10 min • Welcome/Intro

10 min • Myths vs. Facts Pop Quiz!

40 min • Vaping 101

40 min • Prevention & Supporting Healthy Habits

Agenda 30 min • Medical Treatment Options

40 min • Partnering for Prevention Panel & Audience Discussion 10 min • Q&A Myths vs. Facts Pop Quiz

Madelyn Smith – 4H Health Hero Ivy Smith – 4H Health Hero Myths vs. Facts Vape clouds are just water vapor? Myth! Vape clouds contain a lot of dangerous chemicals. Because of how new vaping is, we don’t have a lot of research on the effects of second-hand vape. 1 Youth vaping has been declared an epidemic? Fact! U.S Surgeon General Jerome M. Adams declared e-cigarette use among youth an “epidemic” during a press conference on

December 18th. 2 Teens who vape are less likely to smoke? Myth! Teens who vape are up to 4x more likely to start smoking. 3 Popcorn Lung is a condition caused by eating too much popcorn? Myth! Popcorn Lung is a condition caused by inhaling Diacetyl, a chemical used in vape flavoring. 4 Marijuana wax can be used in most vape pens? Fact! Marijuana wax can be used in a vape pen. The difference is that when marijuana wax is burned it does not emit a smoke or vapor. Marijuana wax is incredibly difficult to extract and therefore harder to come by? Myth! There are YouTube videos teaching teens to extract their own marijuana wax at home. The process of extracting the wax is dangerous and has led to explosions that have demolished homes. There have been less than 300 reported cases of serious lung disease related to vaping across the U.S? Myth! As of November 13, 2019, there have been 2,172 cases of serious illness and 42 deaths across the U.S that have been linked to vaping by the CDC. Teens who consistently vape will begin to need higher and higher doses of nicotine to continue to get high? Fact! Teens who consistently vape will develop a higher tolerance to nicotine over time causing them to need a higher dose to get high. Vaping 101: What We Know & What We Don't Know

Michele Dritz, MD, FAAP Adolescent Medicine Physician Ohio AAP Agenda

• The numbers • Vaping in general & JUULing in particular • Nicotine: The body & the developing brain brain • A few additional points • So where do we go from here?

THE NUMBERS Tobacco Product Use in US High School Students

Data: National Youth Tobacco Survey (CDC) Data: National Youth Tobacco Survey (CDC) Data: National Youth Tobacco Survey (CDC) Perceived Risk versus Use

Opposite Trends

Monitoring the Future Youth Survey, 2012 (University of Michigan) PerceptionPerception MeansMeans AA Lot…Lot…

• “Self-Identified Tobacco Use and Harm Perceptions Among US Youth” – Used survey data from the CDC National Youth Tobacco Survey

Users of tobacco products that Among those believing labeled themselves as non-users “all tobacco products were harmful” users of the following believed Roll your Own/Pipe tobacco 82.2% their product was not harmful: E-Cigarettes 59.7% E-Cigarettes 74.6% Cigars 56.6% Hookah 56.0% Hookah 44.0% Smokeless tobacco 38.5% Smokeless tobacco 41.8% Cigarettes 26.5% Cigarettes 15.5%

Agaku, I, Odani, S, Vardavas, C, Linda Neff. “Self-Identified Tobacco Use and Harm Perceptions Among US Youth”. Pediatrics Apr 2018, 141 (4) e20173523. VAPING IN GENERAL & JUULING IN PARTICULAR Electronic Cigarettes o Vape devices and vape pens o Personal vaporizers o Electronic Nicotine Delivery Systems (ENDS) o Alternative Nicotine Delivery Systems (ANDS) o Electronic cigars or e-cigars o E-hookah or hookah sticks/pens o Mechanical tanks Anatomy of an E-Cigarette Electronic Cigarettes: The Generations

1st Generation 2nd Generation 3rd Generation Pod Systems • Most similar to • Larger in size • Customizable and • Very diverse traditional • Tank system reservoir modifiable • Departure from cigarettes to hold the solution • Advanced Personal traditional cigarette (e-liquid) Vaporizer(APV) or • Hard to recognize as • Vape devices and vape Mods e-cigarette pens • JUUL, Phix, Suorin Anatomy of a JUUL “JUULing”

• 75% of the e-cigarette market (as of Oct. 2018)

• THEY ALL CONTAIN NICOTINE – Uses nicotine salt with benzoic acid = higher [nicotine]/puff

• Attempts to deliver peak nicotine in 5 minutes

• Single JUUL 5% pod = ~200 puffs = 1 pack of cigarettes – 3% pods now available but coupled with potentially more vapor absorption

• Small “plume” so easier to hide

• Lots of accessories to customize

• Capability to refill with other liquids

• Starter kit = $20-35 In the news… FDA takes new steps to address Juul has stopped selling all fruity flavors (online) epidemic of youth e-cigarette use, The company previously pulled kid-friendly flavors including a historic action against more than 1,300 retailers and 5 from stores.Juul stops selling mint ahead of anticipated federal ban on (does not include mint, menthol & tobacco flavors) major manufacturers for their - October 17,most 2019 e-cigarette flavors (online & retail) roles perpetuating youth access The move comes as the CDC reports that illnessesWarning linked letters to and civil money vaping have topped 2,000. penalty complaints to retailers are - NovemberGovernment 7, 2019 plans to ban largest coordinated enforcement effort flavors used in e-cigarettes in agency history; FDA requests (only states to do so far: MI & manufacturers provide plan for NY) mitigating youth sales within 60 days; - September 12, 2019 warns it may restrict flavored e- Ohio “Tobacco 21” cigarettes to - September 11, 2018 law goes into effect today - October 17, 2019 Appealing to Their Future Market The Hooks…

