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Taken on my digital camera at Chick-Fil-A Frankfort. 

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When answering the question about who i am today Chick-Fil-A was the first thing that popped into my mind. Its brought me new opportunities and a surplus of new friends that i talk to and work with everyday. Chick-Fil-A will help me achieve my dreams in the future as i have already once been promoted to the leadership position of a team trainer which means next year when i apply for college i will be able to apply for and hopefully get accepted into Chick-Fil-A's leaders scholarship program.

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Taken on my Mom's phone during homecoming pictures. 

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My mom has always been one of the biggest inspirations in my life. She has always had an amazing work ethic and has always taught me that i have to work hard for what i want to achieve in the future. She showed me a strong indepent household figure my entire life growing up which has now taught me to act the same and not count on anyone else for what I want in life. My mom also works as a travel nurse and has been available to guide me through all my ups and downs this year while taking my CNA class with Mrs.Jones and also the state test.

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The way I was raised has greatly affected how I have been shaped as a person. My entire life my dad has done nothing but spoiled me and given me any and everything i've ever wanted but not at no cost. He never had any sons so whether it was mowing the grass, washing the dishes, or even just sitting with him to watch a football I was always around him but i would get whatever i wanted in return. He is one of the hardest workers I know and i belive i get that quality from him as well. He also taught me to never settle and be indepent. He's taught me how to change my breaks and oil, fix my spark plugs, put a tire on and many more things which have all greatly shaped me into the women I am today.

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Taken by me on my digital camera at Cookout in Frankfort 

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I don't play any sports and im only involved in a few extracurriculars at school so the the majority of my time is spent with the people I work with. When looking at the questions it really made me think about how they have changed the way I think and act but also the impact they've left on my heart. They are kind, smart, encouraging, funny, hardworking and leaders and they really do push me everyday to do better. When i accomplished goals like being promoted to trainer and also passing my CNA exam which boost me to my future goals they were all there all there to congratulate me which makes them a big part of who I am today.

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Picture taken by me in Lululemon Lexington

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One thing is for sure and it is that I would not be who I am today without Kate. Through I met Kate just two short years ago I feel like I've known her forever. We have very similar goals in life and she pushes me everyday to be better and achieve those goals. She is kind hearted, gentle, caring and is the first person to tell me to fix my attitude. As were growing up and focusing on college and jobs we've been worrying about if/when well have time to hangout but Kate is always the first person to make free time in her schedule which has taught me punctuality and that you should always make time for what you care about.

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Picture from American College of Surgeons website on a webpage about Trauma Surgery. 

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There were two things that immediately came to mind when I saw the question "what are your dreams for the future" the first of which was trauma surgery and emergency medicine. From a very young age I've always had a love for helping others and ever since my mom has taken me into the hospital with her I've had a love for surgery and emergency medicine. I love the thrill and adrenaline that comes with the aspect of not knowing what you could do that day but I also love the intricacy and detail that it takes to preform a surgery. Saving lives is always something I've known that I want to do so there is no doubt in my mind that I want to work somewhere in emergency medicine.

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The other thing that popped into my mind when thinking about what my goals are in the future was that I want to someday start a family. In the picture above is one of my favorite content creators Devin Cordle. She shares the real realities of being a mom and I find it so raw and inspiring. I've always loved kids and can not wait to someday raise my own. My parents and content creators like Devin make me realize that I can have both the amazing job and a family and still be able to make it work.

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Image from the Boston Globe website on a Article about Energy drinks in College 

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The first thing that popped in my mind when I read "who are you today" was energy drinks. Most people my age who are around me often know me to always have an energy drink in my hand. Yes, they taste good. Yes, I am slightly dependent on the caffeine and yes, I know that is not healthy nor good for me. I use the energy drinks more as a way to cope with my social anxiety. They keep my mind distracted from events where I am anxious and they also sometimes start conversation. I am naturally a very anxious person and get myself worked up often over things that I don't need to be upset over and having a energy often calms that sense of anxiety and brings me a sense of peace and routine.

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Picture taken sometime in 1980 in my grandparents living room. 

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I strive everyday to use the values my grandparents and parents taught me for good. My grandpa battled cancer for 18 years but always had a smile on his face. He taught me to be kind, caring, compassionate, inspiring, and to push through any obstacle you come in contact with. My grandparents were married for 50 years and my nana stuck by my grandpa's side through the countless chemo and radiation sessions, the surgeys, trips and experimental trials he went through and never once complained even though she was hurting too. I have never meet two stronger more loving people and they have greatly shaped me into who I am today.

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Whenever I was thinking about how to answer the question of how I will achieve my goals all I could think about is my CNA state test that I just took (and passed!!) along with my plan to take EMT next year in order to work in the ER at UK or Baptist while i'm in college to get me in that ER/ emergency medicine setting as soon as I can. That in short is the timeline/ plan I have set out so far for myself but I couldn't or wouldn't not have even thought about any of that if it hadn't been for Mrs.Jones. She gave me all those opportunities and has pushed excel in all of them making it possible for me to get on track to accomplishing my dreams and goals as soon as possible.

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One of the biggest influences on social media right now is Alix Earle. I've noticed the use of rhetoric while watching Alix's videos specifically through the use of ethos. She is a new grad college student who shows all the aspects of her life from getting to go to college and completing her degree, get ready with me, parties and even her dirty room. She is very relatable which ,makes it easy for her to use rhetoric through ethos to influence us all. She also uses kairos as everything she does is either already trending, starting to trend or she is about to make it start trending.

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One thing I see advertised everyday in bloom super greens. Bloom uses rhetoric specifically through logos. Bloom does not directly make ads to influence us however they partner with our favorite influencers, at this point it seems to be anyone who has over 100 thousand followers, to get us to buy these greens. They pay influencers to tell viewers about how these greens taste so good and make them feel so thin and debloated and gives them so much natural energy. This is an example of rhetoric through logos as they know that women want to feel skinny and not bloated and use that to their advantage to sell their product.

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When I scroll through Instagram i often see reels that I find funny and relatable. These reels also use rhetoric. This one in specific uses ethos as the author is a women who posts about fashion and beauty and influences me to buy things like the Charlotte Tilbury bronzer which is pictured. I chose this video in specific because it also used an appeal to kairos. At the time of viewing this video i had just gotten paid and was debating on buying some makeup from sephora and i did so after watching that reel.

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Bourbon and Beyond 2024 lineup posted on facebook by Lex-18

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One place I see rhetoric often is in the lineups for music festivals. For this specific one they have two of my favorite artists, Zach Bryan and Tyler Childers headlining the 4-day festival. The creator of this lineup poster uses the rhetorical device of ethos to convince me that I need tickets. They one do this by showing us the credentials they have as a music festival as they say they are the worlds biggest and best music and bourbon festival. They also show their credibility as Childers and Bryan are not small underground artists, they are very big with millions of monthly listeners and do not just headline any festivle.

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Screenshot From a travel account on tiktok 

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As a teenager I spend so much time scrolling on tiktok. When I was planning a trip my friends and I are taking to Knoxville it was the first place I went to look. This creator in specific uses both ethos and logos in his videos. To start he lives in Knoxville and this is a key part of his content. He talks alot about how hes lived there for more than 5 years and "tried it all" making him sound like a credible source. Also most of his recommended things are budget friendly and appeals to logic as when I was planning the trip we had one big expensive thing but also wanted a few cheaper things to fill our time and this video influenced me to plan out the smaller things he recommended.

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Red Bull advertisement at the Gas station 

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I have an energy drink everyday, which can get farley expensive. When I walked into the gas station this immediately caught my eye and made me think "yes!! this is exactly where i see rhetoric everyday", as this is such an appeal to logos. Red Bull's are usually around 3 dollars and 40 cents at the gas station, though i don't often by them individually it can get very expensive when you do. This uses logos as it uses logic to convince you to buy the two instead of the one because if you buy another one later on, say the next day you would be losing money as you would pay say $3.40 twice instead of only $6 once.

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One of the biggest things I see on TikTok everyday is new hairstyles, and i try them everytime. These videos always use either logos or ethos to convince me to try a new hairstyle or a new hair product. When these videos use logos its usually a video like the one pictured of a slick-back hairstyle, ranging from buns to braids. These appeal to logos as if my hair is dirty or greasy and i don't have much time its easy to do one of these slick-back methods. When the video appeals to ethos its usually someone who has similar hair to mine showing a hairstyle or product which i then go try because they are similar to me.

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The biggest thing i see on my For You Page on TikTok is TikTok shop ads. This one in particular is an example of rhetoric in daily life as it uses the appeal to logos to convince you to buy this concealer. The concealer is originally 32 dollars but is half off with the TikTok shop coupon. Even if a person had just bought this concealer from the store they would still probably repurchase while this coupon is valid as you could buy two for the price of one.

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This sweatshirt diy has been all over my titkok lately and every video uses rhetorical devices to convince me to make it myself. This video in particular uses logos to convince me to make it. She shows all the materials she uses and the cost of the materials which all together I much less than your normal sweatshirt so it makes sense to make this one if i think it is cute. She also uses ethos as she makes step by step videos to these sweatshirts which boosts her credibility as a rhetor.

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Posts like these always convince me that i need to buy that prom dress. Often the boutiques that post these around january-march as it is just in time for prom season. This is the use of kairos. Since they are posting these posts right around the time everyone is going prom dress shopping they are convincing you to come shop at their dress shop for your prom dress if you like the ones they post.

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One of the biggest issues in health today is overeating and obesity. The article proposes that over half of adults will be obese by 2030 if there is no change. The article talks about how obesity is a difficult disease to treat as most people will not chose to help themselves. Most people who aren't obese don't make excuses for people who are obese.This being said, they don't feel bad for the people who are obese and not wanting to help themselves. Obesity also leads to many more health problems like heart diseases among other problems.

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A big mental health struggle in today's society is Anxiety. The article talks about how the COVID pandemic and previous trauma have greatly affected peoples mental health. After being in the house and working from home after COVID many people have lost all their social abilities and now have intense anxiety about leaving the house. After covid there was a 24% increase in anxiety. There is not as much of a stigma around mental health now as there used to be so it is pretty normalized by the rest of society to have anxiety or other mental health issues.

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Picture from NBC News article on rising covid-19 and flu cases 

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The flu has always been around, however it had been normalized to get your flu vaccination so cases were not as high as they are now. Since people pushed back on the covid vaccination they also stopped getting their flu vaccinations. Since December flu cases have been rising. Researchers from the CDC say that its not too late to get your flu vaccination and you should still get it since cases are so high.

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Picture from the National Library of Medicine from an article about a nursing shortage.

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A huge problem currently is the shortage of nurses. This article talks about how increasing age, lesser work ethic, and nurse burnout are causing a shortage in nurses. The National Library of Medicine says that the job outlook is not looking to grow much as new nurses are experiencing burnout since they is a mass amount of patients and a little amount of nurses. Hospitals and corporations aren't doing much to help this issue as they aren't incentivising or rising the pay of nursing careers much.

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Picture from Infection Control today on an article about STI's

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Sexually transmitted infections have been increasingly rising recently as, like the article says, people are not using simple protection like a condom because they are more worried about not getting pregnant. People think that if they are on birth control then they don't have to use a condom so this is causing an increase in STI's. The article talks about how there is an increase in "hook up" culture as many people are just looking for one night stands and then are not getting tested afterwards.

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Abortion is one of the biggest health, social, and political issues today. The article talks about how Ohio residents are begging the Biden administration to ease up on abortion laws. The article highlights a women who was detained by police in Ohio when she sought care for her terminated pregnancy. People today usually have strongly opinionated views on this subject and they are either completely against abortion or completely for it.

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Image from an NPR article on rising syphilis cases.

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This article talks about the rising amount of syphilis. In the article they highlight how syphilis cases are reaching all time highs since 1950 and how the amount of cases is varying amongst all age groups including newborns. The article also talks about how stds present no symptoms so people don't know they have it, which is causing a rapid spread. Most people today who are exposed to syphilis and other std's are often at or below poverty level which makes it hard to control the outbreaks of these diseases and also hard to prevent the outbreaks.

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Article from NBC news about a growth hormone causing ALzheimer's.

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This article talks about the link between a human growth hormone that was given to children years ago that is now linked to causing dementia and alzhemiers. Though the article doesn’t identify exactly which growth hormone it is talking about it does mention how said growth hormone has been led to causing many congnative diseases like the ones listed above. People in the community that had taken these growth hormones are worried about how they may decline in the future are are requesting further testing that truly links the hormone to Alzheimer’s and dementa.

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Article from NBC news about death of Americans after surgeries in the dominican republic. 

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Most women look for ways to change and alter their cosmetic image. One of the biggest and most expensive ways to do this is through cosmetic surgery. Recently people have been looking for ways to get these surgeries but for cheaper than they usually would. In the dominican republic many surgeons are offering cosmetic surgeries to Americans at a discounted rate, however these surgeries are leading people to many complications and so far over 90 deaths. However many people are still looking for and getting these surgeries because they are cheap and they want the results.

