Teens: E-Cigarette & Vaping

Fact and Fiction: It’s not just a “mist”

Linda Schanne MSN, RN-C, CEN, CCRNClinical Nurse Educator

Bryn Mawr Hospital Emergency Department Radnor Township Board of Health Chair

& A Michael Blanche, MSS LCSW

TherapeuticAlliance.com

Source: Photo by Mandie Mills, CDC.

Objectives:1. Discuss the prevalence of teen vaping2. Describe types of vaping devices and e-liquids3. Identify the health consequences of vaping 4. Describe how parents, faculty and administrators can recognizing

teen vaping5. Discuss how to talk to teens about vaping6. Identify resources on vaping

What is VAPING?Vaping is done by using a e-cigarette which produce an aerosol by heating a liquid that usually contains nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products—flavorings, and other chemicals that help to make the aerosol.

ENDS = (Electronic Nicotine Delivery System) known as a e-cigarette

Users inhale this aerosol into their lungs.

Bystanders can also breathe in this aerosol when the user exhales into the air.

VariousENDS

Source: CDC 2019

Vaping Rising Among Teens:

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Source: NIH 2019

Why should we be concerned?

Source: NIH 2018

Source: NIH 2018

How is media influencing our teens?

Bottom Line___________

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Source: U.S. Department of Health and Human Services 2019

PA Statistics

1 in every 4 high school seniors in PA reported having used an e-cigarette in a 30 day period.

2017 National Youth Tobacco Survey showed about 12 percent of high school students and 3 percent of middle school students had used them in the past 30 days.

PA is 10% higher that the national average.

More teens used a e-cigarette in PA in 2015 versus cigarettes and smokeless tobacco.

Must be 18 years old to purchase E-cigs in PA

Big Business

E-cigarettes are a 3.6 billion dollar business in the US(up from 1.5 billion in

2014)

$125 million annually to advertise e-cigarette products

Marketed as a “safer & less toxic” as traditional cigarettes

Very easy for youth to buy on-line: loose disclaimers

Source: Photo by M andie M ills, CDC

What are Pre-teens & Teens VAPING?

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Vaping Devices:

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• Electronic cigarette: smokeless, battery operated device used to deliver nicotine with flavorings or other chemicals to the lungs.

• Vaporizer pen or vape pen: a device ranging in size from a standardpen to a large cigar used to generate an inhalable vapor from a solid, semi-solid, or liquid substance.

• Three components: A liquid cartridge used to produce the vapor. A heating element known as the atomizer and a rechargeable battery to power the atomizer.

Creative names fore-cigarettes:

“cartridges”“e-cigs”“mods”“carts”“vapes”

‘”ank systems”“water pipe”

“vape pipe/pen” “Juul”“ends”

Note. Some e-cigs connect to other electronic devices to play music and answer calls

Juul E-cigaretteJUUL is a brand of e-cigarette that is shaped like a USB flash drive. It’s battery-powered device that heats a nicotine-containing liquid to produce an aerosol that is inhaled.

News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.

Other companies sell e-cigarettes that look like USB flash drives. Examples include the MarkTen Elite, a nicotine delivery device, and the PAX Era, a marijuana delivery device that looks like JUUL.

Juul e-cigarette

Juul 75% of market share of e-cigarettes – contain nicotine

Juul sales have surged to 800% this past year!

“Juuling”… a new verb??

Can purchase at local WAWA, 7 Eleven, & Shell stores

Sells for $62.00 for starter Packet

Pack of 2 pods sells for $24.00 (only mint & Virginia tobacco)

Starter PacketJuul Pod1 pod = 200 puffs40 mg nicotine = 1 pack of cigarettes

USB Charger

Hookah:water pipes that are used to smoke specially made tobacco that come in different flavors

In the US it has become more popular among teens and young adults and in college towns, seen as a “popular social activity”

Even after it has been passed through water, the tobacco smoke in a hookah pipe contains high levels of cancer-causing chemicals

Smoke inhaled in a typical one-hour hookah session can equal 100 cigarettes or more (WHO 2011)

E-Liquid/E-Juice: Is it candy?Main ingredient: propylene glycol (PG ) and/or vegetable glycerin (VG) usually with water-soluble food flavorings. With or without nicotine, THC

Allergies to PG are rare, but it can irritate the lungs and eyes and may be more harmful to people with chronic lung diseases like asthma and emphysema.

The FDA generally views both PG and VG as safe in food, drugs and cosmetics BUT there have not been sufficient scientific studies done on what the impact of inhaling them on a short or long term basis may be

It is not always clear what is in e-liquids

“Harmless” Vapor?? Toxic chemicals are formed as the e-liquid heats up to make the aerosol that e-cig users inhale:

Are E-cigarettes less harmful than regular cigarettes?Yes—but that doesn’t mean e-cigarettes are safe. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular

E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents

POPCORN LUNG ?Findings confirm the presence of diacetyl and “other flavoring chemicals” in e-juices.

Diacetyl is added to food to produce a buttery taste and is perfectly harmless when ingested this way. The issue is that when heated up and then inhaled diacetyl is not so benign.

Inhaling it over a long period may prove harmful to health, specifically being linked to bronchiolitis obliterans (a lung disease).