Influencers Flavors

Social Media Go To The Youth… The Line (components)…

• Humectants (substance to reduce loss of moisture) – Propylene glycol (+ flavorants = acetals) – Glycerol • Flavoring Toxicants – Different toxicant profiles -- many unknown – Aldehydes and Acetals – lung inflammation – Diacetyl – “popcorn lung” • Particulate Matter (from heating element) – Metallic nano-particles = tin, nickel & chromium • Carcinogens – propylene glycol + heat = formaldehyde – From particulate matter • Psychoactive ingredients (added by users or pre-packaged) The Sinker…

Nicotine Is Still Nicotine

NICOTINE: THE BODY & THE DEVELOPING BRAIN (and yes, we will talk about EVALI…) How much nicotine do you get?

Nicotine Salts Equivalence in Pod • Different bioavailability per Systems puff • Depends on many factors: $6 1 Pack Cigarettes = 20 Cigarettes – Temperature of atomizer – How much liquid used $4 1 JUUL Pod = 1 pack of cigarettes – Size of droplets – Depth of the puff $4 1 PHIX Pod = 2 packs of cigarettes – Concentration of the e-liquid • Absorption: $5 1 Suorin Pod = 3 packs of – Large droplets = oropharynx & cigarettes upper airway – Small droplets = lung alveoli with more rapid transit to brain Physical Effects Poisonous & Deadly

• Large amounts of nicotine are lethal. – 60 mg adult, 6 mg children • It is an insecticide and toxicant. • Can be absorbed: mucosa, inhalation, skin

• American Association of Poison Control Centers (AAPCC), 2019 EVALI E-cigarette/Vaping product use Associated Lung Injury Illness How patients • As of November 13, 2019: present: – 2,172 cases of lung injury and 42 deaths – 49 states with cases, including Ohio • 95% with respiratory sxs – ALL patients reported e-cigarette/vape product use • SOB, cough, chest pain – THC found in 80%, but 10% nicotine only • 77% with GI sxs – Direct lung toxicity similar to chemical burn? • Abd pain, nausea, vomiting, diarrhea – No current specific test or marker to confirm • 85% with constitutional cause sxs – Diagnosis based on history of vaping and • Fever, chills, weight clinical symptoms loss • ~50% need ICU care 22% require mechanical – Demographics: • ventilation – 70% male – 79% younger than 35 years old • CDC, MMWR, "Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette– 15% or Vaping under product Use18 Associated years Lung old Injury", October 18, 201921% 18-20 years old • CDC website, accessed 10/17/19 Real-time Investigation

• Laboratory & Imaging Features: – Leukocytosis: 87% with WBC count >11,000 • 94% with a neutrophil predominance – Elevated procalcitonin: Median level = 0.58 μg/l – Pathology: 7 out of 14 BAL specimens with lipid-laden macrophages – CXR: 100% with Bilateral pulmonary opacities • History Features: – 84% reported using THC products in the e- cigarette device – Most common product: ‘Dank Vapes’ • Treatment Features: – 92% received systemic glucocorticoids with documented clinical improvement • Steroid course was given for at least 7 days in all cases.

N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print] Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. Layden et.al. Vitamin E Acetate (+/- others)?

• Analysis of THC-containing products – common additives & Vitamin E Toxicology: thickening agents: Oral and topical use = OK for use (FDA) – Vitamin E acetate, Medium chain • Common uses: Food/vitamins, cosmetics triglyceride (MCT) oil, other lipids? Heated/inhalation use = lung injury risk • Lipid properties • Evaluation of 29 EVALI BAL • Can disrupt ability of lungs to inflate samples: • Needs to be heated to high level to – ALL with Vitamin E acetate vaporize – THC in 23 of 28 BAL samples • 20 of the 23 who said they smoked THC • 3 in patients who said they did not smoke THC – Nicotine in 16 samples FDA: Code of federal Regulations, accessdata.fda.gov Blount BC, et al. Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury MMWR ePub: 8 November 2019. Case Definitions

“Confirmed” Case “Probable” Case • Use of an e-cigarette in 90 days • Use of an e-cigarette in 90 days before symptom onset before symptom onset • +Pulmonary infiltrates • +Pulmonary infiltrates • Absence of pulmonary infection on • Infection identified by culture or initial workup PCR, but not considered to be the • No evidence of alternative plausible sole cause of the disease process diagnosis (ex: cardiac, • No evidence of alternative plausible rheumatologic, neoplastic) diagnosis

N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print] Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. Layden et.al. Evolving Theories of Pathogenesis

Lipoid Pneumonia? Chemical Burn? • Presence of lipid-laden macrophages in BAL • Evidence of acute lung injury on biopsy: fluid in several reports: – Acute fibrinous pneumonitis – Diffuse alveolar damage • But could lipid-laden macrophages be a – Organizing pneumonia, usually consequence rather than a cause? bronchiolocentric and accompanied by bronchiolitis – 2019 by Maddock et al: NEJM 6-patient vaping case series with lipid-laden macrophages but – 100% with non-specific foamy macrophages and without other classic lipoid pneumonia features pneumocyte vacuolization present “Although difficult to discount the potential role of lipid, we • Pathology: •believe2019 that by the Butt histologic et al: changes NEJM instead 17-patient suggest that case vaping - – Foamy (lipid-laden) macrophages = common in BAL associatedseries lung injury represents a form of airway- centered specimens/lung biopsy & not specific for chemical pneumonitis from one or more inhaled toxic aspirated/inhaled lipid substances rather than exogenous lipoid pneumonia as such, – Likely explanation for their presence = airway but the agents responsible remain unknown.” narrowing or obstruction.

