for just a few years or a couple years, I think it is. Those have three or six milligrams of nicotine and could be highly addictive and really change an adolescent brain. So, lots of nicotine and tobacco products on the market that we’re very concerned about.
What is Zyn, and what concerns for you have about it?
[0:03:42]
BONNIE HALPERN-FELSHER: So, Zyn are little white pouches about that big, and you put them between your gum and your lip or cheek, and your lip area could be bottom or top. Most young people seem to be using it up top, and they are nicotine. Supposedly, the tobacco is taken out. It’s just the nicotine. But we’re worried about other ingredients that might be in there. They’re not well studied yet. We still don’t know a lot about the ingredients, the chemicals, the pharmacological aspects of them, but what we do know is that young people are using. A lot of young people are initiating nicotine use through pouches, meaning they’re not going, “Ah, let me use cigarettes. Oh, let me switch to something else.” They’re starting with these nicotine pouches, Zyn. And we’re seeing some teens are using one to three, four, five pillows—these pouches—at a time, and the concern is that they’re either three milligrams or six milligrams of nicotine. So, you’re looking at potentially using a half a pack or a pack of cigarettes in one or two sittings if you’re using multiple pouches at a time.
How have nicotine levels changed in cigarettes over the years?
[0:05:04]
BONNIE HALPERN-FELSHER: The nicotine levels in e-cigarettes has gone up dramatically, starting around 2015 when Juul came out. Before that, we had around zero to 36 milligrams of nicotine per e-cigarette product. Now we’ve gotten in the tens to hundreds, depending on the product. The point is that a pack of cigarettes, each cigarette has about eight milligrams of nicotine. What you inhale is about one to one and a half milligrams of nicotine. If you inhale or smoke an entire pack of cigarettes, it’s 20, 25 milligrams of nicotine. Most e-cigarettes today have double that, if not more. So I think it’s important to realize that when we’re talking about electronic cigarettes—huge amount of nicotine, huge amount of health harms, definitely effects on the heart and lungs. We’re seeing people with lung collapses, with other lung lesions, with lung issues. We’re seeing heart issues right now, and not just adults, with young people as well. Part of it’s the nicotine, part of it’s the inhaling, part of it is some of the other chemicals that are in there, and the flavors themselves. But I think that the amount of nicotine often gets overlooked. And we really—in the U.S.—we have no maximum nicotine level. We do in other countries, but right now, there’s no nicotine standard. E-cigarettes, Zyn, can have as much nicotine as they want, and companies are taking advantage of that, and really on the backs of young people who are suffering and becoming addicted.
Why are young people more susceptible to nicotine addiction, and do the risks differ between cigarettes, e-cigarettes, and nicotine pouches?
[0:06:45]
BONNIE HALPERN-FELSHER: So, nicotine is nicotine. So, whether it’s coming in an inhaled version, like cigarettes or electronic cigarettes, or an absorbed version, like with Zyn or other nicotine products, we are worried about an adolescent brain. Adolescent brains and young adults brains—our brains continue to develop until about age 25. The problem is, as our brains are developing, we’re born with the ability to become addicted to nicotine. So, in a lot of ways, and as our brain is changing, we’re getting rid of, we’re pruning away the parts of the brain that aren’t working for us, we don’t need any more, but so that includes nicotine receptors. We would prune those away, but if we add our nicotine to our bodies during our adolescence and into our young adult time, those receptors say, “Huh, I’m going to stay and maybe I’m going to have more and I’m going to want more nicotine and if you don’t give me nicotine, and I’m used to nicotine, I’m going to be going through withdrawal because I’m now addicted or dependent on that nicotine.” So, I might go through withdrawal and feel pretty sick. So, what happens is, during this time, nicotine actually changes the brain chemistry of an adolescent, young adult. It’s why the tobacco industry targets young people. If you look at all the ads in the marketing, because they know if we can get a young person and a young person addicted, we can have them addicted for life.
What role does marketing play in shaping kids’ and teens’ perceptions of nicotine products?
[0:08:21]
BONNIE HALPERN-FELSHER: So, the marketing is pretty ubiquitous. We don’t see with cigarettes, with all the federal legislation and regulation that’s gone on, for example, TV and radio—we don’t see cigarettes, which is great, but electronic cigarettes, Zyn, still are not being regulated and regulated well. They’re not being regulated well. And we’re seeing marketing on social media. We’re seeing ads for these products, but also, we’re seeing young people, adolescents, young adults, who will make their own marketing. We saw this a lot with Juul, for example, where teens were influencers and adults were influencers. And so, even if it supposedly wasn’t the company marketing, although there’s some evidence that they were also paying people to market for them, but even if they weren’t doing that, just the idea that a young person or an influencer goes on and says, look at what I’m using. I’m using Zyn, or I’m using Juul, or I’m using Vuse, or any other product that’s out there on the market that they’re using those and really enhancing the appeal of those products.
How can parents talk to their children about these products?
[0:09:34]
BONNIE HALPERN-FELSHER: Go home and say to your kids, “I just listened to this interview, and can we find out more about these products.” You’re not going to find out immediately if your kid is using, you know, “Hey, Johnny, are you using?” is not a good way to approach it. “Let’s learn together.” Our Stanford REACH lab has a whole lot of resources and curriculums. They’re completely free, not selling anything to anybody. We have parent resources. We have school resources. We have free curriculums to help students learn, to help teens learn, and help parents have those conversations with their kids. So, we really hope that you’re reaching out to find out more. Just have that dialogue.
Do you have any advice for reporters covering this topic?
[Posted January 22, 2025 | Download video]
