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
§ E-cigarettes heat a liquid solution to a high enough temperature so that it § Evolution of the e-cigarette 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 of 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 ones 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 odor 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 outh. 1 in 4 high school students 1 in 10 middle school students Source: 2019 National Y outh 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 outh 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 outh 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 (9 th 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 ." Jama 314.7 (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 6 th 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 other 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
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