Chest 141(4):1110–1113 An unexpected consequence of electronic cigarette use. McCauley L, Markin C, Hosmer D (2012) N Engl J Med. DOI: 10.1056/NEJMc1912038. Pulmonary lipid laden macrophages and vaping. Maddock SD, et al. Am J Clin Pathol. 2019 Oct 17. Lung Biopsy Findings in Severe Pulmonary Illness Associated with E-cigarette Use (Vaping). Mukhopadhyay, et.al. N Engl J Med. 2019 Oct 2. [Epub ahead of print] Pathology of Vaping-Associated Lung Injury. Butt, Larsen et.al. Other Proposed Vitamin E acetate is used as an Pathologic Mechanisms: additive in the production of e- cigarette, or vaping, products. This • Acute interstitial lung disease is the first time that we have (including acute eosinophilic pneumonia) detected a potential chemical of • Respiratory bronchiolitis-associated concern in biologic samples from ILD patients with these lung injuries. • Acute and subacute hypersensitivity pneumonitis • Chemical pneumonitis (including thermal injury) • Lipoid pneumonia - CDC MMWR, Nov 8, 2019

Blount BC, et al. Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury MMWR ePub: 8 November 2019. REPORT cases of severe pulmonary disease of unclear etiology + h/o e-cig use within the last 90 days to state or local Health Dept

ASK all patients with history of vaping, about signs and symptoms of pulmonary disease

OBTAIN DETAILED VAPING HISTORY, if it is suspected as the cause for severe pulmonary disease

•Substances used •Source of substances (commercially available vs. homemade) •Devices used (Manufacturer, brand name, model, etc) Current CDC •Where the products were purchased •Method of substance use (aerosol, dabbing, etc) Recommendations •Sharing devices with others for Clinicians: SEND FOR TESTING any remaining product, devices or liquids Consider ALTERNATE ETIOLOGIES such as infectious, rheumatologic, neoplastic, etc

Consider HIGH-DOSE CORTICOSTEROIDS in severe pulmonary illness suspected to be vaping-related

Consider BAL depending on the clinical situation.

Consider LUNG BIOPSY depending on the clinical situation.

Arrange FOLLOW UP with a Pulmonologist to monitor pulmonary function.

Source: CDC.gov. COUNSEL to stop all vaping, do not purchase modified or off street, do not add substances, do not https://emergency.cdc.gov/han/HAN00421.asp start Dangerous from the first puff

• Primary psychoactive ingredient in tobacco • Nicotine goes to brain 6 seconds after inhalation • Occupies 50% of nicotinic receptors in the brain with 1-2 puffs • Smokers can control their brain nicotine level

The Real Cost: "Don't get Hacked" https://therealcost.betobaccofree.hhs.gov/ Percentage of those ever using who become addicted

Ages 15-54 31.9 National Comorbidity Study (1994) 23.1

16.7 15.4

9.

CANNABIS ALCOHOL COCAINE HEROIN TOBACCO

Anthony, J. C., Warner, L. A., & Kessler, R. C. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2(3), 244-268. Addictive

• Imitates the effects of our acetylcholine on brain neurons • Causes dopamine release in the limbic system • Reward circuitry activated How Addiction Manifests

• Physically addictive – Tolerance develops – Withdrawal occurs – re-dosing prevents withdrawal • Emotionally addictive – Gives sense of well-being • Boosts mood and may relieve minor depression – Stimulates memory and alertness • People depend on it to accomplish certain tasks and perform well – Decreases appetite • Behaviorally addictive – Use is reinforced by social cues and habits Nicotines Effects on the Developing Brain

• More sensitive to the addictive properties of nicotine

– Dependence at lower levels of nicotine use: • In most susceptible = within 1-2 days of 1st use – Higher risk for withdrawal symptoms with lower use: • In most susceptible = before reaching level of 2 cig/day

Goriounova & Mansvelder, “Short- and Long-Term Consequences of Nicotine Exposure during Adolescence for Prefrontal Cortex Neuronal Network Function”, Cold Spring Harb Perspect Med. 2012 Dec; 2(12): Modulation at the Brain Receptor Level

Short & long-term brain receptor modulation • Nicotine imitates the actions of Acetylcholine • Crosses BBB & binds target = nicotinic acetylcholine receptor (nAChR) • Found throughout the brain including prefrontal cortex • Depending on exact location, may have excitatory or inhibitory effect on the neuron • Nicotine exposure modulates these receptors, as well as glutamate receptors

For teen brains > adult brains… • More sensitive to nAChR up-regulation Greater positive nicotine effects; fewer negative • Longer lasting effects on nAChR effects binding and function • Even longer effects on glutamate receptor regulation Prefrontal Cortex = Executive Functions + Attention Performance

• Still maturing and thus vulnerable to imbalance

Reason = earlier maturation of limbic region/reward systems with slower development of prefrontal cognitive control • Clinically relevant: • Increased cognitive impairment, particularly later in life • Increased risk for developing psychiatric disorders • Increase in attention deficit issues, that increase with years of use A FEW ADDITIONAL POINTS… Reliability of Vape Labels

