Rupin R. Thakkar, MD, FAAP Immediate Past President, Washington - - PowerPoint PPT Presentation

Rupin R. Thakkar, MD, FAAP Immediate Past President, Washington Chapter of the American Academy of Pediatrics Lead Physician, Swedish Pediatrics- Edmonds

§I have no actual or potential conflicts of interest in

relation to this presentation

§I will refer to specific trade names among vaping

devices

§What are e-cigarettes? §Prevalence of vaping among youth §Health effects of vaping §How should we talk to patients about

vaping?

§Advocacy: Regulations that can prevent

future use

§If time permits…Vaping-related lung illness

§ Evolution of the e-cigarette § E-cigarettes heat a liquid solution to a

high enough temperature so that it produces an aerosol that is inhaled.

§ E-cigarettes are battery-powered. They

can be disposable or rechargeable.

§ E-cigarettes come in many forms. They

can resemble combustible cigarettes, cigars, pipes, pens, or flash drives.

§ Many of the compounds used in e-liquids

have been approved by the FDA for oral consumption, but not for inhalation due to the lack of research regarding the safety

• f these compounds when inhaled.

§ Vegetable glycerin, propylene glycol, flavoring chemicals, liquid nicotine § Proplyene glycol can form carcinogens when heated § Diacetyl, used in many flavors, is the chemical linked to popcorn lung

(bronchiolitis obliterans)

§ Other chemicals found: Ultrafine particles, Volatile organic chemicals, Heavy

metals (nickel, tin, and lead), Formaldehyde

§ Liquid nicotine content is highly variable in e-cigs but the newer pod-based

• nes tend to contain twice as much as the early e-cigs

§Pre-filled cartridges §Appeal to consumers

• Low cost
• Low maintenance
• Easy to use
• Sleek & Discreet

§Top-selling brands §JUUL, Phix, MyBlu

§Resembles a USB flash

drive and can be charged in a laptop or USB charger

§Can purchase designer

“skins”

§Little to no detectable

• dor or visible exhalant

§Until a few months ago, it

came in many fruit and candy flavors

All pods contain nicotine. Nicotine in 1 pod (59mg/ mL) is equivalent to 20 cigarettes (1 pack) Nicotine salts deliver a higher volume of nicotine more smoothly (less throat irritation) than combustible tobacco or vaping products that contain freebase nicotine, and the nicotine is absorbed faster.

Our Y

• uth.

1 in 4 high school students 1 in 10 middle school students

Source: 2019 National Y

• uth Tobacco Survey (use in the past

month) conducted by FDA

§About 60% of students who JUUL report they receive

their vaping products socially rather than through purchasing themselves.

§Educators report that youth are using JUUL in

classrooms, hallways and restrooms, and are sharing devices with their peers.

§This social use encourages non-users to try JUUL, and

enables students who are too young to purchase these products, or who could not otherwise afford them, to access them through peers.

• Y
• uth are particularly susceptible to

dependence and addiction since their brains are still developing well into their mid-20’ s

• 95% of people who smoke started before

they were age 21

• Developing brains are more susceptible

to the rewarding effects of nicotine

• The impact of nicotine on learning,

memory and attention affects school performance and job prospects

• Nicotine use increases the risk for

addiction to other drugs

§According to the 2016 Washington State Department of Health

Y

• uth Survey, only 29.7% of 10th graders perceived vaping to

be harm ful, but alm ost all of the students surveyed (80%) thought cigarettes to be harm ful.

§According to research by the Truth Initiative, m ore than 60

percent of JUUL users aged 15-24 did not know that the product contains nicotine. They think of it as flavored vapor, but one JUUL pod contains nicotine equivalent to 20 combustible cigarettes.

§Youth m ay not realize that nicotine is highly addictive. While

they may understand that cigarettes and other tobacco products are addictive, they may mistakenly believe that it is the tobacco, not the nicotine, that creates an addiction.