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One of the biggest concerns with teens in todays day and age is vaping and the wide consumption of nicotine products. Nicotine and the chemicals in vapes are linked to cancer and other terrible diseases. In this article they talk about the short term and long term effects vaping takes on the body and also about what causes it to be addictive and things you can do to stop. Lots of statements like this are put out on platforms teens use everyday in order to get them to stop vaping and consuming the harsh chemicals which is why Facebook and adults continue to fund, make and push them onto social media

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This article from Jama Network discusses the new advancements in screening for Eating Disorders. Eating Disorders is one of the biggest health issues amoungst teens and young adults. Almost 80% of eating disorders go undiagnosed according to the arcticle only and about 10% of dignosed patients seek treatment. Eating disorders effect mental, physical and emotional heath. The article talks about how eating disorders were previously diagnosed through a few screening questions that talk about your eating habits and how you feel after you eat and also though a calorie intake test. Now, new research suggests that these screenings were not going in depth enough and leaving people who had ED symptoms undiagnosed.

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Recent Advances in Developmental and Risk Factor Research on Eating Disorders - PubMed

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In this article PubMed talks about how eating disorders in teens and young adults has been linked to leading to developmental issues in the brain and other organs. Often teens with eating disorders are not providing their body with enough health nutrients like fatty acids, protein and certain vitaminas that their bodies need to grow and develop the article states. It talks about how teens are only eating things that are low in calories which in turn are also low in nutrients. PubMed suggests that around 1 in 4 teens today have an eating disorder and atleast 1 in 5 are suffering with developmental issues due to it.

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diagnostic and statistical manual of mental disorders

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national center for biotechnology information

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Recent Advances in Developmental and Risk Factor Research on Eating Disorders - PubMed

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The Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5) currently recognizes three primary eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. The origins of eating disorders are complex and remain poorly understood. However, emerging research highlights a ...

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Prevalence of eating disorders in elite athletes is higher than in the general population - PubMed

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Athletes are the most prominent group in eating disorder studies as over 40% of athletes struggle with eating disorders. PubMed suggests dancers, cheerleaders, basketball players and wrestlers along with other athletes are being shown to have the highest numbers of eating disorders compared to other athletes and the general population. Along with these specific sports female athletes have been shown to be at a greater risk for eating disorders as they are viewed through different societal standards. These eating habits in athletes have been linked to lower athletic performance and also higher injury risk.

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Prevalence of eating disorders in elite athletes is higher than in the general population - PubMed

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The prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports. A collaborative effort among coaches, athletic trainers, parents, physicians, a…

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More States Call on Schools to Provide Period Products, But Many Don't Fund Mandates

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Another big health issue today is the availability of period products for teens in school. Only 8 states require period products to be placed in schools with funding and 9 states require them in schools with no funding. The article states that 1 in 4 women have to chose between eating and buying menstrual products. This is causing women to miss out on jobs, educations and opportunities as they have to decide whether they will have food on the table or have sanitary products. The article talks about how this is causing other health issues like anxiety, depression and other social/ emotional issues.

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The new laws aim to address "period poverty," a term coined by student advocates who say inadequate access to tampons and sanitary pads can make it difficult for low-income menstruating students to attend school and engage in classroom work during their periods.

New York became the first state to require free period products in schools in 2018, and many other states have passed or considered similar bills in the time since, according to an analysis released last week by the National Association of State Boards of Education.

"While nothing prohibits a school from providing menstrual products to students free of charge, many school leaders are unaware of the disparate access to these items, the negative impact the disparity has on access to education, and the low-cost solution," the analysis says.

But new state laws don't always lead to universal access to the products, the report found, suggesting issues of funding, compliance, and details like where products are offered in schools affect whether the policies are effective in helping students.

What states require schools to stock free period products?

"Menstrual products are as necessary as toilet paper and soap, but can be one expense too many for struggling families," former New York Gov. Andrew Cuomo, a Democrat, said as he signed the state's 2018 law.

While some states, like California, had required schools to provide pads and tampons in high-poverty schools, New York's was the first to make the requirement universal for schools with 6th- through 12th-grade students.

Sixteen additional states and D.C. have passed various versions of "period poverty" laws since, the NCSB report found, but 10 states and the District of Columbia do not provide funding to support those efforts.

Six additional states don't require schools to offer pads and tampons, but they provide some funding to support voluntary efforts to do so.

Funding levels and grant qualifications vary in those states. In Colorado, for example, a 2021 law created an application-based program that provides grants from $1,000 to $5,000 to districts where at least 50 percent of students qualify for free- and reduced-price meals.

In contrast, a 2022 Utah law is far more expansive. It requires public school districts and charter schools to offer free menstrual products in all girls' and unisex restrooms in elementary, middle, and high schools. The state will provide funding to support those efforts in early years, but districts must find ways to pay for them independently by 2025. That bill passed unanimously in the state's legislature.

"We need to make sure [these products] are available to every young girl in our schools," Senate Majority Whip Ann Millner, a Republican, told the Deseret News at the time.

How pervasive is 'period poverty' for students?

Providing access to menstrual supplies coincide with schools' larger efforts to address students' nonacademic needs. Fatigue, lack of laundry access, need for mental health services, and unreliable transportation can all create hurdles to learning, school leaders say.

Student advocates have said efforts to provide free menstrual products make sense in that context. But there is no official federal data on students' access to supplies like sanitary pads and tampons.

Fifty-one percent of respondents said they had worn products longer than recommended, which can lead to dangerous health conditions, such as toxic shock syndrome. Thirty-eight percent of respondents said they sometimes or often "cannot do their best schoolwork due to lack of access to period products," the survey found.

Differences in policies on period poverty

State laws that require schools to provide menstrual products vary. While some require schools to stock restrooms with the supplies, others allow them to make the products available by request from school nurses. The latter can be a barrier for shy students or those who aren't aware of the option.

Most state laws require period supplies in girls' and unisex restrooms. In some states, schools without unisex restrooms must make them available for male students as well, a requirement aimed at inclusivity for transgender and nonbinary students.

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More States Call on Schools to Provide Period Products, But Many Don't Fund Mandates

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Seventeen states and the District of Columbia require schools to stock free menstrual products for students, an analysis finds.

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The case for free tampons and pads in schools

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This NPR article discusses a plea by women all over the country for free menstrual products in school. The article says 4 in 5 women miss school or work due to then not having access to menstrual products. I personally think this is a public health problem because women should not have to risk their education or their jobs/ income due to not having access to a product that allows us to function normally during a period which is a natural bodily function. The article discusses how public schools don’t have the budget or funding from the state to be able to provide these products for free and how administrators and legislators don’t see the big problem.

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At age 9, Mahoro Amani got their period for the first time. At home, their mother talked openly about everything they needed to know. But, their mom told them, never mention this at school.

"I was told to basically keep it a secret," says Amani, who's now 15 and a 10th grader at Miami Arts Charter High School, in Florida. The school, they say, doesn't teach students about periods or supply menstrual products to students in restrooms.

"It was really concerning to me how many kids have had panic attacks or cried in the bathroom because they don't have pads and none of their friends have pads on them," Amani said.

Amani is the president of the school's student council, and they're working with others on the council to get free menstrual products in the school's restrooms. However, administrators have told them there are no plans to use school funds to do so.

Florida is one of many states that do not require schools to provide menstrual products, and a growing number of organizations, activists and students like Amani are trying to change that.

Dozens of states are considering laws related to period equity

This year, bills related to period equity have been introduced in 37 states, according to Women's Voices For The Earth, a nonprofit advocacy group. But as of this fall, only five states require schools to provide menstrual products. Last month, California became the latest to do so, mandating that public schools and colleges stock free pads, tampons and other products in their restrooms.

In Michigan, the city of Ann Arbor recently passed a law to stock all public toilets with menstrual products.

In Florida, legislation that would require free products in school restrooms has been introduced twice, but has yet to pass.

Recent studies have shown that about a quarter of menstruating students struggle with access to period products, and that many teens still feel a stigma around menstruation.

"This country already expects schools to provide toilet paper and soap," says Damaris Pereda, the national programs director of PERIOD, a nonprofit advocacy group. Why, she asks, shouldn't students who menstruate have the same access to basic supplies? "So that if something happens, they just go to the restroom and get their things and continue to live their lives."

Access to period products has an impact on learning loss

Currently, many schools keep menstrual products in the school nurse's office.

At those schools, "while you can get a period product, you often have to walk across the campus while you're still bleeding through," Pereda says. "What happens in that case is that a lot of students feel ashamed and like they've lost some of their dignity."

Right now, there is little national data about teenagers' access to menstrual products. But what little information there is suggests the lack of access is worse for poor students. The only publicly available study tracking the impact of period poverty among U.S. teenage students, which was funded by PERIOD and Thinx, found that 23 percent of students have struggled to afford period products.

California addressed this lack of access in 2017 by requiring schools in low-income districts to provide free period products in schools. The legislation passed in October expanded that access to all schools and requires products to be in half of a school's bathrooms.

"It becomes a barrier to education," says Cristina Garcia, the Democratic state assemblywoman who introduced the legislation, which was signed by Gov. Gavin Newsom (D) in October. "These are our most vulnerable kids, who already have a lot of barriers. This should not be one of them."

Nicky Dawkins, who runs PERIOD's Miami chapter, is hoping the recent legislative win in California will help mobilize educators, students and health professionals across Florida.

"We don't want to continue to Band-Aid this problem," Dawkins says. "We want to solve the issue, which is done through passing bills."

The study also found that 70% of students felt that their school environment made them feel self-conscious about their period.

At Miami Arts, Amani feels like the stigma can be seen everywhere. They told NPR that there isn't a nurse that students can go to when they need period products or have questions about their period.

"There are people who think they're dying because they started bleeding," Amani said. "They freak out and don't know what to do, and if schools were more open about menstruation, we could lessen the stigma."

Alfredo de la Rosa, the founder and principal of Miami Arts Charter, told NPR that while the school does not employ a nurse, students can go to an administrator's office if they need menstrual products. "A female assistant principal (or delegate if she is absent) is assigned to provide menstrual products to any young lady who requests them," he said in an email.

Activists see period products as a medical necessity

Advocates say the issue goes beyond stigma, to affect the quality of education as well. The study found that 4 in 5 menstruating teens said they have either missed class time, or know someone who missed class time, because they did not have access to period products.

Pereda says this learning loss often happens when students need to go home because they are unable to find products they need: "Then, they don't want to come back to school, or if they do, they've already lost that time, all because they didn't have access period products at school."

Like Amani, Margaret Schedler approached her school about stocking the bathrooms with period products. She's a junior at The Altamont School, a private college prep school in Birmingham, Ala. Schedler says the administration was receptive to the idea, and agreed to her plan to have her school club raise money for the project. The school provides, and pays for, menstrual products to students in the front office and nurse's office.

Now, Schedler's club, Ladies of Lavender, relies on student donations to provide menstrual products in Altamont's restrooms. Even though the club receives a lot of donations, Schedler says it still feels unfair that the students bear this responsibility, especially because they have to hold donation drives every month, and students often complain that they've already donated supplies in the past.

"Schools should realize that [menstruation] isn't a choice," Schedler argues. "And if they want to support menstruating citizens, they should do the bare minimum and make sure that public- and state-funded places have period products that people can use."

Cost is often cited as a factor when considering whether to provide widespread access to these products. Free the Tampon, an advocacy group focused on getting period products in state budgets, estimates that it costs $5-7 per year per student to supply period products. Advocates working with the Office of Legislative Services in New Jersey are estimating the cost of the recent law requiring schools to provide period products to students in public schools at about $750,000 per year.

Advocates say the costs bring benefits for students. A pilot program in New York City found that attendance increased by 2.4% among girls at a city high school after making tampons and pads available in its restrooms.

Others argue that the question of cost sidesteps a larger point.

"Menstrual products should be treated in the same way you treat restocking toilet paper," says Michele Anzabi, one of the presidents of the PERIOD chapter at the University of Pennsylvania. "It's a medical necessity and therefore, it shouldn't be hindered by conversations about cost, but treated as something that needs to be addressed."
Mansee Khurana

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The case for free tampons and pads in schools

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Activists say menstrual products are a basic necessity that shouldn't require a long walk to the school nurse's office, and that providing them is key to removing the stigma of periods.

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'Do you even lift, bro?:' toxic gym culture perpetuates harmful lifestyles

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A big concern in the health of the public is obesity however most people are intimidated to go to the gym due to the culture that is present. Toxic gym culture is a big issue as it is driving people away from the gym due to anxiety, embarrassment and peer pressure which is leading to obesity and unhealthy lifestyles. The article also discusses how this leads people to injury’s and furthering their already current injuries as they are scared of what people may say if they don’t go to the gym and lift heavy loads.

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Extreme carb deficits, strict fluid-only diets and compulsive exercise are some examples of toxic fitness plans. Personal fitness is a commitment to bettering oneself. However, pressure from other gym-goers, witnessing twisted forms of "fitness journeys" on social media and personal toxic ideals, can all lead individuals down a darker fitness path.

When thinking about addiction, oftentimes images of drugs and alcohol come to mind. However, not all forms of addiction are tangible, such as exercise addiction. According to the National Center for Biotechnology Information (NCBI) , negative gym environments can cause exercise addiction, appearance anxiety and body dysmorphic disorder (BDD).