Cheng, T, “Chemical evaluation of electronic cigarettes”. Tob Control 2014; 23 Vaping for Smoking Cessation

• For adults ALREADY smoking traditional cigarettes & trying to quit: If used VAPING to 1 year after quitting: quit: 80% still using e- 18% successfully quit at cigarettes 1 year If used OTHER NICOTINE REPLACEMENT 1 year after quitting: options: 9% still using nicotine

9.9% successfully quit replacement treatment Plus Behavior Behavior Plus Change Support Change at 1 year

Hajek P et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med 2019 Jan 30; Affecting Those Around Us • Bystanders exposed to exhaled aerosol: – In general, levels lower than tobacco cigarettes, but found: • Nicotine • Glycerin • Aluminum • Polycyclic aromatic hydrocarbons & nitrosamines (carcinogens)

• Cotinine levels (nicotine marker) of bystanders similar in cigarettes and e-cigs

• Evidence of clinical health consequences for bystanders and in pregnancy – asthma, respiratory symptoms, pregnancy/fetal effects

• Perception Is Important: Families are less likely to have vape-free homes versus smoke-free homes – 63.8% of dual users did not smoke in the house – 26.3% of dual users did not vape in the house

1) Visser WF et al. The Health Risks of Electronic Cigarette Use to Bystanders. Int J Environ Res Public Health. 2019;16(9):1525. Published 2019 Apr 30; 2) Lødrup Carlsen KC, et al. The toxicity of E- cigarettes and children's respiratory health..Paediatr Respir Rev. 2018 Sep; 28:63-67. Epub 2018 Feb 10. 3) Drehmer JE, Nabi-Burza E, Hipple Walters B, et al. Parental smoking and e-cigarette use in homes and cars. Pediatrics. 2019;143(4):e20183249. Vaping & Risks for Other Substance Use

• Adolescents who used e-cigarettes were more likely to: – Binge drink alcohol – Use marijuana – Use other illicit drugs

• Of those using e-cigarettes: – 9% had used marijuana in the e-cigarette – “Dab”= vaporizing cannabis concentrate • aka: wax, shatter, live resin, etc. • Highly concentrated = 50-95% THC (vs 1980s = 3-4%) – Some studies show 24% HS students have used concentrates

• Vaping cannabis is incorrectly seen as 'safer' – Adolescent brain effects: • Changes noted both in the grey & white matter • Berry KM, PATH Study, JAMA Open Network, Feb 2019 • Changes in brain activation & function • McCabe J Adolesc Health 2017 and Silveira Drug Alcohol Depend 2018 • Attention & memory deficits even after abstinence • Boykan Pediatrics 2019 • Trivers JAMA Pediatrics 2018 • Increased risk for psychosis • Morean et al, Pediatrics, 2014 • Physical conditions: hyperemesis, arrythmias & MIs • Meier, M Pediatrics 2019

SO WHAT DO WE DO? Vaping Prevention & Supporting Healthy Habits

Michele Dritz, MD, FAAP – Ohio Chapter, AAP Madelyn Smith – 4-H Health Hero Ivy Smith – 4-H Health Hero Agenda

Adolescent Brain Talking about What Motivates Creating Adolescent- Conversations & Resources Development Screening Teens to Vape Relevant Messages Effective Counseling

Let's Talk about Vaping... Schools Youth Groups Sports Teams

Many Opportunities With At home to Talk with Youth Friends & Peers

Pharmacies & Doctors' Offices & Health Stores Clinics After-School Programs How Do We Talk About Youth Substance Use Now? • Tools Used in the Medical Community:

CRAFFT: 6 Questions to screen for problematic alcohol + drug use SBIRT: Coupled with clinic- BSTAD: 15+ Questions to screen for alcohol + other use based brief counseling (intervention) & S2BI: 3-7 Questions to screen for alcohol, tobacco + marijuana use referral if needed

• Tools Used in the School/Youth Programming Community:

ALL STARS: 4-12th grade curriculum to reduce risk behaviors Health & Physical Education: LIFESKILLS: Curriculum to reduce substance use and violence Topics often embedded into ATLAS: Program for sports teams to reduce anabolic steroid use broader curriculum We need to ask.

Regardless of We need to listen. Our Setting… We need to be able to answer questions.

We need to be support youth in learning the skills to be healthy, resilient, and successful adults.

We need to know when to ask for help. Why Do Teens Vape? “We are often still too young to be thinking about long-term consequences, yet old enough to believe we know what’s best.” Peer Pressure

What Works? Peer-to-Peer Prevention Teens are often more likely to listen to other teens then to adults. Teens see this as helpful guidance from a peer, rather than an adult telling them what to do. Keep It Short

Teens have a very short attention span. The average 15 year old's attention span is 8 seconds. A goldfish has a attention span of 9 seconds. If a teen is engaged they can focus on a task for about 45 minutes. Those first 8 seconds it is necessary to get their attention and hold on to it. The Power To Choose

Teens don't want to be told they can't do something. Instead of telling teens not to vape, we should be telling them what the consequences of vaping are, then allowing them to make an informed decision for themselves. Creating Structure for Support A Framework for Conversations

Brief Referral to Screening Intervention Treatment

• Brief • Referral to • Screening to motivational, specialty care assess risk awareness- (or other and use raising supports) if intervention needed Change Talk SBIRT