“There is substantial evidence that e- cigarette use increases risk of ever using com bustible tobacco cigarettes am ong youth and young adults.” ––The 2018 National Academies of Sciences, Engineering, and Medicine Report

§Studies show that vaping increases risk of ever using combustible

tobacco

§E-cigarette users almost 3X as likely to initiate cigarette smoking a

year later (9th graders in LA)1

§E-cigarette users almost 8X as likely to initiate cigarette smoking a

year later (young adults in CT)2

§Moderate evidence that e-cigarette use increases frequency and

intensity of subsequent smoking 3

So urc e : 1. L e ve ntha l, Ada m M., e t a l. "Asso c ia tio n o f e le c tro nic c ig a re tte use with initia tio n o f c o mb ustib le to b a c c o pro duc t smo king in e a rly a do le sc e nc e ." Jama314.7 (2015): 700-707. 2. Prima c k, Bria n A., e t a l. "Pro g re ssio n to tra ditio na l c ig a re tte smo king a fte r e le c tro nic c ig a re tte use a mo ng US a do le sc e nts a nd yo ung a dults." JAMA pe diatric s 169.11 (2015): 1018-1023. 3. Da i H, e t a l. Pe dia tric s 2018; 141(5). Ava ila b le a t: http:/ / pe dia tric s.a a ppub lic a tio ns.o rg / c o nte nt/ 141/ 5/ e 20173787

• For the 6th year in a row e-cigs were

the most commonly used tobacco product

• However, we are now seeing a rise

in other products again, particularly cigars

• 1 in 3 respondents of the NYTS (both

high school and middle school students) reporting using 2 tobacco products in the past month, with the most popular combinations being e- cigs and cigars followed by e-cigs and cigarettes

§E-cigarettes mimic combustible cigarette use and help re-

normalize smoking behaviors

§Pleasurable sensations caused by nicotine result in

seeking more sources

§If vapor products are favorable, the expectation develops

that other tobacco products will also be enjoyable

§Risk behaviors build §E-cigarette retailers may also advertise and sell

traditional cigarettes

Short-term

§Common adverse events after e-cigarette use are: mouth

and throat irritation, nausea, headache, cough, increased blood pressure and heart rate Second-hand

§Data very limited. Low levels of nicotine in secondhand

aerosol have been detected in some studies.

§Animal data shows that exposure to secondhand e-

cigarette vapor harms lung function

Long-Term

§Unknown §There are no long-term studies yet on e-cigarettes, and this can

take decades as it did with tobacco products. But, it is biologically plausible that long-term exposure to e-cigarettes could increase risk of serious disease.

§Exposure to toxicants in e-cigarette aerosol is significantly lower

for e-cigarettes than the smoke from combustible tobacco. But…

§Flavoring agents and propylene glycol not tested for safety via

inhalation

§Vape aerosols have been found to contain the following: §Formaldehyde & free radicals Cancer? §Diacetyl Bronchiolitis Obliterans? §Inhalation of ultra-fine particles deep into lung. Chronic lung

disease?

Explosions and burns

§ 2035 e-cigarette explosion and burn injuries presented to US emergency

rooms in 2015–2017 (same lithium ion batteries that made news over explosions of Samsung phones) E-liquid poisonings: ingestion or skin absorption

§ Nicotine poisonings can happen when vapor liquid is ingested or

absorbed through the eyes or the skin. Children’ s skin is much more porous so the nicotine can be absorbed easier.

§ 440 calls to WA Poison Center for nicotine exposures in 2017. 373 (85%)

involved children < 5 years

§ Initial symptoms: vomiting, nausea, sweating, dizziness § Higher exposures can cause lethargy, seizures, and respiratory muscle

weakness

§ 1 teaspoon of liquid nicotine can kill an average-sized toddler.

