A Chat with Dr. Bonnie Halpern-Felsher

Anti-Vaping Activist and Creator of the Stanford Tobacco Prevention Toolkit

The air feels dynamic around Dr. Bonnie Halpern-Felsher. Whether it's the strength and passion of the scientific arguments she makes against Big Vaping, or the many miles she logs while tirelessly lobbying for prevention, constant momentum surrounds her.
Since early 2018, we at FCD Prevention Works have been proud to partner with Bonnie and her team at Stanford Medicine in our use of their groundbreaking Tobacco Prevention Toolkit. Taking the Toolkit and its new complement the Cannabis Prevention and Awareness Toolkit to international classrooms, we help students understand the risks and realities of electronic cigarette use from a health perspective.
FCD has been privileged to witness Bonnie's heroic adventures to stop teen vaping unfold. We recently chatted with her about all things research, education, and advocacy.
FCD Prevention Works: How are you?! What's new in your world?
Dr. Bonnie Halpern-Felsher: Hello! I'm excited for 2020, as my team and I - and many other educators and health groups - work hard to tackle the teen vaping epidemic.
In the next few months, I'm working on a number of initiatives. Our new Healthy Futures: Alternative to Suspension curricula just launched. These one-, two-, and four-hour curricula are aimed at helping youth who are vaping. The curricula help teens to understand what kind of addictive drugs they are using when they vape. The lessons also help kids to take steps toward quitting.
We continue to build out more materials within the Tobacco Prevention Toolkit and the Cannabis Awareness and Prevention Toolkit , including online self-directed courses for youth, and tons of new parent and healthcare provider materials. Please do keep checking back to the websites for more new information.
FCD: Both the Stanford Medicine Tobacco Toolkit and the Cannabis Toolkit are incredible, publicly available resources for schools, students, and communities. What was your drive to create them in the first place?
BHF: Thank you. A few years ago, a middle school asked me to come teach about tobacco. At the time, I struggled to find a curriculum that would really interest youth. Further, most curricula weren't online. Instead, educators had to pay for them, send away for them, and wait for them to arrive. Even then, the materials were often outdated.
My team and I really wanted access to an interactive, activity-based curricula built on the latest information about tobacco and cannabis products, including of course e-cigarettes. We wanted all other educators themselves to have access to this information too. But, we couldn't find it out there. So, we were really motivated to develop free, online lessons that were easily updated and met the needs of all - educators, parents, providers, and youth.  
FCD: How has your professional anti-vaping journey grown since releasing the first Toolkit?
BHF: Wow, it has certainly grown. We launched the Toolkit in September 2016, just before the e-cigarette and JUULing epidemic blossomed. Since then, the Toolkit has reached well over a million youth in the U.S. and around the globe.
Further, my published research focusing on youth substance use has really influenced the field. I've published on what substances kids are using and what key factors influence why kids are using in the first place, such as flavoring and marketing. I am excited to have contributed to our scientific knowledge.
Finally, I have become an advocate, speaking at the local, city, county, and state levels in favor of tobacco - and especially e-cigarette - regulation. I have been fortunate to testify and speak to members of the United States Congress, at various state-level legislative bodies, and at city and state meetings as well as to the U.S. Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and others.  
FCD: So many adults are concerned about teen vaping. How is it the case that young people, under 18, have access to and interest in electronic tobacco and marijuana cigarettes?
BHF: Yes, teen vaping, whether it is with nicotine or THC products, has grown dramatically, and we are very concerned about such use. Many U.S. states have enacted laws restricting access until the age of 21.
However, we do know millions of youth under this age are using these products, obtaining them from vape shops and other retail locations that are not checking identification.
We also know that it is easy for youth to purchase these products online, or have a friend purchase for them. That is why we need strict regulation of the products overall, including eliminating all flavors - mint and menthol too, which are still popular among youth - reducing allowable levels of nicotine in these products, and disallowing marketing to youth.
FCD: There is a lot of misinformation about electronic cigarettes out there. Can you tell us what is actually known about the health risks of nicotine, THC, and CBD vaping for teens?
BHF: Yes, there is a lot of misinformation, owing largely to marketing and lack of sufficient youth education.
Recent research clearly shows that e-cigarettes affect lung function. E-cigs do not only cause EVALI (E-cigarette/Vaping Product Use-Associated Lung Injury), responsible for thousands of illnesses and at least 50 deaths. Vaping also contributes to asthma, pneumonia, and other illnesses. These diseases have been directly linked to e-cigarettes and their flavorants. This is true for nicotine-based and cannabis-based vapes.
We also know that e-cigarettes harm the heart, and that it is not just the person vaping who is at risk, but also those in their environment. There are both second-hand and third-hand effects of vaping from the resulting aerosol.
E-cigarettes that have nicotine in them, as well as those that have THC in them, are addictive. These drug products change brains and promote disease, especially among young people.
FCD: Fortunately, the fact is that most young people make the healthy choice not to vape. Yet, among those teens who do, we know that addiction is highly likely. How can adults help children who may be struggling with addiction to nicotine and/or marijuana because of vapes?
BHF: We now have not only an epidemic number of youth using e-cigarettes, but also an unprecedented number of youth addicted to them. Unfortunately, we don't yet have any research-validated tools to help youth stop using nicotine, especially in the form of e-cigarettes.
E-cigarettes have a tremendous amount of nicotine in them. Newer products like JUUL, Puff Bar, Suorin and others contain as much nicotine per product item as can be found in one-and-a-half to two whole packs of cigarettes! It's not surprising then that these products are so highly addictive.  
While we don't have FDA-approved nicotine replacement therapy for youth (e.g., the patch), there are promising avenues to help youth quit. Research-based prevention education such as FCD offers, as well as expert-crafted, tailor-made alternative-to-suspension programs like the one we at the Stanford Medicine Toolkit now offer, are available. There are also a growing number of quit vaping call and text lines, built just for teens, being piloted as we speak.
We also know that some healthcare providers are choosing to prescribe patches and other medical treatment to adolescents; however, we don't have the large-scale research yet available to say how effective such measures will be for this age group. Our lab and others are working hard to find ways to support youth, and their families, in quitting.
FCD: As a researcher, an advocate, a developmental psychologist, and a mom, what are your personal goals for the Toolkits?
BHF: I really hope that we reach millions of youth across the globe, and that we will continue to be used by schools throughout the country, as I do believe our curricula are effective. I also truly hope to be a leader in advocating for stricter e-cigarette and cannabis regulations. Prevention education is certainly critical, but we also need to reduce youth access and the current youth appeal of these products. I personally plan to continue to spend hours each day advocating for the health and protection of our kids!
FCD: With or beyond the Toolkits, what are your future plans in the realm of vaping or other drug use prevention education?
BHF: We at Stanford Medicine plan on building out more Toolkit lessons, especially now focused on cessation and quitting. We are also really focused on developing and disseminating targeted materials for parents and healthcare providers especially, so that they can best work with youth to prevent, reduce, and stop substance use.
If you are interested in bringing FCD Prevention Specialists to your elementary, middle, or high school to facilitate research-based prevention education and consultation using the Stanford Toolkits and more, please contact schools@fcd.org.

Thanks to Ian Groves, FCD Prevention Specialist, for his contributions to this article.
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