“It should be just like carrying a first aid kit,” Mr. Childs said.
How do you know if someone is overdosing?
If someone has shortness of breath or is not breathing, is unresponsive or won’t wake up and has pale or discolored skin, they may be overdosing. Other signs include pinpoint pupils, confusion, vomiting and cold or clammy skin.
Trainers will frequently instruct people to perform what is known as a sternum rub.
“You make a fist and with your knuckles you go up and down the sternum as hard as you can,” said Mr. Childs. “It causes excruciating pain, so if someone does not respond to that, you know they are in a state worth responding to immediately.”
If someone is awake, look at their eyes. “Mostly you see the iris, just a tiny black spot in the middle,” said Dr. Steven Daviss, senior medical adviser at the Substance Abuse and Mental Health Services Administration, which is part of the Department of Health and Human Services. “That’s a pretty good sign someone has overdosed on an opioid.”
Another symptom to look for is a snoring noise; this can actually be the sound of someone gasping for breath.
If you think someone is overdosing, call 911, even if you administer naloxone.
How do you give someone naloxone?
Naloxone comes in different forms.
If you are using the nasal spray version, commonly referred to by the brand name Narcan, tilt the patient’s head back and spray it into the patient’s nose. Most people will respond in a few minutes. People at trainings are often told to administer one dose, wait three minutes, do rescue breathing and then give a second dose if there is no response. They may be told to flip a patient on their side to prevent asphyxiation if the person vomits.
Injectable naloxone, which can come in syringes or in “auto-injectors,” is a muscle shot and can be injected into the thigh, buttocks or arms. Again, if it does not work within two or three minutes, administer a second dose.
Some people may need more than two doses.
What if that fails?
If the person is not breathing, or if their breathing is shallow, perform rescue breathing. If nothing has changed and there is no pulse, the person needs CPR from a trained bystander and emergency medical care.
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Where do you get naloxone?
You can get naloxone at your local pharmacy. Some states allow you to purchase it over the counter at stores like CVS and Walgreens, but others require a prescription. And some community groups, local health departments and needle exchanges distribute low-cost or free naloxone kits, which come with gloves, face masks and instructions.
Many emergency workers and medical personnel carry naloxone as well.
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How much does naloxone cost?
It depends. The type of naloxone you can get often differs by state, pharmacy and what insurance you have. Many insurances cover naloxone, so you can ask to see what your share of the cost would be. Some public health programs also offer ways for people to get it for free or at a low cost, as do naloxone’s manufacturers in some cases.
“There is wide variation in the cost of naloxone,” said Kemp Chester, associate director at the Office of National Drug Control Policy at the White House. “It can be as cheap as $35 and as expensive as $100 plus.”
Can you give someone too much naloxone?
No. Naloxone is not addictive. It does force people into opioid withdrawal, so a person receiving it can be distraught, irritable and upset when they come to.
But if you give it to someone and it turns out they are not overdosing, don’t worry. “It is not harmful to give it to someone who is not undergoing an overdose,” said Mr. Chester.
Naloxone only works for overdoses from opioids, not overdoses from other types of drugs.
Do experts think this will save lives or help end the opioid crisis?
Naloxone can save someone’s life during an overdose, but it is not a cure for opioid addiction. Dr. Daviss said that a number of people who go to an emergency room after an overdose will die from a second, third or fourth overdose within a year. “You’ve got to hook them up into treatment,” he said. “Medication-assisted treatment is the way to go.”
“Often, Australians don’t realize it,” she said of the ubiquity of the machines. “It’s like being a fish in water.”
Their operators are often prominent community entities: Woolworths, one of Australia’s largest supermarket chains, is the biggest operator of pokies in the country, controlling about 12,000 machines through its majority stake in the Australian Leisure and Hospitality Group, a large company that encompasses bars, restaurants and wagering.
Though the Woolworths Group doesn’t distinguish liquor sales from gambling revenues in its annual report, estimates suggest that it pulls more than 1 billion Australian dollars, or $770 million, in revenue from the machines each year.