Conditions such as exercise addiction, a debilitating obsession with physical fitness, and BDD, a mental obsession over perceived flaws, can potentially plague insecure gym participants. Those already experiencing exercise addiction or BDD may suffer more greatly from the overuse of a variety of fitness products. These can include illicit drugs used to boost performance, informing the need for educating and supporting those suffering from body image issues.

According to , the irresponsible use of drugs like anabolic androgenic, a steroid used to hasten muscle recovery, can lead to conditions such as sudden cardiac arrest. Considering the main intention of fitness is to promote health, it would be ill-advised to risk one's life simply to fit an expectation or goal.

Negative gym environments affect all sexes as well. According to Bradley University , women are generally encouraged to focus on the circumference of their waist. However, as reported by ScholarWorks , thinner-built women face increased ridicule in toxic gym environments due to them being expected to look not only lean but also muscular. This expectation is unfair because the effort put into the gym is not the only thing that decides build; something like genetics, which is out of any individual's control, also affects everyone's fitness journeys.

For males, societal expectations to consistently exist at top fitness level with a "Greek-god-like" exterior are also a heavy burden to bear. Although looking lean yet muscular isn't the only unhealthy body expectation for men, it can be exacerbated by pressures within gym settings, as reported by Bradley University .

Additionally, men are more likely to obtain an atypical eating disorder and substance abuse issues compared to women. Self-image issues from within gym experiences can then stretch to their daily lives, like what they put into their bodies, as reported by Bradley University . In the same vein as females, a fit appearance is not a prototype that should be used across all individuals because it's different for each person.

Phrases thrown around like "Do you even lift, bro" and ego-lifting, have also contributed to a growing malignant gym setting. According to , integrating these phrases and mindsets into gym-goers' thoughts can lead to a significant risk of illness.

Gym personalities are not the only negative effect of gym culture. Misinformation spread on social media about gym expectations and culture can lead to even larger distorted perceptions of health and fitness. According to Snap Fitness , it's unfair to prescribe the same workout routine to an entire population because not everyone can handle restrictive diets, lifting heavy weights and high-intensity workouts.

Personal fitness should be just that-personal. There is no one perfect body, perfect diet or perfect gym routine. In order to promote a healthier gym environment for anyone invested in that enterprise, it's critical not to stay only at one's own squat rack but also within one's own lane.

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'Do you even lift, bro?:' toxic gym culture perpetuates harmful lifestyles

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Extreme carb deficits, strict fluid-only diets and compulsive exercise are some examples of toxic fitness plans. Personal fitness is a commitment to bettering oneself. However, pressure from other gym-goers, witnessing twisted forms of "fitness journeys" on social media and personal toxic ideals, can all lead individuals down a darker fitness path.

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One of the biggest problems in health care currently is the shortage of nurses. The aacnursing article discusses the reasoning behind the nursing shortage like how new nurses are experiencing pre mature burnout due to the heavy load of patients. Also after the pandemic most nurses left their regular hospital in search for a higher paying travel job as they felt they were working too hard for two little pay. The job outlook is not looking to increase anytime soon bc the new generation (gen z) is more likely to take jobs in the social media, fashion, and marketing industries.

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The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows. Compounding the problem is the fact that nursing schools across the country are struggling to expand capacity to meet the rising demand for care. The American Association of Colleges of Nursing (AACN) is working with schools, policy makers, nursing organizations, and the media to bring attention to this healthcare concern. AACN is leveraging its resources to shape legislation, identify strategies, and form collaborations to address the shortage.
Download Fact Sheet [PDF]

According to the Bureau of Labor Statistics' Employment Projections 2021-2031, the Registered Nursing (RN) workforce is expected to grow by 6% over the next decade. The RN workforce is expected to grow from 3.1 million in 2021 to 3.3 million in 2031, an increase of 195,400 nurses. The Bureau also projects 203,200 openings for RNs each year through 2031 when nurse retirements and workforce exits are factored into the number of nurses needed in the U.S.

The Advanced Practice Registered Nurse (APRN) workforce, including Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives, is expected to grow much faster than average for all occupation, by 40% from 2021 through 2031, according to the BLS' Occupational Outlook Handbook. Approximately 30,200 new APRNs, which are prepared in master's and doctoral programs, will be needed each year through 2031 to meet the rising demand for care.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

In April 2022, Dr. David Auerbach and colleagues published a nursing workforce analysis in Health Affairs, which found that total supply of RNs decreased by more than 100,000 from 2020 to 2021 - the largest drop than ever observed over the past four decades. A significant number of nurses leaving the workforce were under the age of 35, and most were employed in hospitals.

The Institute of Medicine in its landmark report on The Future of Nursing called for increasing the number of baccalaureate-prepared nurses in the workforce to at least 80% to enhance patient safety. The current nursing workforce falls short of this recommendations with only 65.2% of registered nurses prepared at the baccalaureate or graduate degree level according to the latest workforce survey conducted by the National Council of State Boards of Nursing.

Nursing school enrollment is not growing fast enough to meet the projected demand for RN and APRN services.
Though enrollment in entry-level baccalaureate programs in nursing increased by 3.3% in 2021, AACN did report drops in both PhD and master's nursing programs by 0.7% and 3.8%, respectively. These trends are raising concerns about the capacity of nursing schools to meet the projected demand for nursing services, including the need for more nurse faculty, researchers, and primary care providers.
A shortage of nursing school faculty is restricting nursing program enrollments. A significant segment of the nursing workforce is nearing retirement age.

According to a 2020 National Nursing Workforce Survey conducted by the National Council of State Boards of Nursing found that the average age for an RN is 52 years old, which may signal a large wave over the next 15 years.

In a Health Affairs blog posted in May 2017, Dr. Peter Buerhaus and colleagues project than more than 1 million registered nurses will retire from the workforce by 2030.

Changing demographics signal a need for more nurses to care for our aging population.

The U.S. Census Bureau reported that by 2034, there will be 77.0 million people age 65 years and older compared to 76.5 million under the age of 18. With larger numbers of older adults, there will be an increased need for geriatric care, including care for individuals with chronic diseases and comorbidities.
Amplified by the pandemic, insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession.

According to data published in Nurse.com's 2022 Nurse Salary Research Report, 29% of nurses across all license types considering leaving in 2021, compared with 11% in 2020.Among nurses who are considering leaving the profession, higher pay was the most influential motivation to stay, followed by better support for work-life balance and more reasonable workload.

In March 2022, the American Nurses Foundation and the American Nurses Association released the results of its COVID-19 Impact Assessment Survey, which found that 52% of nurses are considering leaving their current position due primarily to insufficient staffing, work negatively affecting health and well-being, and inability to deliver quality care. In addition, 60% of acute care nurses report feeling burnt out, and 75% report feeling stressed, frustrated, and exhausted.

In September 2021, the American Association of Critical-Care Nurses reported survey findings which show 66% of acute care nurses have considered leaving nursing after their experiences during the pandemic.

Many scientific studies point to the connection between adequate levels of registered nurse staffing and safe patient care.

In November 2021, new research in Nursing Outlook examined Variations in Nursing Baccalaureate Education and 30-day Inpatient Surgical Mortality. Researchers found that having a higher proportion of baccalaureate-prepared nurses (BSN) in hospital settings, regardless of educational pathway, is associated with lower rates of 30-day inpatient surgical mortality. The findings support promoting multiple BSN educational pathways.

In the July 2017 issue of BMJ Quality & Safety, the international journal of healthcare improvement, Dr. Linda Aiken and her colleagues released findings from a study of acute care hospitals in Belgium, England, Finland, Ireland, Spain, and Switzerland, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages.

In a study published in the journal BMJ Quality & Safety in May 2013, researcher Heather L. Tubbs-Cooley and colleagues observed that higher patient loads were associated with higher hospital readmission rates. The study found that when more than four patients were assigned to an RN in pediatric hospitals, the likelihood of hospital readmissions increased significantly.

In the August 2012 issue of the American Journal of Infection Control, Dr. Jeannie Cimiotti and colleagues identified a significant association between high patient-to-nurse ratios and nurse burnout with increased urinary tract and surgical site infections. In this study of Pennsylvania hospitals, the researchers found that increasing a nurse's patient load by just one patient was associated with higher rates of infection. The authors conclude that reducing nurse burnout can improve both the well-being of nurses and the quality of patient care.

In a study publishing in the April 2011 issue of Medical Care, Dr. Mary Blegen and her colleagues from the University of California, San Francisco found that higher nurse staffing levels were associated with fewer deaths, lower failure-to-rescue incidents, lower rates of infection, and shorter hospital stays.

In March 2011, Dr. Jack Needleman and colleagues published findings in the New England Journal of Medicine, which indicate that insufficient nurse staffing was related to higher patient mortality rates. These researchers analyzed the records of nearly 198,000 admitted patients and 177,000 eight-hour nursing shifts across 43 patient-care units at large academic health centers. The data show that the mortality risk for patients was about 6% higher on units that were understaffed as compared with fully staffed units. In the study titled "Nurse Staffing and Inpatient Hospital Mortality," the researchers also found that when a nurse's workload increases because of high patient turnover, mortality risk also increases.

A growing body of research clearly links baccalaureate-prepared nurses to lower mortality and failure-to-rescue rates. The latest studies published in the journals Health Services Research in August 2008 and the Journal of Nursing Administration in May 2008 confirm the findings of several previous studies which link education level and patient outcomes. Efforts to address the nursing shortage must focus on preparing more baccalaureate-prepared nurses in order to ensure access to safe patient care.

In March 2007, a comprehensive report initiated by the Agency for Healthcare Research and Quality was released on Nursing Staffing and Quality of Patient Care. Through this meta-analysis, the authors found that the shortage of registered nurses, in combination with an increased workload, poses a potential threat to quality. Increases in registered nurse staffing was associated with reductions in hospital-related mortality and failure to rescue as well as reduced length of stays.

A shortage of nurses prepared at the baccalaureate level is affecting health care quality and patient outcomes. In a study published September 24, 2003, in the Journal of the American Medical Association (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.

AACN is committed to working with the education and healthcare community to create a highly educated nurses in sufficient numbers to meet the needs of the nation's diverse patient population. To address the nursing shortage, AACN is advocating for federal legislation and increased funding for nursing education (Title VIII, FAAN Act); promoting a post-baccalaureate nurse residency program to aid in nurse retention; encouraging innovation in nursing programs, including the development of fast-track programs (second-degree BSN and MSN programs; baccalaureate to doctoral); and working with partner organizations to highlight careers in nursing, including those requiring graduate level preparation.

Since 2010, AACN has operated NursingCAS, the nation's centralized application service for nursing education programs that prepare nurses for entry-level and advanced roles. One of the primary reasons for launching NursingCAS was to ensure that all vacant seats in schools of nursing are filled to better meet the nation's need for RNs, APRNs, and nurse faculty.

In June 2022, the National Council of State Legislatures issued a brief profiling different legislative approaches states are using to address the nursing shortage, including adapting scope of practice laws and offering financial incentives for preceptors,

In a report on How To Ease the Nursing Shortage in America released in May 2022, the Center for American Progress calls for bold policies toward solving the nursing shortage to ensure that more patients with access to safe, high-quality nursing services. The report highlights how federal and state policymakers can address the shortage through coordinated planning, action, and investment.

Many statewide initiatives are underway to address both the shortage of RNs and nurse educators. For example, in October 2022, the University of Minnesota and Minnesota State joined forces to create Coalition for Nursing Equity and Excellence, which will work with every school of nursing in the state, healthcare providers, and others stakeholders to increase enrollment in nurse education programs, expand equity in the nursing workforce, and increase student success. Additional initiatives are also underway in Florida and Louisiana among other states.

Nursing schools are forming strategic partnerships and seeking private support to help expand student capacity.

Buerhaus, P.I., Staiger, D.O., Auerbach, D.I., Yates, C., & Donelan, K. (2022, January). Nurse employment during the first fifteen months of the COVID-19 pandemic. Health Affairs, 41(1).

Buerhaus, P.I. (2021, September/October). Current nursing shortages could have long-lasting consequences: Time to change our present course. Nursing Economics, 39(5), 247-250.

Firth, S. (2022, May 16). More Support Needed to Shore Up Nurse Pipeline, Experts Say. MedPage Today.

Updated: October 2022
Contact

Robert Rosseter
rrosseter@aacnnursing.org

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The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows. Compounding the problem is the fact that nursing schools across the country are struggling to expand capacity to meet the rising demand for care.

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Another health issue in today’s society that is really prominent is the accessibility of insulin for diabetics.  One in two dibetics don’t have access to insulin the article states. They suggest having more coverage by insurance as well as having insulin covered by Medicare and Medicaid as those are the patients that need it the most. The article talks about how over 60 million Americans have diabetics with no access to insulin and are at risk for kidney failure, blindness, and limb amputation

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A global perspective on the issue of access to insulin

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Insulin is so easily accessible for diabetics, especially type two diabetics. Insulin is not as mass produced as other drugs so the price of insulin is very high which is one of the main points the article touches on. 90 to 95% of type two diabetes and over half of those diabetics don’t have access to the amount of insulin they need if they have access to any at all . The article talks about how people are “rationing” their insulin in order to not run out before their next supply that is covered by insurance comes. This is leading people to eating disorders and to be deficient in the vitamins and nutrients they need

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Diabetologia. 2021; 64(5): 954-962.