§The Child Nicotine Poisoning Prevention Act was

signed into law in 2016, requiring that liquid nicotine used for e-cigarette refills be sold in childproof packaging

§Advise patients who use to keep e-cigarettes and liquid

nicotine locked up and out of the reach of children

§Follow the specific disposal instructions on the label §If exposure to liquid nicotine occurs, call the local

poison center

§Insufficient evidence e-cigarettes are effective smoking

cessation aids compared to FDA-approved aids (NRT)

§Completely substituting e-cigarettes for combustible

tobacco would significantly reduce exposure to toxins and carcinogens.

§Most adult e-cigarette users use both e-cigarettes and

combustible tobacco (dual users), and dual use is becoming increasingly common among youth

§The bottom line is that e-cigarettes are almost certainly

safer than regular cigarettes, but they are not safe.

§We should not recommend e-cigarettes to quite smoking.

We should recommend FDA-approved cessation methods.

§Provide early guidance: before middle school §Ask about specific use: do you smoke, vape, mod, or

JUUL?

§Educate youth about the amount of nicotine in JUUL and

• ther devices

§Dispel myths about the addictiveness of nicotine vs.

tobacco

§Educate parents about the rise of JUUL use in schools

and that safer than cigarettes does not mean safe

§ Traditional nicotine replacement therapy used for quitting smoking can

also be used to quit vaping.

§ Truth Initiative has launched innovative resources aimed at teens. § “Ready to Ditch JUUL

” is a social media campaign that features a series of videos highlighting young people ditching their JUULs in creative ways and drives those looking to quit e-cigarettes to Truth’ s “This is Quitting” app.

§ This is Quitting is a free and anonymous, text-based, quit vaping program

that was introduced in January 2019. Preliminary date in “Nicotine & Tobacco Research” shows that 61% of early enrollees (now up to 80,000) reported after just two weeks of using This is Quitting that they had either significantly reduced or stopped using e-cigarettes. Teens and young adults can text “DITCHJUUL ” to 88709 to enroll.

§E-cigarette companies can legally promote their

products by using techniques that cigarette companies have not been able to use since the 1998 Master Settlement Agreement, including television and radio ads, billboards, outdoor signage, and sponsorships.

§9 out of 10 respondents to the NYTS reported they

are exposed to adds that are appealing to youth.

§In 2016, the FDA expanded its authority to

regulate tobacco products to include e-cigarettes and cigars. But, a year later, it announced manufacturers would not have to provide information about e-cigarettes until 2022, and in the meantime the products could stay on the market.

§In March 2018, the AAP, American Cancer Society, American

Heart Association, American Lung Association, Campaign for Tobacco-Free Kids, and the Truth Initiative sued the FDA and the Department of Health and Human Services saying the decision to allow manufacturers to keep selling e-cigarettes without proper review puts children at risk.

§In May 2019, a federal judge ruled in our favor

§F

la vo re d e -c ig a re tte s (e xc luding me ntho l a nd mint) tha t c o nta in nic o tine c a n o nly b e so ld in a g e - re stric te d sto re s, o r so ld o nline with a g e ve rific a tio n

§Pa rtne re d with F

e de ra l T ra de Co mmissio n to ta rg e t e -liq uid ma nufa c ture rs who use d ima g e s a ppe a ling to yo uth

§Wo rke d to re mo ve o nline listing s o n third-pa rty site s

(e .g . E b a y)

§Orde re d ma nufa c ture rs to ta ke vo lunta ry a c tio ns to

pre ve nt yo uth a c c e ss a nd limit yo uth a ppe a l

§Seattle Public Schools and King County have joined multiple other

school districts and local governments across the country in suing JUUL claiming the company’ s marketing has targeted youth. The suits are seeking damages and funding for prevention education and addiction treatment.

§In response to the backlash, JUUL stopped selling most flavors in

retail stores as of November 2018, stopped selling flavors other than menthol and mint both in stores and online as of November 2019, and stopped selling mint a few weeks later.

§JUUL stopped its social media promotions in 2018 and recently

announced a suspension of all print and media adds.

§Hired a new CEO in September, who came from Altria (formerly

Phillip Morris, which now owns a 35% stake in JUUL).