Other community mainstays also operate machines. In Victoria, the heartland of Australian Rules Football, 90 percent of Australian Football League teams operate their own pokies, generating more than 93 million Australian dollars in revenue last year.
Pokies are regulated on a state-by-state basis, instead of by the federal government. Western Australia is the only state or territory that bans the operation of pokies outside casinos.
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State budgets are increasingly made up of revenues from the machines, and legalized gambling, including from pokies, accounted for 7.7 percent of total tax revenues for Australian states and territories in 2016. In some parts of Australia, gamers can deposit 7,500 Australian dollars into a machine in one transaction, and can lose more than a thousand dollars per hour.
A study conducted by Dr. Rintoul comparing two regions outside Melbourne found that the less wealthy one had twice as many pokie machines, and more than three times the per capita losses.
“The people who can least afford to be losing large sums of money are losing the most,” she said.
Dr. Rintoul described the casino-like methods used by venues to maximize revenue, including rewarding patrons with free food and drinks, and hiring part-time models as wait staff.
A visit to one gaming floor at a venue in Sunshine, the region Dr. Rintoul’s study focused on, revealed a busy gaming floor one recent Wednesday night. Gamblers placed “RESERVED” signs under their machines of choice, which Dr. Rintoul said reflected how frequent gamblers come to relate to the machines: picking favorites, and believing that a particular one can get “hot” or due for a win.
A few hours later, in Balaclava, a suburb on the opposite side of Melbourne, patrons filled the gaming room at an Australian Leisure and Hospitality Group venue open until 6 a.m. A large Woolworths supermarket across the road keeps foot traffic in the area high.
“We regularly had people tell us that they often ended up in a gambling venue even when they weren’t intending to gamble when they left the house,” Dr. Rintoul said.
In February, Andrew Wilkie, an independent Australian politician, published leaked documents from two whistle-blowers at Australian Leisure and Hospitality revealing that the company had been secretly collecting data on frequent gamblers, including their favorite sporting teams, their relationship statuses and when they had the most money to spend.
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Gordon Cairns, the chairman of Woolworths, said that the company was “very concerned” about the revelations and that the matter was being reviewed by external auditors.
In a country that has confronted other powerful industries by mandating graphic warnings on cigarette packages and cracking down on guns, some wonder why gambling has escaped tougher regulation. Critics say politicians are increasingly afraid to confront the growing influence of the gambling lobby.
The Rev. Tim Costello, a spokesman for the Alliance for Gambling Reform, compares pro-gambling bodies to the National Rifle Association in the United States in their ability to sway politicians.
Australians, he said, “say Americans have a blind spot on guns.”
“Here, we have a blind spot on pokies,” he added.
Pro-gambling groups frequently refer to Mr. Costello and other gambling opponents as “prohibitionists,” and are quick to point to support services they have developed for frequent gamers. They also argue that tighter regulation of pokies would lead to huge job losses at the venues that operate them.
The groups have increasingly flexed their muscles in state elections. Anti-gambling candidates who ran in Tasmania and South Australia this year faced a barrage of negative advertising from pro-gambling bodies.
In the run-up to the South Australian election, the Australian Hotels Association — which counts Australian Leisure and Hospitality as a member — donated to several opponents of Nick Xenophon, an independent whose new party, S.A.-BEST, vowed to cut in half the number of pokies per venue, and institute smaller betting limits. After positive early campaign polling, Mr. Xenophon and his party ultimately failed to win a single lower-house seat. It was the first election loss of Mr. Xenophon’s 20-year career.
“How much influence they wield, it’s unhealthy,” said Frank Pangello, Mr. Xenophon’s media adviser in the recent election.
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“They bought an election in Tasmania, they bought one in South Australia,” Mr. Pangello added. “They’re like the N.R.A. in America: You take them on, they’ll crush you.”
The Australian Leisure and Hospitality Group declined to comment for this article or discuss whether it spent money on the Tasmanian and South Australian state elections. The hotels group did not respond to a request for comment.