Graphical abstract

The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients' abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO's Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.

Supplementary Information

The online version contains a slideset of the figures for download, which is available at 10.1007/s00125-020-05375-2.

Keywords: Developing countries, Diabetes mellitus, Health services accessibility, Insulin, Review

Introduction

The year 2021 marks a momentous milestone for the diabetes community, with the centenary of the discovery of insulin. Insulin's discovery by Banting and Best at the University of Toronto (ON, Canada) in 1921 meant that type 1 diabetes went from being a death sentence to a manageable chronic condition. Leonard Thompson was the first person to receive insulin as a treatment for type 1 diabetes in 1922 in Canada. That same year, Elliot Joslin stated, 'A new race of diabetics [people with diabetes] has come upon the scene' [ 1] due to the discovery of insulin. Later, in 1925, in his book 'A diabetic life' [ 2], Robert D. Lawrence declared, 'Now modern discoveries, particularly insulin, have completely changed the outlook. There is no reason why a diabetic [person] should not, if he can be taught to do so, lead a long normal life'.

However, these initial positive views on the prospects of insulin therapy in the 1920s are in harsh contrast to the reality that many people with diabetes face some 100 years later, specifically owing to lack of access to insulin. Basu et al. [ 3] found that, globally, in individuals with type 2 diabetes, one in two people had access to the insulin they needed; whilst in sub-Saharan Africa, this number was found to be to only one in seven people, highlighting the impact of poor health systems, and lack of access to insulin and other tools necessary for diabetes management, on the effective delivery of diabetes care.

Global barriers to insulin access

In 2016, the former Director-General of the WHO declared that 'people with diabetes who depend on life-saving insulin pay the ultimate price when access to affordable insulin is lacking' [ 4]. A study in 13 low- and middle-income countries (LMICs), published in 2019, found that mean availability of insulin was 55-80% in facilities that should have had insulin available on the day of study [ 5]. Furthermore, in looking at standardised prices per 10 ml vial of 100 U insulin in this study, the median price governments pay (the government procurement price) for human insulin was shown to be US$5, with analogue (long-acting) insulin being 6.6 times more expensive. Across public and private pharmacies and private hospitals, the median price that an individual has to pay for human insulin is US$9 [ 5]. Clearly, in LMICs, these prices are out of reach for most individuals; however, the affordability of insulin is also an issue in high-income countries [ 6- 8]. The WHO's framework on understanding the life cycle of medicines [ 9] provides a useful model for understanding the complexity of the barriers to access to insulin that are present globally (Fig. ​(Fig.1 1 ).

Research and development and innovation

The first component of the WHO framework [ 9] is research and development (R&D) and innovation. In a study in 2016, Kaplan and Beall looked at insulin-related patents to assess R&D and innovation and found that no patents existed for human insulin and many patents for analogue insulins expired in 2015 for products already on the market [ 10]. Most of the patents were filed by large multinational companies, with a few of the patents identified being from companies in China and India. In the USA, more than half of patents were found to be for insulin-delivery devices rather than insulin itself [ 11].

The transition from animal to human and then analogue insulin is seen as an innovation [ 12], but one that comes at a higher price [ 13, 14]. Some innovations in modes of administration of insulin (inhalable or oral insulin) have not shown any success [ 15, 16]. The promising so-called 'smart insulin' or glucose-responsive insulin that would reduce the risk of hypoglycaemia associated with insulin's use is one innovation that is currently in the pipeline [ 17].

Manufacturing

In looking at the manufacturing of insulin, two factors need to be considered: (1) insulin is a complex biological product that requires specific expertise to manufacture in order to ensure a high quality, safe and efficacious product [ 6]; (2) at present, the manufacturing of insulin is concentrated in three large multinational companies-Eli Lilly, Novo Nordisk and Sanofi (known as 'the big three'). Eli Lilly, Novo Nordisk and Sanofi have a 96% share of the insulin market by volume and hold 99% of the market by value [ 6]. Other insulin manufacturing companies have been identified, including producers in India and China [ 18], but their current impact on the global market is negligible. In parallel to industrial production, so-called 'biohackers' are attempting to provide an open-source method for the production of insulin to possibly lower the costs of production, as well as increase competition [ 19]. Gotham et al. [ 20] estimated that the cost of production for human insulin for a 10 ml 100 U vial would be between US$2.28 and US$3.42, whilst the cost of manufacturing most formulations of analogue insulin was slightly higher (US$3.69-6.34), with the exception of insulin detemir, with costs of production of US$13.47-17.35. In comparing the median government procurement prices in different countries with the cost of production, procurement prices were found to range from 1.8 to 2.6 times higher than production costs for human insulin, and 2.0 to 9.3 times higher than production costs for analogue insulin (Fig. ​(Fig.2 2 ).

Marketing and registration

All medicines are required to have marketing authorisation and must be registered by a national regulatory agency before placement on the market. This requires scientific evaluation of the product to ensure that it meets specific standards of safety, efficacy and quality [ 21]. For biological products, such as insulin, this process is more complex than for chemical entities. For biosimilars, generics of biological products, the process of regulatory assessment is demanding and includes the need for clinical trials [ 22]. These requirements affect the cost of insulin and the entry of biosimilar products into the market.

In parallel to the complex process that is needed for insulin manufacturers to produce and get their products approved by regulatory agencies, there is also the challenge that many regulatory agencies in LMICs do not have the technical capacity to assess the data in the dossiers prepared for biological products. To address this, the WHO developed the Prequalification Programme in 2001, mainly in response to HIV/acquired immune deficiency syndrome (AIDS), to assess the quality of anti-retroviral products. The WHO announced the launch of prequalification for insulin in November 2019 [ 23]. This allows any producer of insulin to submit their product for regulatory review by the WHO. Through this process, competition in the insulin market will hopefully be increased whilst ensuring safety and efficacy of products for governments and their populations.

Selection, pricing and reimbursement

Just because a medicine meets regulatory standards, this does not necessarily mean that it is selected and used. The WHO's Model Essential Medicines List (EML) is aimed at guiding individual countries with regard to their decisions on their choice of medicines, and only includes guidance on soluble and intermediate-acting insulin in vial form [ 24]. Although long-acting insulin analogues were put forward for inclusion on this list in 2019, they were not included because the 'available evidence shows efficacy and safety advantages of analogues compared to human insulin which are insufficiently large to justify the cost differential that continues to exist.' [ 25] For analogues to be considered an essential medicine and included in the WHO EML, more evidence is needed on their effectiveness, as well as a decrease in their price [ 26].

For pricing of medicines, different countries have different policy measures for both the system and individuals [ 27]. For example, in Europe, these processes include health technology assessments to help determine the 'therapeutic value' of a medicine, referencing pricing, value-based pricing (price established based on 'added therapeutic value'), policies encouraging the uptake of generic products and tendering at different levels of the health system [ 28]. Such measures do not exist in many LMICs [ 27] meaning that, as in the USA, prices are free to be set by the 'market'. This can result in increasing prices of insulin, as has been seen in the USA [ 29], due to a lack of government control on medicine pricing. Figure ​Figure2 2 shows the prices for government procurement of insulin (per 10 ml vial of 100 U insulin), which range from US$2.2 to US$43.5 for human insulin and US$6.9 to US$81.7 for analogue insulin.

In many LMICs, the price of insulin is paid for in full by an individual [ 27] or, in some contexts, subsidies are in place [ 30]. In contrast, in most high-income countries, a variety of government-funded or insurance schemes provide some form of financial protection, either ensuring that insulin is provided for free to the individual or, at least, that the person does not bear the full cost [ 27, 28].

Procurement and supply

Pricing policies and approaches taken by governments will affect how medicines are procured. In most LMICs, insulin is purchased via centralised tenders for the public sector [ 31]. In the private sector, this is done via wholesalers and private pharmacies. Another source of insulin includes donation programmes, such as Life for a Child or Novo Nordisk's Changing Diabetes in Children [ 32]. Although these initiatives have had a positive impact for individuals with type 1 diabetes, they have not been integrated into the formal health system, which raises issues of sustainability [ 32].

Once insulin is procured, dependent on the sector and health system, the price difference between the government procurement price and patient price might increase due to import tariffs, storage costs, transportation costs, dispensing fees, sales taxes and other fees. These mark-ups also apply at different stages of the supply system in the private sector. Ball et al. [ 33] found that these mark-ups cumulatively equalled 8.7-47.7% of the manufacturer's selling price for locally produced insulin and 10.0%-565.8% for imported insulins. It is important to note that, beyond price, a variety of geographical and health system factors can have an impact on access to insulin, such as distance of the patient to healthcare facilities [ 31].

Prescribing

The prescribing of insulin is affected by the organisation of care and where in the health system (e.g. in the hospital or in primary healthcare [PHC]) people can receive their diabetes care. For example, in Vietnam, access to insulin is mainly provided in major urban areas and in hospitals [ 34]. In some contexts, only specialists are able to prescribe insulin [ 30]. At PHC level, there is often a lack of experience and expertise, gaps in knowledge, fear of hypoglycaemia, missing guidelines and even fear of prescribing insulin [ 35, 36]. Additional challenges to insulin prescribing include the fact that some health professionals no longer know how to use human insulin as they have received their training in contexts where only analogue insulin is used [ 37] and the possible impact that the pharmaceutical industry might have on prescribing decisions of doctors [ 38, 39].

Dispensing

Dispensing, or the provision of insulin by the health system to an individual, faces two clear challenges in many LMICs [ 30, 31, 34]: (1) the often-large distance between communities and health facilities that provide diabetes care; and (2) the fact that insulin prescriptions may only be available from secondary or even tertiary healthcare facilities. Beyond these factors, there is also the issue that the insulin may not be available in the pharmacy when the individual goes to get it. For example, in Peru, although insulin is supposed to be available in the public sector, it is frequently unavailable, resulting in people going to the private sector, where insulin is more expensive [ 40]. Data from a variety of countries show that median patient prices for human insulin in the private sector are 2.2 times higher than in the public sector (Fig. ​(Fig.2). 2 ). In addition, in 13 countries in sub-Saharan Africa [ 41- 45], poor availability of insulin has been found in both the public and private sectors (Fig. ​(Fig.3), 3 ), as well as at different levels of the health system, with, for example, insulin being more highly available in hospitals than in PHC settings. The WHO's global action plan on noncommunicable diseases (NCDs) [ 46] comprises a target of 80% availability of essential medicines, which includes insulin; of the 13 countries studied in sub-Saharan Africa [ 41- 45], only two met this target in the public sector and one met it in the private sector (Fig. ​(Fig.3 3 ).

Insulin use

As noted by Holden et al. [ 47], in 1991, in the UK most insulin was used by people with type 1 diabetes. The use of insulin has increased globally, mainly due to the rising prevalence of type 2 diabetes [ 8, 47], and will continue to do so [ 3]. With this overall increase in use, a parallel increase in the use of analogues has also been seen [ 6]. High insulin prices mean that some people are not able to afford insulin and, therefore, either forego or economise their insulin use by not taking a full dose [ 6, 48]. Use of insulin is also influenced by the patient's socioeconomic status, poor knowledge of diabetes, traditional beliefs, use of traditional medicine [ 35] and misperception of insulin as a 'last resort' therapy [ 49]. Basu et al. [ 3] also highlight that overuse of insulin can have a negative impact on disability-adjusted life years, especially in older populations.

Beyond insulin

Since insulin needs to be injected, access to syringes or other delivery devices are essential for insulin therapy and are often not available and affordable [ 30]. Availability and affordability of diagnostic tests in healthcare facilities and glucose meters for self-monitoring of blood glucose was found to be poor in many LMICs [ 30, 50]. Ogle et al. [ 51] looked at a variety of LMICs and found that the annual median cost for the management of diabetes (insulin, blood glucose meters, test strips, syringes and HbA 1c tests) was US$533 (range: US$255 in Pakistan to US$1185 in Burkina Faso). Beyond these tools, a variety of health system factors are needed for the management of diabetes and these are particularly lacking in LMICs. The health system response for NCDs (including diabetes) proposed by the WHO focuses on PHC [ 46] and lacks a clear focus on access to medicines and health products and overall integrated health system responses [ 52]. In addition, other barriers to diabetes care are present, such as lack of healthcare worker training and shifting certain roles in diabetes management from doctors to nurses and other healthcare professionals, ill-adapted organisation of care, poor availability of tailored patient education materials and approaches relevant to the contexts and realities of people living in LMICs, lack of an active role of national diabetes associations in shaping diabetes care and policy, and lack of overall resources allocated to diabetes [ 53]. These various factors that impair diabetes care result in a low or decreased life-expectancy for people with type 1 diabetes [ 42, 48] and a gap in access to insulin for people with type 2 diabetes, which, in turn, can lead to excess morbidity and mortality.

Summary

Access to insulin is truly a global challenge, with a wide range of issues that impact on an individual's capacity to find and afford the insulin they need for their survival (Fig. ​(Fig.4). 4 ). The fact that the insulin market is concentrated by three multinational companies affects the global market and has ramifications at a country level [ 6] . True innovation is lacking with regard to insulin and the delivery of diabetes care [ 14]. Regulatory requirements for insulin need to be stringent enough to protect the population from substandard medicines without being a barrier to market entry. The inclusion of insulin on the WHO Prequalification Programme [ 23] should be seen as a major advance in improving access to insulin in LMICs by allowing other insulin manufacturers entry into the market.

