Vaping & E-cigarettes Nikolina Golob, PharmD, MBA, PGY1 Pharmacy - - PowerPoint PPT Presentation
Vaping & E-cigarettes Nikolina Golob, PharmD, MBA, PGY1 Pharmacy Resident Jeremy Hondl, PharmD Objectives Upon conclusion of the program, the participant should be able to: Describe the prevalence of e-cigarette use across the
Nikolina Golob, PharmD, MBA, PGY1 Pharmacy Resident Jeremy Hondl, PharmD
Upon conclusion of the program, the participant should be able to: – Describe the prevalence of e-cigarette use across the country – Define vaping and the components of an e-cigarette – Review between the different types of e-cigarette devices – Explain the role of e-cigarettes in smoking cessation – Identify pulmonary risks associated with smoking e- cigarettes
– Electronic cigarettes: battery powered electron devices that aerosolize a solution (e- liquid) which typically contains nicotine, but can also be nicotine free
– Electric heating element vaporizes the instilled liquid solution and condenses to form an aerosol
– E-liquid: typically contains nicotine, propylene glycol, vegetable glycerin, water, and artificial flavoring
– Large variety of product availability (both devices and e-liquids) allow for a high degree of customizability
Today, global classification of e-cigarettes is highly variable; however, several countries recognize e-cigarettes as a pharmaceutical product when used for the intent of tobacco cessation
– E-cigarette common names: e-cigs, e-hookah, vape stick, vape pen, Electronic Nicotine Delivery Systems (ENDS), JUUL – E-liquid common names: e-juice, vape juice, vape liquid – Vaping increasing in popularity among younger population as well as adults
– Misconceptions: safer, no addiction, no nicotine
– Vaping products may contain nicotine or tetrahydrocannabinol (THC)
– 1963: Concept of e-cigarettes proposed by Herbert Gilbert as a smokeless, non- tobacco cigarette; patent obtained in 1965 but never entered market – 2003: Han Li, a Chinese Pharmacist, obtains a patent for “a non-flammable electronic atomizing cigarette” – 2004: Ruyan Company of China begins development/distribution of e- cigarettes; obtains an international patent by 2007 – 2006: E-cigarettes in USA August 22nd, 2006 – 2014: E-cigarettes sold in more than 60 countries across the world
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– Older generations utilize free-base nicotine – Newer generations utilize nicotine salts – Salt forms have a lower pH allowing for quicker delivery and higher levels of nicotine with less irritation for the user – No nicotine concentration restrictions in the USA
– Sale of 4% nicotine comprised nearly 75% of the e-cigarette market
– Europe limits nicotine concentrations to 2%
– In a Truth Initiative study, two-thirds of JUUL users aged 15-21 were not aware the product always contains nicotine
– Measured in milligrams or percent content
– i.e. 10 or 25mg; 10% - 90%
– November 2018 study in JAMA
– “Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis” – Vaping devices heat cannabis to higher temperatures – Higher delivery of THC – Increased side effects (anxiety, paranoia, nausea, vomiting, hallucinations)
– Especially for first time users
– Vaping apparel – Hoodies – Backpacks – Phone cases – Pens – Smart watches – USB Drives
– Vaping: electronic heating of an e-liquid and subsequent inhalation through an e-cigarette device – Dabbing: heating a sticky oil or wax of THC and inhaling it – Dripping: typically involves taking the e-cigarette device apart, dropping the e-liquid directly on the coils, creating a smoke which is inhaled
– Apple distributes ~1.8 million apps to iPhones, iPads, and other Apple devices – In June 2019, Apple banned the addition of new vaping apps – As of November, “Apple has removed 181 vaping apps from its online store… following the lead of federal, state, and local regulators, which in recent months have cracked down on e-cigarette products” – Apple prohibits many app categories (i.e. nudity, hate speech, physical harm, apps that encourage excessive drinking, tobacco or illegal drugs and more) – Cannabis related apps still allowed “as long as they are restricted to adults, certain states, and don’t offer sales or explicitly encourage recreational use”
– Public Health Cigarette Smoking Act in 1970