Mr. Costello said that with governments so dependent on gambling revenues, it may be difficult to pass tighter regulation of pokies.
“The states are Dracula in charge of the blood bank,” he said.
Schools say the problem sneaked up on them last fall, when students arrived with a new generation of easily concealed devices that have a sleek high-tech design. The most popular, made by Juul, a San Francisco-based company that has received venture capital money, resemble a flash drive and have become so ubiquitous students have turned Juul into a verb.
Tasting like fruit or mint, these devices produce little telltale plume, making it possible for some students to vape even in class.
“They can pin them on to their shirt collar or bra strap and lean over and take a hit every now and then, and who’s to know?” said Howard Colter, the interim superintendent in Cape Elizabeth.
E-cigarettes are widely considered safer than traditional cigarettes, but they are too new for researchers to understand the long-term health effects, making today’s youth what public health experts call a “guinea pig generation.”
School and health officials say several things are clear though: Nicotine is highly addictive, the pods in vaping devices have a higher concentration of nicotine than do individual cigarettes, and a growing body of research indicates that vaping is leading more adolescents to try cigarettes.
Ashley Gould, the chief administrative officer of Juul, said that the company’s products are intended solely for adults who want to quit smoking.
“We do not want kids using our products,” she said. “Our product is not only not for kids, it’s not for non-nicotine users.”
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She said schools and the e-cigarette industry need to work together to understand why teenagers are vaping, and suggested that stress is a big reason. To that end, she said, Juul has offered schools a curriculum that includes mindfulness exercises for students to keep them away from the devices the company sells.
“We saw the same thing from Philip Morris with the We Card program, and the evaluation was that those things don’t work,” Jennifer Kovarik, who runs tobacco prevention programs for Boulder County, Colo., said of the company’s efforts to keep their products away from teenagers. “If they didn’t want youth to use it, it would be sold in 18-and-over-only establishments. It’s available at Circle K’s across the country.”
E-cigarettes deliver nicotine through a liquid that is heated into vapor and inhaled, cutting out the cancer-causing tar of combustible cigarettes. But vaping liquids contain additives such as propylene glycol and glycerol that can form carcinogenic compounds when they are heated. Diacetyl, a chemical used to flavor some vape “juice,” has been linked to so-called popcorn lung, the scarring and obstruction of the lungs’ smallest airways. A study published in the journal Pediatrics in March found substantially increased levels of five carcinogenic compounds in the urine of teenagers who vape.
“I’m afraid that we’re going to be hooking a new generation of kids on nicotine, with potentially unknown risks,” said Dr. Mark L. Rubinstein, the lead author of the study and a professor of pediatrics at the University of California, San Francisco. “With cigarettes, we’ve been studying them for many years, we have a pretty good idea of what the risks are. We just don’t know what the risks of inhaling all these flavorings and dyes are, and what we do know is already pretty scary.”
The industry points to a 2016 British study that says that vaping does not lead nonsmokers to become smokers. But the 2016 Monitoring the Future study, sponsored by the federal government’s National Institute on Drug Abuse, followed students who in 12th grade had never smoked a cigarette and found that a year later, those who used e-cigarettes were about four times as likely to have smoked a cigarette. A study released in January by the National Academies of Sciences, Engineering and Medicine similarly concluded that vaping led students to smoke cigarettes, although it did not determine whether they became habitual smokers or just experimented.
Schools and local officials have stiffened penalties for students caught with vaping devices, suspending and even expelling them, and sent home letters pleading with parents to be on the lookout for a waft of fruit smell and, as one superintendent wrote, “‘pens’ that aren’t pens.”
Several school districts in New Jersey have recently adopted policies requiring any student caught with an e-cigarette to be drug tested, because the devices can be used to smoke marijuana.
Oak Ridge High School in Placerville, Calif., shut down all but two bathrooms during classes in November and placed monitors at the doors during lunch to make sure not too many students are in the bathroom together. (Juul devices, for example, contain as much nicotine as a pack of cigarettes, so they are easy to share.) New Trier High School in Chicago’s northern suburbs is considering installing vaping detectors in bathrooms.