Insulin provides an interesting example of how evidence has not been adequately used to guide clinical practice. Despite analogue insulin not being included in the WHO Model EML, its uptake has been substantial despite its higher price [ 6, 14, 24]. This change in practice has an impact on the cost of diabetes management for both the individual and the health system. In addition, pricing policies and mark-ups within the health system and supply chain affect the overall financial burden of diabetes management [ 6, 30, 33].

Beyond the actual access to insulin, a variety of health system factors further hamper access to care; these include diabetes care being provided at hospitals vs in PHC, lack of knowledge and expertise of health professionals with regard to insulin therapy, and availability and affordability of diabetes-related supplies [ 30, 34, 40]. These health system factors can also have an impact on the overall cost of diabetes management, with individuals needing to pay for travel from their home to a facility where insulin is present or only being able to access this medicine in the private sector at higher prices [ 5, 30, 34, 40]. Although donation programmes have shown some success in demonstrating that, if access to insulin is improved, type 1 diabetes does not need to be a death sentence in LMICs, these programmes need to be better integrated into the health system [ 32].

At a global level, the United Nations' sustainable development goals (SDGs) [ 54] include targets on NCDs, access to medicines and universal health coverage (UHC), which should guide the global response to diabetes [ 46]. For type 1 diabetes, many countries do not necessarily provide full coverage for insulin and diabetes supplies within the context of UHC [ 55]; should these be provided in a comprehensive way, this could have an impact on mortality [ 56]. To date, the global response to diabetes has mainly focused on prevention rather than diabetes care and access to medicines [ 57]. Both globally and nationally, a lack of leadership, civil society mobilisation and guiding institutions has meant that the issue of access to insulin has not been comprehensively addressed [ 7]. The launch of the Global Diabetes Compact by WHO in November 2020 [ 58] is a positive step; however, the content and approach of this initiative still needs to be defined.

All solutions for improving access to insulin (Fig. ​(Fig.4) 4 ) need to have people with diabetes playing a key role, both being driven by people with diabetes and being designed with people with diabetes in mind. They must also include innovations that decrease global inequalities. Different players will need to be involved, including the WHO, diabetes associations, academia and the private sector. International support is needed to advance WHO prequalification, strengthen national regulatory agencies, and improve processes surrounding the selection, pricing, reimbursement, procurement and supply of insulin. For these aspects, the WHO plays a crucial role in supporting its member states. The WHO or other organisations within the United Nations can also develop a pooled procurement mechanism for insulin and diabetes management-related supplies. In addition, global clinical and scientific diabetes societies have a role in the development of context-appropriate and conflict-of-interest-free guidelines and training. National governments can develop comprehensive policies on selection and pricing of products for diabetes management, ensure insulin and other diabetes supplies are included in UHC packages and remove or regulate mark-ups within the supply chain. Overall, health systems and the way in which diabetes care is delivered needs to be strengthened, ensuring that it is centred on the needs of people with diabetes.

The private sector has a clear mandate, which is included in the SDGs and can play a role in addressing the challenge of access to insulin. Initiatives should focus on creating true partnerships with other players (as is the case in other areas of health [ 59]) and addressing the issue of the price of insulin in a sustainable way. As aforementioned, one area that needs to be further strengthened at a national and global level is civil society mobilisation. Although global and national diabetes organisations exist and provide training, guidelines and education, so far, they have failed to materialise into a truly global movement and ensure that the voice of people with diabetes is heard. The centenary of insulin offers a policy window for this to happen and shape the future of access to insulin and diabetes care globally.

Supplementary Information

Acknowledgements

The authors would like to thank the peer-reviewers for their comments and feedback.

Authors' relationships and activities

The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.

Abbreviations

EML

Essential Medicines List

LMIC

Low- and middle-income country

NCD

Noncommunicable disease

PHC

Primary healthcare

R&D

Research and development

SDG

Sustainable development goal

UHC

Universal health coverage

Contribution statement

DB developed the initial concept for this paper with input from all co-authors. DB and MLP drafted the first version, with critical revision for important intellectual content by JCM and CMM. All authors approved the version to be published.

Funding

DB and MLP are part of the Addressing the Challenge and Constraints of Insulin Sources and Supply (ACCISS) study, which is funded by The Leona M. and Harry B. Helmsley Charitable Trust. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position, policy or views of the Helmsley Charitable Trust. MLP is also funded by a Swiss Excellence Government Scholarship.

Footnotes

Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

21. Rägo L, Santoso B (2008) Drug Regulation: History, Present and Future. In: International Textbook of Clinical Pharmacology. IOS Press, Amsterdam, pp 65-77

25. World Health Organization (2019) The selection and use of essential medicines: report of the WHO Expert Committee on Selection and Use of Essential Medicines, 2019 (including the 21st WHO Model List of Essential Medicines and the 7th WHO Model List of Essential Medicines for Children) (WHO Technical Report Series, No. 1021). World Health Organization, Geneva

31. Beran D. Improving access to insulin: What can be done? Diabetes Management. 2011;1(1):67-76. doi: 10.2217/dmt.10.5. [[ CrossRef] Google Scholar]

35. Haque M, Emerson SH, Dennison CR, Navsa M, Levitt NS. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. S Afr Med J. 2005;95(10):798-802. [[ PubMed] Google Scholar]

56. Chan JCN, Lim LL, Wareham NJ et al (2020) The Lancet commission on diabetes: Using data to transform diabetes care and patient lives. Lancet. 10.1016/S0140-6736(20)32374-6 [ PubMed]

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A global perspective on the issue of access to insulin

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The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life ...

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Cancer has always been an issues in society it seems like everything causes it and nothing solves it. Many people have fought cancer or know people who have fought cancer and can testify to how tough of a battle it is. In this article they talk about a new clinical trial where they are developing small and large cell lung cancer treatments. These treatments have shown better results than previous more invasive treatments that are killing healthy cells as well.

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We're committed to our mission of finding new treatments that may help improve the lives of people with cancer. Our clinical trials for lung cancer study investigational medications alone, or in combination with other study medications, or standard of care therapy. We perform these trials to see if they can help prevent, find, or treat cancer.

Lung cancer occurs when cells inside the lung grow abnormally. As more cells grow, they start to form a tumor and may spread to other areas in the body. There are two main types of lung cancer:

Non-small cell lung cancers (NSCLC); about 80% to 85%

Small cell lung cancer (SCLC); about 10% to 15%

Depending on the stage of your cancer and other factors, treatment options may include surgery, radiotherapy, chemotherapy, or palliative care.

There is a lot to consider when deciding whether to participate in a clinical trial. Any clinical trial includes risks, which the study doctor will review with you. Make sure you understand the risks before participating.
You can also call our clinical trial information center at 1-888-577-8839 to learn more.

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We're committed to our mission of finding new treatments that may help improve the lives of people with cancer. Our clinical trials for lung cancer study investigational medications alone, or in combination with other study medications, or standard of care therapy. We perform these trials to see if they can help prevent, find, or treat cancer.

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The subject i've chosen for this padlet and for my research project is underage nicotine consumption. In this article from the CDC, they talk about the risks of the use of E-cigarettes (vapes) in underage people. The article talks about how the vapes contain nicotine which is a highly addictive chemical and can cause brain alterations at a young age. the article also discuses how about how 76% of students reported using or buying these nicotine products.

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Centers for Disease Control and Prevention

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The use of e-cigarettes is unsafe for kids, teens, and young adults.

Most e-cigarettes contain nicotine. Nicotine is highly addictive and can harm adolescent brain development, which continues into the early to mid-20s.1

E-cigarettes can contain other harmful substances besides nicotine.

Young people who use e-cigarettes may be more likely to smoke cigarettes in the future.

Find Data on E-cigarette Use Among Youth

E-cigarettes are electronic devices that heat a liquid and produce an aerosol, or mix of small particles in the air.

E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.

Some e-cigarettes look like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items. Larger devices such as tank systems, or "mods," do not look like other tobacco products.

E-cigarettes are known by many different names. They are sometimes called "e-cigs," "e-hookahs," "mods," "vape pens," "vapes," "tank systems," and "electronic nicotine delivery systems (ENDS)."

Using an e-cigarette is sometimes called "vaping."

Some e-cigarettes look like regular cigarettes, cigars, or pipes.
Some look like USB flash drives, pens, and other everyday items.

E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other chemicals that help to make the aerosol.

The liquid used in e-cigarettes often contains nicotine and flavorings. This liquid is sometimes called "e-juice," "e-liquid," "vape juice," or "vape liquid."

Users inhale e-cigarette aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales it into the air.

E-cigarette devices can be used to deliver marijuana and other drugs.

News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.

JUUL is a brand of e-cigarette that is shaped like a USB flash drive. Like other e-cigarettes, JUUL is a battery-powered device that heats a nicotine-containing liquid to produce an aerosol that is inhaled.

All JUUL e-cigarettes have a high level of nicotine. According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.2

JUUL is one of a few e-cigarettes that use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes.

News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.

Approximately two-thirds of JUUL users aged 15 - 24 do not know that JUUL always contains nicotine.

Although JUUL is currently the top-selling e-cigarette brand in the United States, other companies sell e-cigarettes that look like USB flash drives. Examples include the MarkTen Elite, a nicotine delivery device, and the PAX Era, a marijuana delivery device that looks like JUUL.

Additional information about USB-shaped e-cigarettes and actions that parents, educators, and health care providers can take to protect kids is available at CDC's Infographic [PDF - 1.2MB]

Most e-cigarettes (vapes) contain nicotine-the addictive drug in regular cigarettes, cigars, and other tobacco products.

A CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine.1

Some vape product labels do not disclose that they contain nicotine, and some vape liquids marketed as containing 0% nicotine have been found to contain nicotine.

Nicotine can harm the developing adolescent brain.2 The brain keeps developing until about age 25.

Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control.2

Each time a new memory is created or a new skill is learned, stronger connections - or synapses - are built between brain cells. Young people's brains build synapses faster than adult brains. Nicotine changes the way these synapses are formed.

Using nicotine in adolescence may also increase risk for future addiction to other drugs.2

When a person is dependent on (or addicted to) nicotine and stops using it, their body and brain have to get used to not having nicotine. This can result in temporary symptoms of nicotine withdrawal.

Nicotine withdrawal symptoms include irritability, restlessness, feeling anxious or depressed, trouble sleeping, problems concentrating, and craving nicotine.3 People may keep using tobacco products to help relieve these symptoms.4

Youth may turn to vaping to try to deal with stress or anxiety, creating a cycle of nicotine dependence. But nicotine addiction can be a source of stress.

What may start as social experimentation can become an addiction.

The most common reason U.S. middle and high school students give for trying an e-cigarette is "a friend used them." 5

The most common reason youth give for continuing to use e-cigarettes is "I am feeling anxious, stressed, or depressed." 5

Youth e-cigarette and cigarette use have been associated with mental health symptoms such as depression.9, 10

Yes. As long as a person stays quit, withdrawal symptoms will fade over time as the brain gets used to not having nicotine.

Scientists are still learning about the effects of quitting vaping on mental health. Quitting smoking cigarettes is associated with lower levels of anxiety, depression, and stress, as well as improved positive mood and quality of life.9

Scientists are still learning about the long-term health effects of e-cigarettes.

Some of the ingredients in e-cigarette aerosol could also be harmful to the lungs in the long-term. For example, some e-cigarette flavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs.1

Defective e-cigarette batteries have caused some fires and explosions, a few of which have resulted in serious injuries.

Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. Nationally, approximately 50% of calls to poison control centers for e-cigarettes are for kids 5 years of age or younger.

E-cigarette aerosol is NOT harmless "water vapor."

The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including:

Nicotine

Ultrafine particles that can be inhaled deep into the lungs

Flavorings such as diacetyl, a chemical linked to a serious lung disease

Volatile organic compounds

Cancer-causing chemicals

Heavy metals such as nickel, tin, and lead1

The aerosol that users inhale and exhale from e-cigarettes can expose both themselves and bystanders to harmful substances.

It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.3

E-cigarettes come in various flavors, including fruit, candy, mint, and menthol.

A study from 2013-2014 showed that most youth who use e-cigarettes first start with a flavored variety, and flavors are the primary reason youth report using e-cigarettes.⁶

In 2023, most youth who reported using e-cigarettes used flavored varieties (89.4%). Among middle and high school students who currently used any type of flavored e-cigarette in 2023, the most commonly used flavors were fruit (63.4%), candy, desserts, or other sweets (35%), mint (27.8%), and menthol (20.1%).¹¹

On January 2, 2020, the U.S. Food and Drug Administration (FDA) finalized an enforcement policy that prohibits the sale of prefilled cartridge e-cigarettes in any flavor other than tobacco or menthol, unless authorized by FDA. FDA has since taken additional steps to prohibit certain companies from selling youth-appealing, flavored disposable e-cigarettes and flavored e-liquids without authorization.⁷

Several states and communities have restricted the sale of flavored tobacco products, including menthol-flavored products.⁸

E-cigarettes are also advertised using the same themes and tactics that have been shown to increase youth initiation of other tobacco products, including cigarettes. In 2021, approximately 76% of students reported exposure to tobacco product marketing through traditional sources and approximately 74% of students who used social media had seen e-cigarette-related posts or content.¹²

Widespread advertising for e-cigarettes, including via media for which advertising for conventional tobacco products is prohibited (e.g., TV), and the lower costs of some e-cigarettes relative to regular cigarettes has contributed to use among youth.¹

Many youth also report using e-cigarettes because they are curious about these products.¹

Many young people who use e-cigarettes also smoke cigarettes.1 There is some evidence that young people who use e-cigarettes may be more likely to smoke cigarettes in the future.