§Tobacco 21 passed in our state last year, and

federal legislation was signed last month.

§Prohibit the sale of flavored tobacco products §Ban vaping in public spaces §Tax vapor products §Regulate advertising and marketing §Regulate density and zoning of stores

§Virtually all (94 percent) of adult smokers had their first cigarette

before turning 21, and most (81 percent) before age 18.

§18 and 19 year-olds are often suppliers for younger teens who rely on

friends and peers to buy tobacco products. This law raises the age to well after HS graduation.

§Increasing the sales age for tobacco products to 21 will help counter

the tobacco industry's efforts to market to teens.

§Matching the age for alcohol sales should ease compliance and

enforcement.

§However, vape shops need more monitoring. A JAMA Pediatrics

article this year showed that 47% of vape shops in California did not card, and a recent Truth Initiative survey showed that 74% of 9-17 year-olds were successful in purchasing from a retail outlet.

§In September, Governor Inslee issued an executive order to

ban the sale of all flavored vape products which the state Board of Health implemented in October. But it expires on February 7.

§In September, President Trump announced plans for an

executive order to ban all flavored products from retail

• utlets. But, he later backtracked after industry pressure.

On January 2 the administration announced the final rule: Allows JUUL and other closed pods to continue selling menthol flavor and still keeps all flavored e-juices sold for

• pen systems on the market.

The watered-down federal flavor “ban” is unlikely to curb the vaping epidemic

§ Many teens will likely just switch from their current preferred flavors

to menthol.

§ Mint was the best-selling JUUL flavor in 2019, and some manufacturers

have already started to relabel their mint flavor as menthol.

§ There are already Y

• uTube videos showing how to refill empty JUUL

pods with e-juices sold for open systems.

§ Teens can also switch to open systems which have become more user-

• friendly. Refillable devices that are gaining popularity: Aspire, SMOK,

Suorin, Lost Vape Orion.

§ There are far more flavor options available for open systems then

JUUL ever sold, and e-juices vary significantly in their content of nicotine and other additives.

§Permanent ban on flavored nicotine products, including menthol §Limit the amount of nicotine in pre-filled vape products to the same

as a single cigarette.

§Increase taxes on vaping products according to nicotine content,

equivalent to tax rates on cigarettes. Right now the tax on a pack of cigarettes in $3.03 while the tax on a JUUL pod is $0.19- that’ s 94% less for the same nicotine content.

§Raising taxes on tobacco products was an effective public health

strategy to reduce tobacco use, and young people are most sensitive to changes in price due to their lower incomes and shorter usage history.

§Tax revenue should be allocated to enforcement of vaping laws and

prevention of vaping initiation.

§ Outbreak began in June 2019. Cases have been declining since a peak in September.

There have been 2,602 hospitalizations across the 50 states and 57 deaths from 27

• states. The median age of those hospitalized is 24 years old, but the median age of

those deceased is 51 years old, with the youngest being 15.

§ Lab data shows Vitamin E Acetate is closely associated. It was identified in

bronchoalveolar lavage (BAL) fluid samples of 48 of 51 cases tested (patients from 16 states), and in none of the samples of a comparison group. But other contents are also being evaluated and there may be more than one cause. At this point no other toxicants have been found in the BAL samples.

§ Vitamin E acetate is commonly used in moisturizing creams, nutritional supplements,

and processed foods. It is considered safe for topical use or ingestion. But, it seems when heated to a vapor and inhaled, it can cause severe lung illness.

§ Vitamin E acetate is used in black market vape marijuana e-juices to cut THC oil and

increase profits because its viscosity is nearly identical to THC oil and it’s much

• cheaper. 80% of surveyed patients reported vaping THC, with just 13% reporting

vaping only nicotine. But the FDA has not found vitamin E acetate in any nicotine products analyzed to date, while they have found it in many black-market THC e-juices that were manufactured in 2019. Most reported brands: Dank, TKO, Smart Cart.