7.3 Adolescent Risk Behaviors, Vaping, and Substance Use Prevention

CDC Youth Risk Behavior Surveillance System (YRBSS)

The Youth Risk Behavior Surveillance System (YRBSS) was established by the CDC in 1990 to monitor health-risk behaviors among middle and high school students across the United States. Conducted biennially, the YRBSS tracks priority health behaviors that contribute to the leading causes of morbidity and mortality among youth and adults.

The 6 Priority Risk Categories Tracked by YRBSS

1. Behaviors Contributing to Unintentional Injuries and Violence (e.g., seatbelt non-use, texting while driving, carrying weapons, bullying, suicidal ideation/attempts).
2. Sexual Behaviors contributing to unintended pregnancy and sexually transmitted infections (STIs/HIV).
3. Alcohol and Other Drug Use (binge drinking, prescription opioid misuse, illicit drug exposure).
4. Tobacco and Electronic Vapor Product Use (cigarettes, cigars, e-cigarettes/vapes).
5. Unhealthy Dietary Behaviors (insufficient fruit/vegetable intake, sugar-sweetened beverage consumption).
6. Physical Inactivity and excessive screen time.

School nurses utilize YRBSS national, state, and local data to perform needs assessments, secure grant funding, and implement targeted primary and secondary prevention programs.

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Electronic Cigarettes, Vaping, and EVALI Recognition

Electronic vapor products (e-cigarettes, vape pens, pods, mods) have revolutionized adolescent nicotine exposure. Modern devices utilize nicotine salts, which allow high concentrations of nicotine (e.g., a single pod containing nicotine equivalent to a pack of 20 traditional cigarettes) to be inhaled with minimal throat irritation.

Health Risks of Adolescent Vaping

• Neurodevelopmental Impact: Nicotine impairs adolescent brain development, specifically affecting prefrontal cortex circuits responsible for impulse control, executive function, attention, and mood regulation.
• Aerosol Toxicity: Vape aerosol is not harmless water vapor; it contains ultrafine particles, volatile organic compounds (benzene), heavy metals (nickel, tin, lead), and flavorings linked to respiratory illness (diacetyl / "popcorn lung").

EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury)

EVALI is an acute, life-threatening inflammatory lung condition recognized during the 2019 epidemic.

• Primary Etiology: Strongly linked to vaping products containing tetrahydrocannabinol (THC) formulated with Vitamin E acetate, an oily thickening agent that disrupts pulmonary surfactant function.
• Clinical Triad of EVALI Symptoms:
  • Respiratory: Cough, shortness of breath, chest pain, hypoxemia (low SpO2).
  • Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain (frequently precedes respiratory symptoms by several days).
  • Constitutional: Fever, chills, weight loss, fatigue, tachycardia.
• School Nursing Action: Obtain pulse oximetry, administer high-flow oxygen if hypoxemic, immediately activate EMS, and document exact vaping history.

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Alcohol, Cannabis, and Synthetic Drug Trends

Alcohol Misuse and Binge Drinking

Alcohol remains the most widely abused substance among high school students.

• Binge Drinking Definition: Consuming 4 or more drinks (females) or 5 or more drinks (males) within approximately 2 hours.
• Acute Intoxication Assessment: Hypothermia, sluggish reflexes, dysarthria (slurred speech), vomiting, severe respiratory depression, and altered mental status. High risk for aspiration of emesis.

Cannabis and Concentrates

Adolescent cannabis use has shifted toward high-potency concentrates (dabs, wax, shatter with >80% THC) and commercial edibles.

• Edible Overdose Hazard: Delayed onset of action (30 to 90 minutes post-ingestion) frequently leads adolescents to consume multiple doses, resulting in severe acute intoxication, extreme paranoia, psychosis, hallucinations, and Cannabinoid Hyperemesis Syndrome (CHS) (recurrent intractable vomiting relieved only by hot showers).

Synthetic Drugs

• Synthetic Cannabinoids (K2 / Spice): Full agonists at CB1 receptors causing extreme agitation, seizures, acute renal failure, and severe psychosis.
• Synthetic Cathinones ("Bath Salts"): Amphetamine-like stimulants causing sympathomimetic toxicity, severe hyperthermia, excited delirium, and rhabdomyolysis.

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School Opioid Crisis & Emergency Naloxone (Narcan) Protocol

The pediatric opioid crisis in schools is driven by illicitly manufactured fentanyl disguised as counterfeit prescription pills (e.g., fake Adderall, Xanax, or Percocet). Fentanyl is 50 to 100 times more potent than morphine, making fatal overdose a constant threat.

Opioid Overdose Clinical Triad

Opioid Overdose Clinical Triad:
┌───────────────────────────────────────────┐
│ 1. Respiratory Depression / Apnea         │
│ 2. Central Nervous System Depression/Coma │
│ 3. Pinpoint Pupils (Miosis)               │
└───────────────────────────────────────────┘
Secondary Signs: Cyanosis, pallor, gurgling/snoring ("death rattle")

NASN Emergency School Naloxone Protocol (CRITICAL EXAM PROTOCOL)

Naloxone (Narcan) is a competitive opioid antagonist that rapidly displaces opioids from mu-opioid receptors in the central nervous system, reversing respiratory depression.

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Screening Tools & Intervention Frameworks: CRAFFT and SBIRT

Early identification of adolescent substance use is a critical competency for certified school nurses.

The CRAFFT Screening Tool (Version 2.1)

The CRAFFT is a validated behavioral health screening tool designed specifically for adolescents aged 12 to 21 years.

• Part A: Asks about frequency of alcohol, marijuana, and other drug use in the past 12 months.
• Part B (The CRAFFT Mnemonic Questions):
  • C - Car: Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?
  • R - Relax: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  • A - Alone: Do you ever use alcohol or drugs while you are by yourself, ALONE?
  • F - Forget: Do you ever FORGET things you did while using alcohol or drugs?
  • F - Friends: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
  • T - Trouble: Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Scoring and Clinical Interpretation:

• A score of 0 or 1 indicates low risk; provide brief praise and general risk counseling.
• A score of 2 or higher indicates a high risk for a substance use disorder and requires brief intervention and a warm referral for comprehensive clinical assessment.

The SBIRT Framework in School Nursing

SBIRT (Screening, Brief Intervention, and Referral to Treatment) is an evidence-based public health practice:

1. Screening: Universal screening using standardized tools (e.g., CRAFFT).
2. Brief Intervention: Motivational interviewing conversation designed to raise student awareness of risks and enhance intrinsic motivation to change behavior.
3. Referral to Treatment: Connecting high-risk students to specialized community-based treatment resources while maintaining student confidentiality within legal standards (FERPA/HIPAA).