– Congress passed the act to ban cigarette advertisements
– 2009: FDA banned flavored combustible cigarettes except menthol – Despite these laws, e-cigarette advertising is prevalent on television, radio, and the internet
– Advertisements are EVERYWHERE: radio, online (YouTube, Twitter, etc.), television – Many advertisements appear to be targeting the younger population – Some e-liquids look like common foods
– i.e. Thin Mints, Tootsie Roll, Sweet & Sour Candy
– E-liquids come in many different appealing flavors
– i.e. Mint, cotton candy, blue raspberry, pink lemonade, and many more
– According to Nielsen, as of October 2019, JUUL holds 64.4% of the e-cigarette market share – Altria, makers of Marlboro cigarettes, acquired 35% stake in JUUL in 2018 for $12.8 billion – In September 2019, Altria executive replaced the former head of JUUL as CEO – JUUL has spent more than $1 million in internet marketing (Twitter, Instagram, YouTube) – According to a recent congressional testimony, “JUUL has targeted children as young as third grade by funding summer camps, visiting schools and paying community and church groups to distribute their materials” – Recently announced to “suspend all broadcast, print and digital advertising in the US”
QuickStats: Cigarette Smoking Status* Among Current Adult E- cigarette Users,† by Age Group — National Health Interview Survey,§ United States, 2015 17
– National Institutes of Health’s National Cancer Institute, CDC, and FDA – 2017 National Health Interview Survey (NHIS)
– Interviewed ~47.4 million US adults
– Of these adults 19.3% admitted to currently using “any tobacco product”
– Cigarettes (14.0%; 34.3 million) – Cigars, cigarillos, or filtered little cigars (3.8%; 9.3 million) – Electronic cigarettes (2.8%; 6.9 million) – Smokeless tobacco (2.1%; 5.1 million) – Pipes, water pipes, or hookahs (1.0%; 2.6 million)
– Among current tobacco product users
– 86.7% (41.1 million) smoked combustible tobacco products – 19.0% (9.0 million) used 2 or more tobacco products
– Bronchiolitis obliterans (AKA Popcorn Lung) – scarring of tiny air sacs in the lungs which causes thickening and narrowing of the airways
– Symptoms similar to COPD
– Microwave popcorn factory workers Removal of diacetyl – Many e-cigarette vapor contain diacetyl for flavoring
– i.e. vanilla, maple, coconut, etc.
– Harvard study on e-cigarettes in 2015
– 39 of 51 e-cigarette brands contain diacetyl – Other harmful chemicals in e-cigs: 2,3 pentaedione and acetoin – 47 of 51(91%) e-cigarettes involved in the study contain one of the there
– According to the U.S. Fire Administration, there have been at least 195 reported cases of e- cigarette explosions between January 2009 and December 31,2016
– Nicotine health effects
– Highly addictive – Toxic to developing fetus – Harmful to developing brain into early 20’s – Cancer causing chemicals and small particles going deep into lungs
– Less so than combustible tobacco products
– “Acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes”
– American Association of Poison Control Center has managed 5,183 cases of exposure – “Exposure”: contact with the substance in some way (i.e. ingested, inhaled, absorbed via skin/eyes) – Between 2012-2018 there have been 8,269 liquid nicotine exposures reported among children <6 years old
But… Maybe?? Available studies give mixed reviews. – Not FDA approved as a smoking cessation aid – U.S Preventative Services Task Force concluded “evidence is insufficient to recommend e-cigarettes for smoking cessation in adults, including pregnant women”
– Cochrane Review September 2016
– “Found evidence from 2 randomized controlled trials that e-cigarettes with nicotine can help smokers stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes”3,7
– CDC Study published April 2017
– Confirmed many adults use e-cigarettes to help quit smoking – However, many report “dual use”
– 2019 U.K. National Health Service study
– Individuals assigned to either Nicotine Replacement Therapy (NRT) or e-cigarette starter pack – E-cigarettes were more effective for smoking cessation
– However, most e-cigarette users were still smoking e-cigarettes at a one year follow up
– Difficult to make concrete recommendation
– Safety and efficacy lacking, diverse products, quality variation, lack of regulation
