What you need to know about Juuling (and other electronic cigarettes)!

Juuling has quickly become very popular in our high schools, colleges, and even middle schools.  While electronic cigarettes were created to help people quit smoking, in young people they are actually becoming the introduction to tobacco use.  Here are some key things to know:

Safer does not equal safe.  Yes there are no studies linking e-cigarettes to cancer.  Just because e-cigarettes are safer than traditional cigarettes does not mean they are safe.  They still contain many chemicals that we know are airway irritants and carcinogens.  They contain nicotine.   We have no long term studies of the safety of e-cigarettes.

Nicotine is addictive. The Juul pods contain the same amount of nicotine as a pack of cigarettes.    Some e-cigarettes juice is even stronger.  Studies have shown e-cigarette fluid that claims to be nicotine free often contains nicotine.  We also know nicotine affects the developing brain leading to difficulties with attention, learning, impulse control, and mood.

Teens are the target of advertisement. Juul, the most common e-cigarette used among teenagers, began advertising on Youtube, Instagram, and Twitter.  There is a huge social media presence of Juul and Juul is starting to show up in TV shows and movies.  #doitforJuul is a common hashtag that people use to show them using a Juul.  This affects teens, even if they do not realize.

People vape a variety of substances. On youtube you can find videos of people using a variety of fluids including caffeine, alcohol, and Marijuana. Anytime someone is breathing in a substance, it is likely to irritate the airwyas.  There have even been cases of people dying after vaping synthetic cannabinoid.

Juul use is increasing tobacco use among teens. Starting in the 1990s there was a steady decline in tobacco use among teenagers, reaching as low as 12% of all teenagers ever using tobacco.  With the advent of Juul, as many as 35% of teenagers admit to using nicotine containing products.  Unfortunately, many of these Juul users go on to smoke traditional cigarettes.

Juul and other ecigarette companies create fruit flavored fluids that appeal to young users.  Juul can be easily concealed and has become a trend among high school students.  Our teens are getting addicted to nicotine and we must do our best to prevent this!

By Dr. Ashlee Mickelson

Parenting Through Puberty

I know when my oldest let me know about the changes, I wasn’t ready.  I had prepared my child with what to expect, gotten her some nice books about it that we read together. But, when the time arrived, I thought, “already?”

The changes of puberty are different for every child, but there are some points that help know what’s ahead, just around the corner.

Physical Changes


For girls, the changes of puberty start between 8 and 13 years old.  Usually the first sign is breast development.  It commonly takes about two years to get from there to the first menses, or period.  Along the way, development of pubertal hair and a growth spurt usually ensue as well.  When girls start menses, it can be irregular in the first year, but it tends to become more regular with time.

For boys, the changes of puberty start between 9 and 14 years of age.  This starts with genitals enlarging, followed by pubertal hair.  Then they will develop increased muscle mass and voice changes, with the start of these averaging at 13 ½ years old. The peak height for boys is usually reached by 17 years old, 2 years past that for girls.

Both girls and boys will have other changes as well, including hair growth, acne, and body odor.  If you have questions or concerns about whether your child’s patterns are normal, it’s important to ask your healthcare provider.

Emotional Changes


Along with the physical changes, there are many emotional changes with puberty as well. Adolescent youth begin to become more independent and less interested in having the attention of their parents.  Some will lose their temper more easily and have more mood swings.  It’s important to keep the conversation open with these changes, both physical and emotional.  Being positively and proactively involved in your child life, even when it’s not invited, helps them know you support them when they need it.

Puberty is Starting Earlier


Despite the normal ranges of puberty described above, the onset of puberty has gotten earlier over the years. The cause is unclear, but we know several factors can lead to an earlier start.  Trends from lifestyle factors include an earlier start for girls with more sugar intake (independent of weight), also an earlier start for girls with obesity.  There are differences in the start of puberty with different racial background as well, with puberty often occurring earlier in African-American children.



Some books that may help open the conversation with you and your child include “The Care and Keeping of You: A Body Book for Girls” by Valerie Lee Schafer and “Guy Stuff: the Body Book” by Dr. Cara Natterson.  These are appropriate for kids 8 years old and up according to Common Sense Media, a website with recommendations on books and movies for kids that are age appropriate.

Are My Child’s Changes Normal?