With so many students caught multiple times, some schools have moved from punishment to intervention, requiring students caught vaping to receive counseling or substance abuse treatment.
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“Despite all of the boundaries set by families and parents and the schools, and at risk of even expulsion, students are continuing to use,” said Liz Blackwell, a school nurse in the Boulder Valley School District in Colorado. “They don’t want to be kicked out of school, they don’t want to suffer any punishment or discipline, and they don’t want to have a bad relationship with their parents. They continue to use because it’s an addiction.”
As part of her treatment plan, one of Ms. Blackwell’s students asked if she could stand at the back of the class and shake her foot when she started to feel the twitch to vape.
Two years ago, Boulder surveyed its students and found that 45 percent of high school students had used e-cigarettes, with 30 percent as current users. Officials say they expect the most recent survey, taken last year, to show about 45 percent of middle school students have used e-cigarettes.
The 2017 Monitoring the Future survey on adolescent drug use found that 24 percent of high school seniors reported vaping daily, which the study defined as vaping on 20 or more occasions in the previous 30 days, said Richard A. Miech, a professor at the Institute for Social Research at the University of Michigan and a principal investigator of the study. Nineteen percent reported vaping on 40 or more occasions during that period.
Fifty-six percent reported vaping only on one to five occasions. Gregory Conley, the president of the American Vaping Association, which supports what he calls “fair and sensible” regulation of e-cigarettes, said that number indicated that most students who are vaping are not becoming addicted. “You can’t use the definition of dependence and apply it to anyone using only one to five days in the prior month,” he said.
Schools say that unlike adults, most students who vape are starting out as nonsmokers.
“I have the same conversation with every student we catch vaping,” said Scott Carpenter, the dean for discipline at Cumberland High School in Rhode Island. “I say, ‘If I handed you a cigarette would you smoke it?’ And 100 percent of them look at you like you’re absolutely crazy for even suggesting that they’d do that.”
Federal law prohibits the sale of e-cigarettes to anyone under 18, and Juul and some other e-cigarette companies ask web purchasers to check a box saying that they are 21 or older. But the growing vaping industry has many items and campaigns that seem to appeal specifically to youth. There are vaping cloud contests, a line of hoodies and backpacks called VaprWear that make it easy to conceal the devices, and labels of vape “sauce” that resemble the designs of well-known candy wrappers like those of Jolly Ranchers and Blow Pops.
In Millburn, N.J., one of the school districts that now require any student caught with a vaping device to be drug tested, teenagers said Juuls began showing up at parties last year, and by fall were at school and football games. Now, students post videos of themselves doing vapor tricks on social media.
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At a local deli where seniors go for lunch, a dozen students interviewed said it was easy to buy a Juul online or at a gas station or convenience store, and to buy refill pods in the hallway at school. None would publicly admit to owning a device, but all said they had tried vaping.
Ryan Wenslau, 18, said he thought vaping started for most students as an occasional diversion, “something to do.” For those who continue, “I wouldn’t necessarily call it an addiction,” he said, “but it’s habitual.”
While there might be chemicals in vaping, they argued, there are more in cigarettes.
“Technically, it’s better,” said Fares Alhabboubi, 17.
Schools lament that teenagers equate safer with safe. But many say the unfamiliarity of e-cigarettes has made it hard to convince parents of the risks as well.
“If I had a pack of cigarettes in my room as a kid, that would have been discovered, here we’re dealing with, first of all, what’s a Juul?” said Michael McAlister, the principal at Northgate High School in Walnut Creek, Calif. The school has about 1,600 students, but parent education nights on the issue have turned out only about 70 people. Yet, out of 53 suspensions last year, 40 were for vaping devices.
“We’re losing a battle and to me, it’s predatory,” Mr. McAlister said. “There’s no way you’re going to suspend your way out of this.”