– Not enough randomized controlled trials – No official guidelines – Assess patient need and vaping habits – All NRT therapy is appropriate – Multiple case studies showing effective smoking cessation
– “In January 2020, FDA issued an enforcement policy on unauthorized flavored cartridge-based e-cigarette products, including fruit and mint flavors, that appeal to kids” – Manufactures are required to comply with the FDA’s Tobacco Regulations
– Manufactures include anyone who “makes, modifies, manufactures, fabricates, assembles, processes, labels, repacks, relabels or imports any ‘tobacco product’”
– Nicotine addictiveness warning statement on packages and advertisements – On December 20, 2019, sale of tobacco products legal age changed from 18 to 21
– EVALI: name given by the Centers for Disease Control and Prevention (CDC) for the newly identified lung disease linked to vaping – First recognized June 2019, number of cases peaked in September but have since declined – Vitamin E acetate, an additive in some THC e-cigarettes, is most closely associated with EVALI
– Study published December 20, 2019
– Bronchoalveolar-Lavage Fluid (BAL) collected from 51 patients in 16 states and 99 healthy participants – Performed isotope dilution mass spectrometry measure the following toxicants: vitamin E acetate, plant
– Vitamin E was identified in 48 of 51 EVALI cases but not in the healthy group
– Possible risk factors leading to higher morbidity and mortality
– Cardiac disease, chronic pulmonary disease, diabetes, and increased age
– As of December 27, 2019, there have been 2,561 reported cases of EVALI
– In 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and the U.S. Virgin Islands)
– Of the 2,561 diagnosed, there have been 55 deaths – Demographics
– 67% males – 78% under age 35 – 78% non-Hispanic white – Median age 52 years (range 17 through 75) – Patients that died, were older than the overall population diagnosed – 2 deaths occurred in patients under 25 years of age
– All EVALI patients reported a history of using e-cigarette, or vaping, products
– Vitamin E acetate was identified as a chemical of concern – Most EVALI patients admitted to THC-containing products
– THC is present in most samples tested by FDA to date
– “Black market” products are linked to most of the EVALI cases
– CDC has analyzed THC containing products reported by EVALI patients
– 152 different brands were reported – Most commonly reported products: Dank Vapes (56%), TKO (15%), Smart Cart (13%), and Rove (12%)
– “While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product source that are being investigated, and there may be more than one cause” – CDC recommends not to purchase THC-containing products from informal sources – Vitamin E acetate should not be added to any vaping product – Best way to prevent EVALI is by discontinuing use of all e-cigarette, or vaping products
– Patient history
– Respiratory symptoms (95%): cough, chest pain, SOB – GI issues (77%): abdominal pain, nausea, vomiting, diarrhea – Fever, chills, weight loss (85%)
– Important information to gather
– Type of substance (i.e. THC, cannabis [oil, dabs], nicotine, modified products, home-made) – Product source, brand, and name – Duration and frequency of use – Deliver system – Method of use (i.e. aerosolization, dabbing, or dripping)
– Physical examination
– Tachycardia (55%), tachypnea (45%), O2 saturation <95% (57%) – Pulmonary findings on auscultation exam – unremarkable
– This is consistently true even for those with severe lung injury
– Laboratory Testing
– Guided by clinical findings
– Imaging
– CXR: pulmonary infiltrates – CT Scan: opacities on chest
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– Illnesses too mild – Misdiagnosis – Did not meet CDC EVALI diagnosis – Happenstance – AK population is low compared to other states – Black market THC products (or chemicals) may not have made it to AK in large quantities – “A review of ingredient lists, the state’s Marijuana Control Board determined that vitamin E acetate did not show up in any approved products in the regulated Alaska Market” – per vice chair of the board Loren Jones
Nikolina Golob: ngolob@scf.cc Jeremy Hondl: jhondl@scf.cc
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