Specifically, a 2018 National Academy of Medicine report found that there was some evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future.4

E-cigarettes also can be used to deliver other drugs, including marijuana; in 2016, approximately one-third of U.S. middle and high school students who have ever used an e-cigarette reported using marijuana in the device.

But e-cigarette use among young people is still unsafe, even if they do not progress to future cigarette smoking.

E-cigarettes expose users to fewer harmful chemicals than burned cigarettes.1

But burned cigarettes are very dangerous, killing half of all people who smoke long-term.

The use of any tobacco product, including e-cigarettes, is unsafe for young people.

Yes. In August 2016, the regulatory authority of the FDA was extended to cover e-cigarettes through the agency's "deeming rule."

Through authority granted by the Family Smoking Prevention and Tobacco Control Act (FSPTCA), FDA has authority to develop regulations that address the manufacturing, marketing, and sale of e-cigarettes.

There are some strategies that the FDA does not have authority to implement, such as including e-cigarettes in smoke-free policies or increasing the minimum legal sales age for these products, unless directed to do so by Congress. However, the FSPTCA does not prevent states and communities from including e-cigarettes in smoke-free policies or from regulating the sale and distribution of e-cigarettes. These types of strategies can include further raising the minimum legal sales age, licensing retailers, implementing price policies, and restricting or prohibiting the sale of tobacco products.

Yes. In 2018, the FDA expanded its successful youth tobacco prevention campaign, "The Real Cost," to reach the more than 10 million youth aged 12-17 who have used e-cigarettes or are open to trying them. The campaign educates youth about the potential risks of using e-cigarettes.

The "Real Cost" reaches teens where they spend most of their time: in school and online. The campaign is also placing e-cigarette prevention materials in high schools across the nation, both in school bathrooms and on educational digital platforms accessed by students during the school day.

Heated tobacco products (HTPs) like IQOS and Eclipse, sometimes marketed as "heat-not-burn" technology, represent a diverse class of products that heat the tobacco leaf to produce an inhaled aerosol. They are different from e-cigarettes, which heat a liquid that can contain nicotine derived from tobacco.

HTPs are available in at least 40 countries and several have been authorized for sale in the United States by the FDA. In 2018, few U.S. adults (2.4% of all surveyed, including 6.7% of people who currently smoke surveyed) had ever used HTPs. In 2023, 1.0% of U.S. middle and high school students, combined, reported having used heated tobacco products in the past 30 days.¹¹

Scientists are still learning about the short-term and long-term health effects of HTPs, but the available science shows they contain harmful and potentially harmful ingredients. Youth use of any tobacco products, including heated products, is unsafe.

It is important that we continue to modernize proven tobacco prevention and control strategies to include newer products entering the market such as HTPs.

Talk to your child or teen about why e-cigarettes are harmful for them. It's never too late.

Set a good example by being tobacco-free and ensure that your kid is not exposed to the secondhand emissions from any tobacco products, including e-cigarettes.

If you use tobacco, it's never too late to quit. For free help, visit smokefree.gov or call 1-800-QUIT-NOW.

Talk to your child or teen about why e-cigarettes are harmful for them. It's never too late.

Get the Talk With Your Teen About E-cigarettes [PDF - 5.2MB] tip sheet for parents. Start the conversation early with children about why e-cigarettes are harmful for them.

Let your child know that you want them to stay away from all tobacco products, including e-cigarettes, because they are not safe for them. Seek help and get involved.

Set up an appointment with your child's health care provider so that they can hear from a medical professional about the health risks of tobacco products, including e-cigarettes.

Speak with your child's teacher and school administrator about enforcement of tobacco-free school grounds policies and tobacco prevention curriculum.

Encourage your child to learn the facts and get tips for quitting tobacco products at Teen.smokefree.gov.

Fact Sheet for Educators:

Conversation Card for Educators:

1. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 [accessed 2022 April 4].

2. Truth Initiative Mental Health x Vaping Headline Survey Internal Data - August 2021.

3. Gentzke AS, Wang TW, Cornelius M, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ 2022;71(No. SS-5):1-29. DOI: http://dx.doi.org/10.15585/mmwr.ss7105a1.

4. U.S. Department of Health and Human Services. The Health Consequences of Smoking-50 years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

5. Birdsey J, Cornelius M, Jamal A, et al. Tobacco Product Use Among U.S. Middle and High School Students - National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023; 72(44);1173-1182.

6. Cooper M, Park-Lee E, Ren C, Cornelius M, Jamal A, Cullen KA. Notes from the Field: E-cigarette Use Among Middle and High School Students - United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1283-1285. DOI: http://dx.doi.org/10.15585/mmwr.mm7140a3

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Quick Facts on the Risks of E-cigarettes for Young People

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Learn quick facts on the risks of e-cigarettes for kids, teens, and young adults, including how they work, why nicotine is unsafe, what is in e-cigarette aerosol, and resources for parents to prevent their child from using e-cigarettes or help them stop.

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This article from the National Library of Medicine discusses how not only are over 30% of high schoolers using vapes there is around 10% of middle schoolers vaping as well. This is casing kids to become addicted earlier and stay addicted longer. The article focuses a lot on how the advertisements for these vapes are marketed towards teens and people with developing brains. These advertisements contain fun colors and pictures and talk about how these vapes can reduces things like anxiety. Along with the advertisements being directed towards teens the flavors of these vapes are as well. They come in flavors like bubblegum, raspberry and rainbow ice. The article also talks about how these addictive chemicals can cause you to be unfocused in the classroom. They stated example about how if you are dependent of this nicotine then you will do anything to consume it this includes skipping out on class times and events with your peers.

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Electronic cigarette (e-cigarette) use has recently risen to the forefront of medical discussions across the country. A significant increase in e-cigarette use by adolescents has been observed over the last decade. This article discusses the targeting…

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In this article the author focuses more on why teens are attracted to and using this form of nicotine as their go to. She talks about how in 2021 the FDA started to "crack down" on the kid-friendly advertisements to stop teens from being attracted to these products. A psychiatrist at the child minds institute says that teens and young adults are more attracted to the sleek and accessible design. The psychiatrist talks about how the design of these vapes allows teens to always have in on them reducing the anxiety of social situations. One mom and school administer also talk about how there isn't much negative reinforcement if children are caught with these vapes. Most schools just take it away however kids can just go out and buy a new one.

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Although e-cigarettes have been around for more than a decade, vaping rates have skyrocketed in recent years, especially among teens. E-cigarettes are now the most frequently used tobacco product among adolescents - some 2.1 million middle and high school students were e-cigarette users in 2017 - far surpassing traditional combustible cigarettes.

JUUL, a popular vape device that comes in fun flavors, looks like a flash drive and can be charged in a USB port, is especially concerning. JUUL delivers high levels of nicotine, making the product extremely addictive. The company that makes and markets JUUL recently exceeded a $10 billion valuation faster than any company, including Facebook. JUUL sales now make up more than half of the e-cigarette market.

The FDA announced that it will be cracking down not only on illegal sales of e-cigarettes to minors, but also the "kid-friendly marketing and appeal of these products" because "we see clear signs that youth use of electronic cigarettes has reached an epidemic proportion." And after recent unexplained illnesses and deaths that have been attributed to vaping, the CDC and the American Medical Association are expressing serious concern, recommending that people should avoid vaping entirely.

Teachers, health professionals and parents are alarmed by the growing popularity of vaping among young people and trying to educate not only teens but also themselves, as it's all still so new.

Vaping is the act of inhaling and exhaling the vapor produced by the heated nicotine liquid (often called "juice") of an electronic cigarette (e-cigarette or e-cig), vape pen, or personal vaporizer. It's also commonly called JUULing (pronounced jewel-ing).

What originated as a smoking cessation aid has quickly became a popular - and addictive - product in its own right. Sarper Taskiran, MD, a child and adolescent psychiatrist at the Child Mind Institute, attributes the recent rise in popularity to packaging and advertising. "The teens are after innovation and they're attracted by sleek design and ease of use," he says. "They look like an Apple product."

Although vaping companies emphatically deny that they are marketing to young people, critics note such features in their advertising as youthful images and colors, animation, actors who appear to be under 21, and suggestions that vaping makes you happier and improves your social status.

Although some of the health risks associated with vaping appear to be less severe than traditional combustible cigarettes (there's no tar, for example), there are still risks.

Some known risks of vaping are:

E-cigarettes contain high levels of nicotine. According to the company's website, the nicotine content of one JUULpod is equivalent to one pack of cigarettes.

Because of these high nicotine levels, vaping is extremely addictive - and teens are already more susceptible to addiction than adults because their brains are still developing, which makes them more likely to habituate to using drugs and alcohol.

Addiction can impact the ability to focus. Dr. Taskiran has observed this with the adolescents he works with, who report that vaping initially increases their alertness and attention, but then experience a decrease in attention span. One student, for example, was able to sit through practice ACT exams but after JUULing for six months "can't sit still because she starts craving, can't think of questions, and just starts fidgeting."

E-cigarettes and similar devices contain carcinogenic compounds, and a recent study found significantly increased levels of carcinogens in the urine of teens who vape.

One study found that vaping does, in fact, cause lung irritation akin to that seen in smokers and people with lung disease and causes damage to vital immune system cells.

There have been several deaths and hundreds of cases of lung illness attributed to vaping. Right now it is unclear if the cause is bootleg cartridges containing THC or CBD oil or legal nicotine cartridges. The CDC and the American Medical Association are recommending that people avoid vaping entirely while this is being investigated.

Taskiran notes that vaping increases heart rate and blood pressure, so can increase circulatory problems. One teen he works with started vaping and found that his swim times dropped because he can no longer sustain the heart rate required for swimming.

Since they leave little odor, e-cigarettes are particularly easy to hide and even use discreetly in public places, including school. Kids are also vaping marijuana at increasing rates, which brings its own health risks.

Why parents should be concerned

One problem with vaping is that teens hear that it's not as bad for your health as smoking cigarettes and many think there is no harm. "They really think that they are mostly flavors and that they are inhaling a pleasant gas," says Dr. Taskiran.

One study of 12th graders found that kids who vaped (but were not previously smokers) were more than four times as likely to "move away from the perception of cigarettes as posing a great risk of harm." The study and others like it have showed that teens who vape are much more likely to start smoking cigarettes.

The packaging does little to convey the risks. "They are very enticing the way they look. It's not transparent at all. It says 5% nicotine, which sounds like nothing, so teens think 95% is water weight or vapor," laments Dr. Taskiran.

Plus, he points out, smoking never stopped being cool. It's still positively portrayed in movies, and JUUL in particular has re-branded it to make vaping an even cooler alternative. But vaping isn't only for the cool kids - many teens are curious (with flavors like mango, cucumber and crème, who wouldn't be?) and presented with the opportunity will give it a try.

Sarah, a mom of two in Ann Arbor, MI, was shocked to get a phone call the other day from her son's middle school principal, requiring her to come get him immediately for "emergency removal and suspension." He and two friends had been caught vaping on school grounds after school, and a passing parent took photos and sent them to the administration.

Though they didn't find any devices on her son - a straight A student with no prior offenses - the school, like many others, is taking a hard stance. "The principal knows that vaping is common and shared that the businesses in downtown Ann Arbor are selling to teens without asking for IDs," relayed Sarah. "However, she feels the need to let my son and his friends know that it's a really, really big deal."

At this school, students caught vaping have to sign behavior contracts, must attend a Teens Using Drugs Class, and cannot participate in any sports, clubs or special events for the rest of the year. If the kids had been across the street, not on school grounds, it would have been a different scenario. But the principal said that had they been in high school rather than middle school, she would have called the police.

Sarah remembers what it was like to be a teenager so doesn't think trying it is that big of a deal, but is concerned about addiction. "Addiction runs in my family and I worry about my son. Of course, I worry about the damage that the chemicals can do to his lungs and body as well," she says.

Although some places are tightening restrictions locally, kids can still go to a website, click a button that says they are at least 21 years old, and purchase online. "The majority of adolescents I see are purchasing JUUL from the Internet," says Dr. Taskiran.

How to talk to kids about vaping

Dr. Taskiran advises parents to start by educating themselves, so they know what they're talking about going in, and to take an inquisitive and curious approach to what their teen's experience is. "The most important thing is keeping it as a dialogue," he says. "Declarative statements like 'It's bad for you' just end the conversation."

Dr. Taskiran recommends starting the conversation more generally by asking if a lot of kids at school vape. Once the conversation is initiated, you can slowly work up to asking things like, "What is your experience with that? What are the flavors like?" He also suggests getting a sense of what they know (or think they know) about the product, which gives you an opening to start educating them.