If your girl starts showing signs of puberty before 8 years old or your boy before 9, it’s worth bringing up with your provider to discuss further.  Similarly, if your girl has not started these changes by the time she reaches 13 or your boy by 14, that’s a good reason to discuss as well. Your annual well-child visits are a great opportunity for providers to evaluate these development milestones and make sure things are on track. Please make sure to keep up-to-date on these important visits.

Entering into the next stage can be an intimidating phase for parents and kids alike, but it’s all about being there for your child in an open and honest way.

By Dr. Deborah Wiser, Chief Medical Officer

Adolescent Suicide on the Rise in Spokane


A recent article in the Spokesman Review states, “Five teen suicides this school year – including three in the past month – have jolted the community. It’s the highest number in the history of Spokane Public Schools, prompting parents, students and community members to ask what they can do to help.”

As a Pediatrician here at CHAS I have noticed since mid –March an increased number of teenagers coming into my office for significant suicidal concerns with several reporting that they don’t feel safe going home from the clinic. This is very alarming and hard to manage if our Mental Health Staff has a full schedule. Periodically, the only option we may have available is to ask the family to go to the Sacred Heart Children’s Hospital Emergency Room for safety and to get prompt access to a mental health professional or other services.

Another article from the Inlander just three years ago, covers this local topic as well. They report, “experts say the region needs to start talking about the problem. Spokane has a rate of suicide higher than the state average. It’s the city’s second-leading cause of death for people ages 10-24.” Suicide isn’t just an issue for Spokane, but the entire Inland Northwest. Coeur d’Alene has the highest suicide rate in Idaho, and Idaho consistently has one of the highest rates in the nation, according to a report by Suicide Prevention Action Network of Idaho.

Both articles go on to discuss the need to work on being open and frank with all adolescents. As a medical care team we need to remember to do annual mental health screenings for all teenagers and the PHQ (Patient Health Questionnaire) is a validated test and a reasonable way to open the conversation with any teenagers in your office. The biggest obstacle is getting over the awkwardness of discussing this topic which is hard for many individuals to do. Teenagers tend to be more open and honest when they feel you are open with them and showing them that you actually care about their personal story.

Scientifically we know the adolescent brain works differently than the adult brain as teenagers seem to be pre-programmed to take greater risks and have less inhibition of impulse behaviors. This makes them appear to live more in their current emotions and less in their analytical/reasoning brain where adults tend to spend more of their time. This can lead to behavior that seems uncharacteristic and reckless to others but does not seem strange or out of the ordinary to teens in my office when they bring up the topic.

To try and keep this commentary to a minimum, I have provided links to both of the recent articles which I feel are informative for our community. They do go on to provide resources which I have attached below.

What Causes Suicide?

According to the National Alliance on Mental Illness (NAMI), “90 percent of youth suicide victims have at least one major psychiatric disorder, although younger adolescent suicide victims have lower rates of psychopathology.” Overall, NAMI asserts that 90 percent of people who complete suicide could have been treated for a mental or substance-abuse disorder.

Suicide Prevention Meetings

Prevent Suicide Spokane is hosting a meeting about what can be done in the community to help. The event is 1 to 3 p.m. Friday at Spokane Regional Health District, 1101 W College Ave. For more information contact Sabrina Votava at (509)475-7334 or sabrina@yspp.org.

Prevention Resources

First Call for Help Crisis Hotline: 509-838-4428

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)


LGBTQ Crisis Hotline: 1-866-4-U-TREVOR

American Foundation for Suicide Prevention: afsp.org

QPR Institute: qprinstitute.com

Youth Suicide Prevention Program: yspp.org

Some Warning Signs

  • Talking or writing about death, dying or suicide when these actions are out of the ordinary for the person
  • Acting reckless or engaging in risky activities — seemingly without thinking
  • Increasing alcohol or drug use
  • Withdrawing from friends, family and society
  • Feeling anxious or agitated, being unable to sleep, or sleeping all the time
  • Experiencing dramatic mood changes
  • Changes in eating and sleeping habits
  • Unusual neglect of personal appearance
  • Marked personality changes
  • Frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.
  • SOURCES: National Suicide Prevention Lifeline (suicidepreventionlifeline.org); National Alliance on Mental Illness (nami.org)

By Dan Moorman, Physician