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 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

Background

Nicotine Dependence 1

E-cigarettes 2,3 – 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-Cigarettes Background 2,4 – 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)

History on E-cigarettes 2,5 – 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 22 nd , 2006 – 2014: E-cigarettes sold in more than 60 countries across the world

Types of E-Cigarettes 6

7

Nicotine Content 3 – 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

Nicotine Content 8

THC Content 9 – 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

More Discrete Options 10 – Vaping apparel – Hoodies – Backpacks – Phone cases Pens – – Smart watches – USB Drives

1 st & 2 nd Generation Vapes How do they work?

Pod-Based System

Smoking Methods 11 – 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

Apps for your Mobile Device 12

Apple & Vape Apps 13 – 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”

Advertising

Marketing Tactics 3 – 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

Marketing Tactics 3 – 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

7,000 e-liquid flavors and 460 brands of e-cigarettes 14,15

E-cigarette Ads & Youths 16 More than 18 million (7 in 10) US middle and high school youth were exposed to e-cigarette ads in 2014 More than 1 in 2 middle and high school youth were exposed to e-cigarette ads in retail stores Nearly 2 in 5 middle and high school youth saw e- cigarette ads online

E-cigarette Ads & Youths 16

JUUL 3 – 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”

Taxation 3

Prevalence & Statistics

Prevalence of Use 4

QuickStats: Cigarette Smoking Status* Among Current Adult E- cigarette Users, † by Age Group — National Health Interview Survey, § United States, 2015 17

Adult E-Cigarette Use 19 – 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

Safety

E-Cigarette Safety 6

Diacetyl 20 – 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

Exploding Devices 21,22 – 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

Health Effects 23 – 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”

Poison Concern 24,25 – 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

Vaping & Pregnancy

E-cigarettes & Smoking Cessation