The silver lining of Sarah's experience with her son is that he actually told his dad about the experience even before he knew he'd been caught. "They had a full one hour conversation about it after I was already asleep. He told my husband that he tried it for the first time and that it burned his throat and he didn't like it." She got the call from the principal the next morning before her son had a chance to tell her himself. "He's a great kid and doesn't really get in trouble except for talking in class because he's bored. My goal has always been open communication and to keep him talking to us. He did!"

Of course, while parents need to educate themselves, the onus isn't entirely on them. "Schools need to own this as well and provide educational strategies for both teachers and students," says Dr. Taskiran. Prevention is a lot easier than treatment later on, he says, and notes that peer education can play a particularly important role.

If you are concerned that your child has become addicted there are plenty of treatment options. Dr. Taskiran recommends consulting with a clinician who is well-versed in addiction treatments. "This is a true nicotine addiction," he says. "People usually think this is different from cigarette use - but it can be more severe than cigarette use."

For tips on how to talk to teenagers about vaping, check out this guide from the Partnership for Drug-Free Kids.

Frequently Asked Questions

What should I do if my teenager is vaping?

Why do teens vape?

Why is vaping bad for teens?

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Teen Vaping: What You Need to Know - Child Mind Institute

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Why do teens vape? What are the effects of vaping? Learn what are the dangers of e-cigarettes, why parents should be concerned, and get guidance on how to talk to kids about it.

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Like most articles this one is titled "know the risk" but unlike most other articles it actually goes into the longterm and shortterm effects of what actually happens not only to your body but to your mind. One of the main risks is the risk of addiction. The article states that if you get addicted to nictone at a young age you are more likely to use stronger tobacco products in the future as well as other drugs. They also talk about the risks your brain is at like the risk of mood disorders and the loss of impulse control.

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Know the Risks: E-Cigarettes and Young People | U.S. Surgeon General's Report

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Know the Risks of E-cigarettes for Young People | Know the Risks: E-cigarettes & Young People | U.S. Surgeon General's Report

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E-cigarette use poses a significant - and avoidable - health risk to young people in the United States. Learn about all the health risks for youth and young adults who use e-cigarettes.

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Another popular form of nicotine consumption is through pouches that sit in your upper lip pocket called "Zyns". Zyn pouches, like vapes come in fun flavors and are easy to use. The pouches contain just nicotine, no tobacco and are most popular among athletes like baseball and hockey players as they can put the pouch in their mouth while they are playing and get the effects. The article talks about how these pouches are harder to direct which makes them so appealing to kids as they cant get caught.

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School districts have spent the last several years cracking down on vaping, but there's another addictive product gaining popularity among teens: oral nicotine pouches.

The pouches, most popular under the brand name "Zyn," are smokeless, and users tuck them into their upper lips-making them harder to detect. They come in flavors like mint, menthol, coffee, and cinnamon

In recent years, e-cigarette products have faced federal flavor restrictions, and there's evidence that at least high school students are vaping less. But some experts fear that as children move away from vapes, they may move toward nicotine pouches because they do not face the same flavor restrictions.

Another potential draw for young people: the pouches don't generate smoke or otherwise draw attention in the same way as cigarettes and vapes, so it's tougher to catch students using them. The vape detectors that many schools have installed in high-traffic areas like bathrooms, often with money from legal settlements with the e-cigarette manufacturer Juul Labs, can't pick up on students using the pouches.

As nicotine pouches gain popularity, it's important that districts draw on lessons learned from the rise of previous products-like cigarettes and e-cigarettes. Schools need to be proactive with prevention and intervention efforts, according to school district leaders.

"This is a very resilient problem, and we see different kinds of tobacco and nicotine products rise in popularity all the time, but we've learned over the years what works," said Toby Gilbert, director of public awareness for Alhambra schools in southern California. "We may not have a specific program for Zyn, but we have been working on this issue for years and we'll have to keep focused on that."

The efforts schools have found to be effective include student-run awareness campaigns, education for students and parents on the dangers of nicotine and tobacco products, and counseling and rehab services for students who are caught using them.

Effective prevention strategy: 'Kids talking to kids'

In Alhambra, the most effective strategy for battling teens' nicotine and tobacco use has been "kids talking to kids," Gilbert said.

In recent years, that's included districtwide PSAs created by students, small group interventions when students have been caught using tobacco and nicotine products, and anti-tobacco education both in science class and during after-school programs.

It works, she said, because oftentimes students begin using the products because they're branded as "the cool thing" and will help them bond and fit in with their peers. If that narrative changes, students tend to shy away from vapes and nicotine products, Gilbert said.

Alhambra students who are caught using nicotine or tobacco products more than once are required to attend individual or group substance abuse counseling sessions, Gilbert said. The district is also starting a "Saturday school" for repeat offenders and their parents to attend. There will be about six sessions, Gilbert said, on the dangers of using the products.

"We try to calibrate the way we respond so that we're staying in conversation and collaboration with the students and their families," Gilbert said.

Brian Swatland, principal of Williamsville East High School near Buffalo, N.Y., agreed that clearly establishing the expectations for students is important. That should include proactively communicating the dangers and consequences of using tobacco and nicotine products both through education campaigns and school district policy, he said.

Swatland also agreed that students seem to respond best when hearing from their peers.

Dida Akinlua, a Williamsville East junior, is a member of the district's student advisory council and meets regularly with district leaders about issues important to students, including vaping and nicotine use.

Akinlua said her group has created and put up posters around the school to "passively educate" students about how vaping can be a problem and often meets with other students to hear their feedback and ideas about how to address nicotine and tobacco use.

"I think students like being heard and being involved in the solution," Akinlua said.

Because the nicotine pouches are relatively new, the full range of health effects aren't known. But experts say using the products could drive teens' interest in and enjoyment of nicotine, leading to long-term addiction and the health effects that go along with it. Nicotine is an addictive chemical.

In the U.S. Centers for Disease Control and Prevention's 2023 National Youth Tobacco Survey, about 1.5 percent of middle and high school students reported using nicotine pouches within the 30 days prior to taking the survey.

'The FDA must take action now to prevent Zyn from becoming the next Juul'

The popularity of Zyn among teens may be increasing thanks to social media.

Sen. Chuck Schumer, the Senate majority leader, this month called on federal regulators to investigate Zyn for concerns about the marketing of its products and their health effects, according to CBS News.

The New York Democrat said the pouches are becoming the next "trend in addiction for teens" and that they "seem to lock their sights on teens and use social media to hook them." He said "Zynfluencers" make videos and posts about the products on social media, which young people often see.

Zyn's parent company, Philip Morris International, said it doesn't market products to teens. In a statement to Education Week, a spokesperson said Zyn is intended as a smoke-free alternative for people already using tobacco or nicotine products. He said the company does not use social media influencers or "engage in product placement" for Zyn, and said employees monitor social media content and report "concerns where possible to address underage use, product misuse, and inappropriate content or claims."

"Our marketing practices-which prohibit the use of social media influencers-are focused on preventing underage access and set the benchmark for the industry," the statement said. "Real-world evidence shows this approach is working: the latest data from the Centers for Disease Control and Prevention and the FDA show oral nicotine pouch use by those under the legal age remains exceptionally low."

Yolanda Richardson, president and CEO of the Campaign for Tobacco-Free Kids, said in a statement to Education Week that the organization supports Schumer's call for a federal investigation into how Zyn is marketed and promoted, particularly on social media.

"We're very concerned that Zyn is being promoted on social media in the exact same ways that fueled Juul's popularity with kids," Richardson said. "The FDA must take action now to prevent Zyn from becoming the next Juul and addicting yet more kids."

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A New Nicotine Challenge: What Schools Should Know About 'Zyns'

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Nicotine pouches evade detection systems set up for vapes. But schools may be able to apply lessons learned from anti-tobacco efforts.

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Zyns like described in this New York Times article are little white pillows filled with nicotine that are packed into your upper lip. Your saliva causes the nicotine to release from the pouch directly into your blood stream meaning you may only need to have the pouch in for 10 minutes. The article focuses more on what gets these teens hooked onto zyns and what persuades them to try them in the first place rather than the chemicals behind them. Zyns are a fairly new product so people who are using them only know what they've been told. Young teenage boys favorite influencer on tiktok and their friends are what is influenced them to try these pouches an once they start it is hard to stop.

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Opinion | Our Kids Are Living in a Different Digital World

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Enormous numbers of kids follow social-media influencers who boost addictive drugs to audiences who are too young to legally buy them.

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This article from a news station in Buffalo New York. The experts in this article talk a lot about how bans and restrictions on vaping are making it harder for teens to get their hands on these products which they are used to using. This is causing teens to find other nicotine products like Zyn pouches but also things like weed and other recreational drugs. Since people don't know a lot about these pouches they go easily undetected in schools which is allowing kids to pop them in during class and leave them in while the teacher is instructing causing them to miss no instruction but also get their nicotine fix.

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WILLIAMSVILLE, N.Y. (WKBW) - With vaping under pressure for health risks, parents are being warned about what could become a popular alternative.

They're small, white pouches that look a lot like chewing gum. ZYN is sold at local gas stations. They're tobacco free, and a lot like chew, but loaded with addictive nicotine.

Experts, like Dr. Frank Michalski of East Amherst say these are the next trend in addiction for teens, and say these pouches can be especially dangerous to growing, adolescent minds.

"We need kids to realize that the addiction to the nicotine itself is the most harmful thing in many cases," he said.

Dr. Michalski is setting up a program for youth in the Williamsville Central School District to help them try to get out of addiction.

He says with the vaping ban, we're seeing a transitional process, and teenagers are turning to other addictive things like the pouches.

"With the vaping ban you're seeing an increase in depression, alcohol use, cannabis use, and nicotine replacement therapies such as ZYN pouches."

Experts say the pouches deliver nicotine to the blood stream for about an hour. They're used much like chewing tobacco and are highly addictive for teenagers.

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Concern over nicotine pouches targeting teens

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With vaping under pressure for health risks, parents are being warned about what could become a popular alternative.

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This was the most informational article i could find about what a Zyn truly was and how they have been developed and regulated. The article says that these pouches are not yet regulated by the FDA meaning they are much easier for teens to get their hands on. Since these pouches are just nicotine they have been developed to be stronger than vapes and other products teens have been using. This is causing a quicker "buzz" but also quicker side effect like the alterations it makes in your brain. They have also been found harder to quit as they are what is used as a resource for people who have previously used nicotine to quit.

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As youth e-cigarette use remains a public health concern with 2.5 million middle and high school students reporting e-cigarette use in 2022, a different type of flavored nicotine product is gaining popularity: oral nicotine pouches.

With cigarette smoking on the decline, tobacco companies have shifted focus to "smokeless" tobacco products, including oral nicotine pouches. Oral nicotine pouches are used similarly to snus - an oral pouch containing shredded tobacco leaf - but unlike snus, they contain a nicotine powder instead of tobacco leaf. Nicotine pouches contain nicotine which is harmful to young people in any form. Due to the absence of tobacco leaf, the Food and Drug Administration does not classify oral nicotine pouches as a smokeless tobacco product.

Oral nicotine pouches include brands such as Zyn, On! and Velo. These products have gained popularity in recent years: overall sales of nicotine pouch products increased from $126.06 million units from August to December 2019 to $808.14 million units from January to March 2022. During this period, sales of nicotine pouch products containing a higher concentration of nicotine (8 mg) increased more rapidly than products with lower nicotine concentrations (e.g., 4 mg and 6 mg). In addition, Altria has announced to its investors that it will be introducing a new version of its On! nicotine pouch product that has a higher concentration of nicotine than its current On! products.

Advertisements for oral nicotine pouches highlight flavors and emphasize the "freedom" of using nicotine pouches anywhere, according to new research co-authored by Truth Initiative. Leading nicotine pouch brands spent nearly $25 million on ads between January 2019 and September 2021.

In the past, Truth Initiative has submitted recommendations that federal agencies monitoring tobacco use include measures for oral nicotine pouches in national surveys. In 2022, the CDC included oral nicotine pouches in their National Youth Tobacco Survey where they estimated that 1.1% of middle and high school students had used these products. As more information emerges, here are some important things to know about these products.

How much nicotine is in oral nicotine pouches?

Nicotine concentrations differ across oral nicotine pouch brands. For example, in the United States Zyn is sold in 3 and 6 mg, Velo is sold in 2, 4, and 7 mg, and On! is sold in 1.5, 2, 3.5, 4, and 8 mg, according to each brand's website. Altria's new On! nicotine pouch product, called On! Plus, will offer nicotine strengths of 6, 9, and 12mg.

What flavors do nicotine pouches come in?

Oral nicotine pouches come in an array of youth-friendly flavors, including fruit, mint, and other flavors.

The availability of sweet, fruity, and candy-like flavors is troubling because, as pod-based e-cigarettes like JUUL face federal flavor restrictions in response to high rates of youth vaping, young people may switch to other nicotine products that still offer flavors. For example, disposable e-cigarettes, which were exempted from the partial flavor restrictions FDA enacted in January 2020, have skyrocketed in popularity. Sales of menthol-flavored e-cigarettes, which were also exempted, experienced a drastic, immediate rise in sales with an increase of almost $60 million and its market share more than doubled.