5As

It’s all part of the same puzzle…

Having Effective Conversations & Supporting Healthy Behavior Changes

Brief Motivational Negotiated Interviewing Interview Foster a safe space to talk Foster • Create adolescent-friendly environments Getting The • CLINICS: Make confidential time routine starting in early adolescence Conversation • SCHOOLS: Utilize strategies to allow frank discussions and support services Started

Build rapport Build • Create time to check-in with them and their lives • CLINICS: Shift the visit focus from parents to teens • SCHOOLS: Foster mentorship and social-emotional connections

Explore strengths, goals, support networks and resiliency skills Explore • Develop an understanding of what matters to them and their supports • CLINICS: HEEADSSS/SHADES psychosocial assessment • SCHOOLS: Curriculums that evolve with developmental needs and promote skill building School & Community Curriculums

CATCH MY BREATH TOBACCO-FREE TOOLKIT GET SMART ABOUT TOBACCO (University of Texas) (Stanford University) (Scholastics Books)

• 4 lessons = 30-40 min • 30+ modifiable lessons • 3 lessons per age group each • Teacher & Family • Teacher & Family Resources • Teacher & Family Resources Resources • Resources still found on • Extensive materials on non-scholastics book • Additional healthy living vaping plus other tobacco websites components including products, marketing physical activity, tactics and positive healthy nutrition, and youth development sun safety -Middle School & High School -Middle School & High School - Elementary School & Middle School - FREE -FREE -FREE Learning From Others

• School Policy Resources: – Minnesota Department of Health • https://www.health.state.mn.us/communities/tobacco/ecigarettes/schools.html#policy – Stanford University "Tobacco-Free Toolkit" • https://med.stanford.edu/tobaccopreventiontoolkit/resource-directory.html#school-policies • "Healthy Futures" Curriculum (Alternative program to suspension) – http://med.stanford.edu/tobaccopreventiontoolkit/curriculums/HealthyFutures.html – Colorado Department of Public Safety (School Resource Center) • https://www.colorado.gov/pacific/cssrc/vaping-and-e-cigarettes Validated Screening Tools for Clinics

S2BI CRAFFT BSTAD (Screening to Brief Intervention) (Mnemonic for screening questions) (Brief Screener for Tobacco, Alcohol & other drugs) • In the past year, how many times • Screens for use + associated risk • Friend use – 3Q have you ever used: behaviors • Personal Use – 3Q – Tobacco, nicotine or e-cigs like • Specific drugs of use – 5+Qs JUUL? • C: Driven/Ridden in Car – Alcohol? • R: Use to Relax/Fit In • Determines: – Marijuana? • A: Use Alone – Personal & Friend Use – Anything else to get high? • F: Forget things while using – What type • F: Family/Friends suggest quit – Frequency • Frequency: • – Weekly? T: Gotten in Trouble b/c use – Monthly? – Once or twice? – Never? -Developed by Boston Children's Hospital -Created by Boston Childrens Hospital -Longer & based on National Alcohol Center for Adolescent Substance Abuse -Often used with CRAFFT screener Research (CeASAR) - Free to use with permission -Free to use with permission -Free to use with permission Asking About Vaping

Early Adolescence: Late Adolescence: Middle School/Early High School Late High School/Post-HS “Do any of your friends or people you hang out “In the past year, how many times have you with vape, JUUL or smoke?” vaped, JUULed or smoked?”

“How about you? In the past year, how many times “How about your friends? Do any of your friends have you vaped, JUULed or smoked?” or people you hang out with vape, JUUL or smoke?

“When you see friends or other people your age vape or smoke, is it difficult for you not to as well?

Do you sometimes feel you really need a Juul, vape or smoke? If a teen tells you they have vaped (or thought about it) Listen to their story…

What? When? Why? What else?

• What type? • Last time? • Friends? • Tried stopping? • Flavorings? • How often? • Social? • Perceived • Nicotine? • Has it changed • Stress? benefits? • Other over time? • Curiosity? • Worries/Risks? substances? • Negative consequences? Goals of The Conversation:

UNDERSTAND THEIR USE UNDERSTAND THEIR BUILD ON THEIR KNOWLEDGE TO UNDERSTAND & FOSTER THEIR MOTIVATION SUPPORT INFORMED DECISIONS READINESS FOR CHANGE Readiness for Change “Change Talk” Tools Core “Change Talk” Skills & Concepts PACE OARS RULE DARES P = Partnership of O = Open-Ended R = Resist Telling Them D = Develop Discrepancy Equals Questions What to Do A = Acceptance A = Affirmations U = Understand Their A = Avoid Through Empathy Motivation Argumentation and Autonomy C = Compassion R = Reflective L = Listen with Empathy R = Roll with Resistance Listening E = Evoke Their Own S = Summarizing as E = Empower with E = Express Empathy Wisdom You Go Achievable Goals and Ways to Overcome Barriers S = Support Self-Efficacy Ask about what they already know

Take time to congratulate & reinforce the healthy choices being made Supporting Positive Ask permission to share why you may be worried & inform with facts Behavior Change Be clear about the importance of abstinence as the healthiest choice

Explore their own ambivalence through pros & cons

Reinforce autonomy and developing the skills for independence

Elicit and negotiate THEIR goals PATIENT-DIRECTED HARM REDUCTION SMALL STEPS COUNT BUILD SELF-EFFICACY

Thinking about Behavior Change Goals How the Conversation May Look Different

Schools/Community Organizations Clinics/Counselors/Pharmacies

Group discussion where youth are also One-on-one confidential conversations learning from one another – Peer-to-Peer

