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.