Flavors play a significant role in drawing youth to tobacco products - nearly 85% of young e-cigarette users choose a flavored product, according to 2022 NYTS data.

How are oral nicotine products regulated?

Oral nicotine products are, as yet, not regulated as tightly as other tobacco products. The FDA places some regulations on these products, including requirements that manufacturers submit certain information to the agency, use nicotine warning labels, and comply with some basic marketing restrictions. No current federal regulations exist that prevent or restrict the sale of oral nicotine pouches, and the marketing restrictions on these products are not as strict as those on combustible tobacco products.

What are the health effects of oral nicotine pouches?

While specific long-term health effects of nicotine pouches like Zyn remain unknown, youth use of nicotine in any form is unsafe. Nicotine use during adolescence can disrupt the formation of brain circuits that control attention, learning, and susceptibility to addiction. Research has shown early age of nicotine use is correlated with daily use and lifetime nicotine dependence. Nicotine use can also intensify symptoms of depression and anxiety.

Truth Initiative strongly urges the FDA to remove all unauthorized oral nicotine products from the market, including Zyn. To prevent youth from using these products, eliminating all flavors from tobacco products is crucial, as is instituting restrictions to curb exposure to marketing.

Quitting Zyn and oral nicotine pouches

Quitting oral nicotine pouches like Zyn can be challenging, and the high levels of nicotine in Zyn can lead to nicotine addiction. The good news is, you can quit Zyn with similar strategies used to quit other nicotine products.

Read about how to quit Zyn and other oral nicotine pouches from EX, a proven-effective tobacco cessation program directed and funded by Truth Initiative.

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What is Zyn and what are oral nicotine pouches?

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As youth e-cigarette use remains a public health concern a different type of flavored nicotine product is gaining popularity: oral nicotine pouches.

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Smokeless tobacco is another form of nicotine consumption that is popular among athletes. The article says that compared to other high school students, high school athletes use double the smokeless tobacco. Though it is not the most popular form of nicotine consumption as the flavors aren't as good and its pretty obvious when your using it, it is still used by teens around me. Smokeless tobacco is one of the leading causes of mouth cancer and it is very rapidly occurring after the use of smokeless tobacco.

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Centers for Disease Control and Prevention

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Smokeless tobacco is associated with many health problems. Using smokeless tobacco:

Can lead to nicotine addiction1,2

Causes cancer of the mouth, esophagus (the passage that connects the throat to the stomach), and pancreas (a gland that helps with digestion and maintaining proper blood sugar levels)1,2

Is associated with diseases of the mouth1,3

Can increase risks for early delivery and stillbirth when used during pregnancy²

Can cause nicotine poisoning in children⁴

May increase the risk for death from heart disease and stroke1,3

Using smokeless products can cause serious health problems.
Protect your health; don't start. If you do use them, quit.

Smokeless tobacco contains nicotine, which is highly addictive.1,2

Because young people who use smokeless tobacco can become addicted to nicotine, they may be more likely to also become cigarette smokers.⁵

Many smokeless tobacco products contain cancer-causing chemicals.1,6

The most harmful chemicals are tobacco-specific nitrosamines, which form during the growing, curing, fermenting, and aging of tobacco. The amount of these chemicals varies by product.¹

The higher the levels of these chemicals, the greater the risk for cancer.²

Other chemicals found in tobacco can also cause cancer. These include:⁶

A radioactive element (polonium-210) found in tobacco fertilizer

Chemicals formed when tobacco is cured with heat (polynuclear aromatic hydrocarbons-also known as polycyclic aromatic hydrocarbons)

Harmful metals (arsenic, beryllium, cadmium, chromium, cobalt, lead, nickel, mercury)

Smokeless tobacco causes cancer of the mouth, esophagus, and pancreas.¹

Smokeless tobacco can cause white or gray patches inside the mouth (leukoplakia) that can lead to cancer.¹

Smokeless tobacco can cause gum disease, tooth decay, and tooth loss.1,3

Using smokeless tobacco during pregnancy can increase the risk for early delivery and stillbirth.²

Nicotine in smokeless tobacco products that are used during pregnancy can affect how a baby's brain develops before birth.2,7

Using smokeless tobacco increases the risk for death from heart disease and stroke.1,3

Smokeless tobacco can cause nicotine poisoning in children.⁴

Additional research is needed to examine long-term effects of newer smokeless tobacco products, such as dissolvables and U.S. snus.

1. World Health Organization. [IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 89: Smokeless Tobacco and Some Tobacco-Specific N-Nitrosamines.PDF-3.18 MB] Lyon (France): World Health Organization, International Agency for Research on Cancer, 2007 [accessed 2014 Oct 31].

2. U.S. Department of Health and Human Services.The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2014 Oct 31].

3. Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn E, et al. Impact of Smokeless Tobacco Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment: A Policy Statement from the American Heart Association. Circulation 2010;122(15):1520-44 [cited 2014 Oct 31].

4. Connolly GN, Richter P, Aleguas A Jr, Pechacek TF, Stanfill SB, Alpert HR. Unintentional Child Poisonings Through Ingestion of Conventional and Novel Tobacco Products. Pediatrics 2010;125(5):896-9 [cited 2014 Oct 31].

5. Lund I, Scheffels J. Smoking and Snus Use Onset: Exploring the Influence of Snus Debut Age on the Risk for Smoking Uptake With Cross-Sectional Survey Data. Nicotine and Tobacco Research 2014;16(6):815-9 [cited 2014 Oct 31].

6. Stanfill SB, Connolly GN, Zhang L, Jia LT, Henningfield JE, Richter P, et al. Global Surveillance of Oral Tobacco Products: Total Nicotine, Unionised Nicotine and Tobacco-Specific N-Nitrosamines. Tobacco Control 2011 May;20(3):e2. doi:10.1136/tc.2010.037465 [cited 2014 Oct 31].

7. California Environmental Protection Agency. [Safe Drinking Water and Toxic Enforcement Act of 1986: Chemicals Known to the State to Cause Cancer or Reproductive Toxicity (November 23, 2018). PDF-23.6 KB] California Environmental Protection Agency, Office of Environmental Health Hazard Assessment [accessed 2014 Oct 31].

Page last reviewed:

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See the health effects associated with smokeless tobacco.

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The article says 1 in 10 high school students are using vapes and 1 in 8 high school students reported currently using nicotine products. This being said the article by the CDC goes on to talk about how students are more likely to be using these products now more than ever as they are peer pressured by their classmates and they see their parents using the as well. Students reported that they didn't know how to say no to their friends when they first tried it and now they are addicted.

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Centers for Disease Control and Prevention

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Youth use of tobacco products in any form is unsafe.
Preventing tobacco product use among youth is critical to reducing tobacco use among the nation's youth.

Tobacco product use is started and established primarily during adolescence.1,2

Nearly 9 out of 10 adults who smoke cigarettes daily first try smoking by age 18.

Flavorings in tobacco products can make them more appealing to youth.4,5

In 2021, 80.2% of high school students and 74.6% of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product during that time.⁶

In 2023, 90.3% of high school students and 87.1% of middle school students who used e-cigarettes in the past 30 days reported using a flavored e-cigarette during that time.⁷

Electronic cigarettes (E-cigarettes)

E-cigarettes have been the most commonly used tobacco product among youth since 2014.

In 2023, about 1 out of every 22 middle school students (4.6%) reported that they had used electronic cigarettes in the past 30 days.7

In 2023, 1 of every 10 high school students (10.0%) reported that they had used electronic cigarettes in the past 30 days.⁷

Cigarettes

Cigars

Smokeless Tobacco

Hookah

Heated Tobacco Products

In 2023, less than 1 of every 100 middle school students (0.8%) and about 1 of every 100 high school students (1.0%) reported using heated tobacco products in the past 30 days.⁷

Heated tobacco products, also known as "heat-not-burn" products, deliver nicotine to the user by heating tobacco leaves rather than a nicotine-containing liquid like e-cigarettes.

Nicotine Pouches

All Tobacco Product Use

Many young people use multiple tobacco products.
Youth who use multiple tobacco products are at higher risk for developing nicotine dependence and might be more likely to continue using tobacco into adulthood. 1, 2

Tobacco Product

Overall

Girls

Boys

Any tobacco product†

12.6%

14.1%

11.2%

Notes:
* "Current use" is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days.

† In 2023, any tobacco product includes e-cigarettes, cigarettes, cigars, smokeless tobacco (composite), pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), hookahs, heated tobacco products, nicotine pouches, and other oral nicotine products.

Tobacco Product

Overall

Girls

Boys

Any tobacco product†

6.6%

7.5%

5.7%

Factors associated with youth tobacco product use include the following:

Social and physical environments2,10,11

The way mass media show tobacco product use as a normal activity can make young people want to try these products.

Youth are more likely to use tobacco products if they see people their age using these products.

High school athletes are more likely to use smokeless tobacco than those of the same age who are not athletes.¹¹

Young people may be more likely to use tobacco products if a parent uses these products.

Biological and genetic factors1,2,10

There is evidence that youth may be sensitive to nicotine and that teens can feel dependent on nicotine sooner than adults.

Genetic factors may make quitting smoking harder for young people.

Smoking during pregnancy may increase the likelihood that the child will smoke cigarettes regularly in the future.

Mental health: There is a strong relationship between youth smoking and depression, anxiety, and stress.²

Personal views: When young people expect positive things from smoking, such as coping with stress better or losing weight, they are more likely to smoke.2,10

Other influences that affect youth tobacco use include:2,10

Lower socioeconomic status, including lower income or education

Not knowing how to say "no" to tobacco product use

Lack of support or involvement from parents

Accessibility, availability, and price of tobacco products

Doing poorly in school

Low self-image or self-esteem

Seeing tobacco product advertising in stores, on television, the Internet, in movies, or in magazines and newspapers

National, state, and local program activities have been shown to reduce and prevent youth tobacco product use when implemented together.2,12,13 These activities include:

Higher costs for tobacco products (for example, through increased taxes)2,13

Prohibiting smoking in indoor areas of workplaces and public places2,13

Raising the minimum age of sale for tobacco products to 21 years2,12

TV and radio commercials, posters, and other media messages aimed at kids and teens in order to counter tobacco product ads2,13

Community programs and school and college policies that encourage tobacco-free places and lifestyles2,12

Community programs that lower tobacco advertising, promotions, and help make tobacco products less easily available2,13

Some social and environmental factors are related to lower smoking levels among youth. Among these are: ² It is important to keep working to prevent and reduce the use of all forms of tobacco product use among youth.

Being part of a religious group or tradition

Racial/ethnic pride and strong racial identity

Higher academic achievement

1. Flavored Tobacco Product Use Among Middle and High School Students-United States, 2014U.S. Department of Health and Human Services. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2019 Feb 28].

2. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012 [accessed 2019 Feb 28].

3. Substance Abuse and Mental Health Services Administration. 2018 National Survey on Drug Use And Health: Detailed Tables. Substance Abuse and Mental Health Data Archive [accessed 4 Dec 2019].

4. Centers for Disease Control and Prevention. Flavored Tobacco Product Use Among Middle and High School Students-United States, 2014. Morbidity and Mortality Weekly Report, 2015;64(38):1066-70 [accessed 2019 Feb 28].

5. Wang TW, Gentzke AS, Neff LJ, et al. Characteristics of e-Cigarette Use Behaviors Among US Youth, 2020. JAMA Netw Open. 2021;4(6):e2111336. doi:10.1001/jamanetworkopen.2021.11336

6. Gentzke AS, Wang TW, Cornelius M, Park-Lee E, Ren C, Sawdey MD, Cullen KA, Loretan C, Jamal A, Homa DM. Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021. Morbidity and Mortality Weekly Report, 2022; 71(No. SS-5):1-29.

7. Birdsey J, Cornelius M, Jamal A, et al. Tobacco Product Use Among U.S. Middle and High School Students - National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023; 72(44);1173-1182.

8. Gentzke AS, Wang TW, Jamal A, Park-Lee E, Ren C et al. Tobacco Product Use Among Middle and High School Students, United States, 2020. Morbidity and Mortality Weekly Report 2020;69(50);1881-1888 [accessed 2020 Dec 17].

9. Marynak KL, Wang X, Borowiecki M, et al. Nicotine Pouch Unit Sales in the US, 2016-2020. JAMA. 2021;326(6):566-568. doi:10.1001/jama.2021.10366

10. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000 [accessed 2019 Feb 28].

11. Centers for Disease Control and Prevention. Combustible and Smokeless Tobacco Use Among High School Athletes-United States, 2001-2013. Morbidity and Mortality Weekly Report, 2015;64(34):935-9 [accessed 2019 Feb 28].

12. Gentzke AS, Glover-Kudon R, Tynan M, Jamal A. Adults' attitudes toward raising the minimum age of sale for tobacco products to 21 years, United States, 2014-2017. Prev Med. 2020 Feb 3;133:106012. doi: 10.1016/j.ypmed.2020.106012. Epub ahead of print. PMID: 32027916.

13. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs-2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2019 Feb 28].

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Smoking and smokeless tobacco use are almost always initiated and established during adolescence. Adolescent smokeless tobacco users are more likely than nonusers to become adult cigarette smokers.