Opportunity to voice thoughts in a safe Opportunity to reinforce “social norming” space

Coupled with curriculum focusing on More robust exploration of personal broader skill development strengths, supports, and resiliency skills

Potential for group dialogue and community- Potential for immediate medical wide action management options if needed 01 Build Rapport: Explore how things are going in life beyond just substance use. Elicit likes, strengths, community connections, Raise the Subject goals, support networks, and resiliency skills. Ask Permission: “Would It Be OK to talk about what makes me worried about what you just shared?” 02 Summarize What they Have Shared. Reinforce Positive Choices: “It sounds like some of your close friends vape, and It’s Provide Feedback great to hear that you don’t always join in, I worry about the risks we know occur even with occasional use. What makes you sometimes not vape?” Provide Feedback: “Vaping can be dangerous for many reasons, including the way nicotine rewires the way our brains respond plus the other chemicals even just in the flavorings that we know are harmful.” Recommend (or reinforce) Abstinence: “You’re making a really smart and adult-like decision to keep yourself healthy by saying “no” to vaping sometimes. As your doctor/teacher/coach/mom AND as someone who cares about you – I totally agree with that important choice. That’s really impressive. I’m wondering if you can use your strategies in saying “no” sometimes to say “no” more often.” Elicit Feedback: “What do you think as you hear me say that?” 03 Explore Pros and Cons: “What do you like about vaping?” “What are some of the not so good things about vaping?” Enhance Motivation Summarize both sides. Explore Readiness to Change: “On a scale where 0 is not at all and 10 is very ready, how ready are you to stop vaping?” Respond: “What made you choose X and not a lower number?” Reasons to Change: “What are some of the best reasons you can think of to avoid vaping?” 04 Reinforce Autonomy: “What you choose to do is ultimately up to you.” Elicit Input: “What next steps would you like to take Negotiate and and how can I help?” Advise Negotiate a Goal: Focus on small, achievable goals to build self-efficacy and advance their level of readiness. Harm Reduction: No dabbing (adding marijuana); No vaping before sports, etc. Assist with Developing a Plan: Help them think through and problem-solve around potential obstacles. Address co-occurring mental health or other issues. Arrange Follow-Up Plan: How soon depends on level of risk and/or goals, but create some type of follow-up plan for accountability and to help support progress. Thank Them. Coding & Reimbursement for Medical Providers Approximate CPT Description Code Reimbursement WHAT: Smoking Cessation 99406 (3-10 min) Smoking or tobacco use cessation $12-15 Counseling 99407 (>10 min) counseling with specified time

Validated Screening Patient-focused Health Risk 96160 $3-10 Tool Used Assessment (Bright Futures, S2BI, etc)

SBIRT 99408 (15-30 min) Validated screening plus face-to-face $30-60 99409 (>30 min) brief counseling intervention done with specified time WHO: physicians, nurse practitioners, physician assistants, psychologists, clinical social workers, licensed counselors Quit Resources for Teens & Young Adults

My Life, My Quit (Text or phone support by National Jewish Health) mylifemyquit.com #MYLIFEMYQUIT

This is Quitting (Texting support by the Truth Initiative) www.thetruth.com/articles/hot-topic/quit-vaping

SmokeFreeTeen (Text or app support by the NIH) teen.smokefree.gov quitSTART app OR smokefreeTXT Resources for Us

Schools & Community Organizations Clinics, Counselors & Pharmacies Parents & Families

• “Catch My Breath” curriculum: • Adolescent SBIRT Toolkit for Providers: • CDC Tip sheet for catchinfo.org/modules/e-cigarettes/ www.mcpap.com/pdf/S2BI%20Toolkit parents: e- • Stanford Toolkit: .pdf cigarettes.surgeongeneral.gov/documents/SG med.stanford.edu/tobaccopreventionto • AAP Policy Statement on Vaping: R_ECig_ParentTipsheet_508.pdf olkit.html pediatrics.aappublications.org/conten • NYT “How to Talk to your teen about Vaping”: • Scholastic's “Get Smart about t/143/2/e20183652 www.nytimes.com/2018/02/14/well/family/h Tobacco”: www.scholastic.com/get_sm • American Lung Association Medical ow-to-talk-with-teenagers-about-vaping.html art_about_tobacco/ Billing Guide: • AAP info for parents: • CDC Tip sheet for www.lung.org/assets/documents/tob www.healthychildren.org/English/health- coaches: cdc.gov/tobacco/basic_inform acco/billing-guide-for-tobacco-1.pdf issues/conditions/tobacco/Pages/Facts-For- Parents-About-E-Cigarettes-Electronic- ation/youth/information- • NIDA Screening Tools: Nicotine-Delivery-Systems.aspx sheet/index.htm www.drugabuse.gov/nidamed- • MA State clearinghouse of resources: medical-health- • Campaign for Tobacco Free: youthengagementalliance.org/wp- massclearinghouse.ehs.state.ma.us/cate professionals/screening-tools- content/uploads/2016/08/JUUL-Fact-Sheet-2- gory/Vaping.html resources/chart-screening-tools 5-18.pdf Adolescent Vaping Regionals

General Information and Resources OH AAP: Positive Youth Development Primer – Sep 2019 Resources on Positive Youth Development – Sep 2019 Adolescent TeenVaping – with MD edits Vaping Resources Vape myths vs facts – CO Dept of PH – Aug 2019

Screening and Starting the Conversation Page Quitting Resources http://ohioaap.o Resources for Health Care Professional Resources for Schools and Communities rg/adolescent- Resources for Youth and Families vaping- Additional Resources regionals/ References & Additional Resources

• State Tobacco-Free Resources: – Ohio: odh.ohio.gov/wps/portal/gov/odh/know-our-programs/tobacco-use-prevention-and- cessation/JUUL2/ – Colorado: www.tobaccofreeco.org/know-the-facts/ – Massachusetts: www.mass.gov/info-details/learn-about-youth-use-of-e-cigarettes-and-other-vaping- devices • SBIRT & Behavior Change Resources: – Oregon: www.sbirtoregon.org/sbirt-workflow/ – Colorado: www.sbirtcolorado.org/adolescent-sbirt • School Curriculum Resources: – Kentucky: odcp.ky.gov/Reports/KY- ODCP%20Drug%20Prevention%20Program%20in%20the%20Schools%20Recommendation%20final%20(AD A)_asm.pdf – Minnesota: www.health.state.mn.us/communities/tobacco/ecigarettes/docs/schooltoolkit.pdf • Other Resources: – Ohio 4-H Peer-to-Peer Health Heroes: https://ohio4h.org/vaping-and-e-cigarettes E-cigarette Cessation Treatment

Presented by: Jangus B. Whitner, PharmD Kelsey Schmuhl, PharmD Keep in mind…

Data to support pharmacologic treatment of nicotine dependence in adolescents is limited.

Cognitive Behavioral Therapy (CBT) and motivational interviewing are considered the “gold standard” of treatment. CME Disclosure We have, as documented, no financial relationships to disclose or Conflicts of Interest (COIs) to resolve. Overview

Non-Pharmacologic Treatment – Behavioral Support Resources (covered by Dr. Dritz)

Pharmacologic Treatment – Nicotine Replacement Therapy (NRT) – Bupropion (Zyban®) – Varenicline (Chantix®) Scoring:

<4 points = minimally dependent 4-6 points = moderately dependent 7-10 points = highly dependent Nicotine Replacement Therapy (NRT) • NRT reduces cravings and withdrawal symptoms by “replacing” the nicotine that is delivered by smoking a How does it work? cigarette. • Available in patches (21mg, 14mg, 7mg), gum (2mg, 4mg), lozenges (2mg, 4mg), nasal spray (10mg/mL), and How is it supplied? inhaler (10mg) Nicotine gum, patch, and nasal spray have been studied in adolescents

Patch • Place 1 patch on a dry, hairless, clean patch of skin on the upper body or upper outer arm once daily • If smoking >10 cigarettes/day: Start with 21mg/day for 6 weeks, followed by 14mg/day for 2 weeks, then finish with 7mg/day for 2 weeks • If smoking ≤10 cigarettes/day: Start with 14mg/day for 6 weeks, followed by 7mg/day for 2 weeks

Gum/Lozenge • Chew 1 piece of gum/use 1 lozenge when the urge to smoke occurs. To increase chances of quitting, chew/use at least 9 pieces per day during the first 6 weeks. (Maximum of 24 pieces of gum or 20 lozenges/day) • If the patient smokes their first cigarette within 30 minutes of waking up, use 4mg gum/lozenge How is it taken? • Weeks 1-6: Chew 1 piece of gum/1 lozenge every 1-2 hours • Weeks 7-9: Chew 1 piece of gum/1 lozenge every 2-4 hours • Weeks 10-12: Chew 1 piece of gum/1 lozenge every 4-8 hours

Nasal Spray • Spray 1 spray in each nostril 1 to 2 times every hour. To increase chances of quitting, use at least 8 sprays in each nostril per day. Maximum of 5 sprays in each nostril per hour or 40 sprays in each nostril per day.

Inhaler • Inhale 6-16 cartridges/day for up to 12 weeks. Continuously use cartridge for about 20 minutes for best results. To increase chances of quitting, inhale at least 6 cartridges/day for the first 3-6 weeks. Maximum of 16 cartridges per day Nicotine Replacement Therapy (NRT) continued

Patch • Local skin reactions, headache, tiredness, sleep disturbances, dizziness • If vivid dreams occur, remove the patch before going to bed

Gum/Lozenge What are the side • Sore throat, jaw pain effects? Nasal Spray • Nasal irritation or burning, taste and smell disturbances

Inhaler • Sore throat, mouth irritation, hiccups, cough What patients should • Precautions should be taken in people under 18 years old, women who are pregnant or breastfeeding, and this not be given to? people who have had a recent heart attack, abnormal heart rhythms, or worsening chest pain • Studies have shown that NRT is well-tolerated by adolescents • Evidence of efficacy is lacking Use in Teens? • Not currently recommended for adolescent smoking cessation treatment, however, benefits of NRT may outweigh risks in certain situations Image from www.target.com Image from www.Walmart.com Image from www.amazon.com

Image from www.drugline.org

Image from www.goodrx.com Bupropion (Zyban®) • Works in the brain to help reduce the urge to smoke and reduces withdrawal symptoms How does it work? • Dopamine & norepinephrine (aka “adrenaline”) How is it supplied? • 150mg SR tablets (generic available) • Typically twice a day How is it taken? • Usually started 7-14 days prior to an agreed upon quit date Main: • Insomnia *Could take in AM then 8 hours later in evening (not close to bedtime) to help avoid insomnia What are the side • Dry mouth effects? Others: • Headache, nausea, irritability, increased heart rate, seizures (1 in 1000) • Weight loss? (14-23%) *Might delay weight gain What patients should • Should not be given to people with a seizure disorder, history/current eating disorder, or who recently stopped this not be given to? using alcohol or benzodiazepines • Black Box Warning: Increased suicidal ideation and behavior in children, adolescents, and young adults Medical staff should monitor for changes in mood and suicidality Other Considerations • If significant progress has not been made by the 7th week of therapy, success is unlikely; consider combination therapy, or discontinuation and use of an alternative agent

Use in Teens? • Not currently recommended for adolescent smoking cessation treatment Varenicline (Chantix®) • “Partial agonist” at the same receptor nicotine occupies • Prevents stimulation of the dopamine pathway that associated with nicotine addition How does it work? *Note: although varenicline does stimulate dopamine activity, it is too a much smaller degree than what nicotine does = decreased craving/withdrawal symptoms • 0.5 mg & 1mg tablets (Brand only, no generic available) How is it supplied? • Starting Month Box/Continuing Month Box • Typically twice a day after eating with a full glass of water (once a patient is through the introductory period) • Usually started 7-14 days prior to an agreed upon quit date How is it taken? - During this time a patient is gradually increasing the daily dose until reaching 1mg BID • Taken with a full glass of water Main: • Unusual/vivid dreams, insomnia *Could take in AM then 8 hours later in evening (not close to bedtime) to help avoid insomnia What are the side • Nausea (dose dependent) effects? Others: • Headache • Neuropsychiatric* (behavior changes, irritability/agitation, depression, suicidal ideation) What patients should • Should not be given to people with a seizure disorder or those who drink alcohol this not be given to? • An adjustment in dose is required for those who have reduced kidney function Other Considerations • Information related to the use of varenicline in pregnancy/breastfeeding is limited/insufficient to recommend it

Use in Teens? • Not currently recommended for adolescent smoking cessation treatment Resources

• Camenga, D., Chadi, N., Hadland, S., Harris, S., Masonbrink, A. E-cigarettes and adolescents: responding to the new “nicotine epidemic” [PowerPoint Slides]. Accessed September 5, 2019. Available at https://www.adolescenthealth.org/SAHM_Main/media/AM19/Handouts/E-cigarette- workshop_SAHM-2019-FINAL.pdf • Farber HJ, Walley SC, Groner JA, Nelson KE. Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke. Pediatrics. 2015;136(5):1008-17. • Moolchan ET, Robinson ML, Ernst M, et al. Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction. Pediatrics. 2005;115(4):e407-14. • Muramoto ML, Leischow SJ, Sherrill D, Matthews E, Strayer LJ. Randomized, double-blind, placebo-controlled trial of 2 dosages of sustained-release bupropion for adolescent smoking cessation. Arch Pediatr Adolesc Med. 2007;161(11):1068-74. • Bailey SR, Crew EE, Riske EC, Ammerman S, Robinson TN, Killen JD. Efficacy and tolerability of pharmacotherapies to aid smoking cessation in adolescents. Paediatr Drugs. 2012;14(2):91-108. • Serlin DC, Clay MA, Harrison RV, Thomas LA, Brower KJ. Tobacco treatment guideline for clinical care – ambulatory. University of Michigan Health System Faculty Group Practice, Quality Management Program. 2012 March;1-16. • Nicotine. Lexi-Drugs. Lexicomp. Wolters Fluwer. Hudson, OH. Available at https://online.lexi.com. Accessed September 5, 2019. • Bupropion. Lexi-Drugs. Lexicomp. Wolters Fluwer. Hudson, OH. Available at https://online.lexi.com. Accessed September 5, 2019. • Varenicline. Lexi-Drugs. Lexicomp. Wolters Fluwer. Hudson, OH. Available at https://online.lexi.com. Accessed September 5, 2019.

• Madelyn • Ivy Smith Smith • Teen Expert Dayton • Teen Expert • 4-H Health • 4-H Health Hero Panelists Hero

• Jodi Kulka, MEd. • Theresa • School Ferrari, • Kelsey Psychologist and Schmuhl, PhD Prevention PharmD • OSU Program Specialist, • OSU • Supervisor Ohio 4-H • Pharmacist • Montgomery Youth County Development Educational • Taylor Service Center Kachmarik • Joan Keith, • Ohio Dept of RN, LSN, NCSN Health • Ohio Dept of • PH Consultant, Health Tobacco Use • School Nurse Prevention and Consultant Cessation Program Please introduce yourself and describe your involvement in vaping and tobacco prevention.

Tell us about the programs you have been involved in and the aspects that have been most successful. Creating a Collective Impact

From your vantage point, where do we struggle in prevention and cessation efforts?

What do you see as opportunities for us as individual organizations and as a collective? Making a Collective Impact Together! Teens Advocating for Vaccines-TA4V

Brush, Book, Bed (BBB) Program Help families develop a nighttime routine that includes toothbrushing, reading together, and a regular bedtime - to improve lifelong health!

- Brush, Book, Bed Training will provide November 13, 2019, 1:30 – 4:30 pm education to improve discussions with In Person: Ohio University (Athens), Baker Center families on oral health, early literacy, Distance: Webinar Available and sleep routines - MOC Part II/CME credit available Register Now at: http://ohioaap.org/brushbookbedregionaltrainings/

For more information on the Brush, Book, Bed QI Program or Training: • Hayley Southworth, [email protected] or (614) 846-6258 • Visit http://ohioaap.org/brushbookbed