Because of the associations between diacetyl and bronchiolitis obliterans and other severe respiratory diseases among workers inhaling heated vapors containing diacetyl, urgent action is recommended to further evaluate the extent of this new exposure to diacetyl and related flavoring compounds in e-cigarettes (CDC).

NicotineE-cigarettes can increase nicotine addiction among young people and may lead kids to try other tobacco products, including conventional cigarettes

Teens don’t always know how much nicotine they are inhaling

“Nicotine High” – YES in higher concentrations

Vaping Marijuana(THC)THC(tetrahydrocannabinol) is the chemical responsible for most of marijuana's psychological effects(high)

Liquid THC is applied to a vaping device the same way that flavored nicotine liquid is

Use of hash oil(higher concentrated THC), is becoming more common

Illegal sources have vitamin E as the base solution and may be linked to recent respiratory compromise.

Dabbing: not your typical fun “dance”…Dabbing is a method used to convert marijuana into a concentrate.

vaping highly concentrated doses of cannabisoil, is the next level of vaping marijuana for both recreational and medicinal purposes. But for vaping waxes, you need a special vaporizerknown as a wax vaporizer

It uses butane, which is highly flammable, to extract THC from the cannabis plant

Also known as butane hash oil (BHO), honey oil, budder, crumble, shatter and/or wax

While marijuana in its traditional plant form has a THC concentration of about 20 percent, the wax used for dabbing can have a concentration of up to 80 percent

Dripping: A more labor-intensive method of vaping in which the user manually applies a few drops of liquid directly to the exposed heating coil of the e-cigarette every so few puffs

1 in 4 teens who vape say they’ve used this method

Dripping produces thicker clouds of vapor, gives a stronger sensation in the throat and makes flavors taste better (Journal of Pediatrics)

Dripping generates higher heating coil temperatures than conventional use of e-cigarettes, which lead to greater emissions of a class of harmful chemicals.

Some chemicals released are associated with cancer, chronic obstructive pulmonary disease

Handling liquid exposes teens to direct skin contact with nicotine which is absorbed rapidly through human skin

Made with Safe Ingredients

Our formula is composed of pharmaceutical-grade Caffeine and infused with an organic base of USP-grade vegetable glycerin.

Manufactured in the USA, our Caffeine liquid formula is tested for maximum evaporability, under the direction of certified toxicologists in an ISO-accredited laboratory. We do not use harmful chemicals or source ingredients from international labs.

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Inhale Health Caffeine Sunburst Orange Inhaler

Alcohol Vaping(vapshot)When alcohol vapor is inhaled, it goes straight from the lungs to the brain and bloodstream, getting the individual drunk very quickly.

Rates of alcohol poising are much higher

“Vaportini” or “Vapshot”

Alcohol Vaping…Not a “real” soda bottle

Dangers of E-Cigarettes3 times more likely to have dangerous chemicals in their systems

2 times as likely to start smoking traditional cigarettes

Nicotine in E-Cigarettes places teens at risk for:◦ Nausea & anxiety – short term◦ Altered brain development◦ Mood disorders◦ Lowered impulse control◦ Attention & learning problems

Defective batteries have caused fires & explosion – injuries

Vaping Related Lung DiseaseA representative story ……

18 year old male present toemergency room with nausea and flu like symptoms over the last few days. He also had mild nonproductive cough.In the morning prior to ER he noted chest pain and shortness of breath.In the ER he was anxious with blood oxygen level reduced to 80%.

His chest xray should look like this

Vaping Related Lung Disease…… but this is CXR result

he requires high flow oxygen and is admitted to intensive care

medical history: only notable for mild intermittent childhood asthma

social history: he is a student preparing to go back to college with no recent travel and no sick contacts, there has been no relevant travel history, he reports regular vaping with flavored nicotine cartridges or pods in a “Juul”

Vaping Related Lung Disease

Despite initial treatments for pneumonia and trial of steroids progressive respiratory failure requiring mechanical ventilation

Continued progression ofhypoxia requiring referral for ECMO and evaluation for emergent lung transplant

Vaping Related Lung DiseaseSymptoms have included nonproductive cough, pleurisy chest pain and shortness of breath several days to weeks prior to hospitalizations.

◦ Systemic symptoms include tachycardia, fever, chills or fatigue.

Many have GI symptoms including nausea, vomiting abdominal pain and diarrhea preceding respiratory symptoms.

◦ Hospital presentation notable for significant hypoxia.

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Wikimedia Commons 2015

Vaping Related Lung Disease: Epidemic• CDC, FDA and PA Department of Health investigating multistate outbreak of

lung disease associated with E cigarette products.

• E cigarettes include a variety of delivery systems but all heat a liquid to produce a aerosol that users inhale in their lungs – the content can include nicotine, THC, CBD oils and other additives.

• In the month of September, eight cases of vaping related lung disease have been reported across MLH with two requiring referral for ECMO / transplantevaluation.

Dangers of E-CigarettesUpdated October 11, 2019 at 1:00 PM ET: CDC

What We Know

As of October 8, 2019, 1,299* lung injury cases associated with the use of e-cigarette, or vaping, products have been reported to CDC from 49 states, the District of Columbia, and 1 U.S. territory.

Twenty-six deaths have been confirmed in 21 states.

All patients have reported a history of using e-cigarette, or vaping, products.

Dangers of Vaping to YouthSecond had smoke dangers? Still unknownMost popular and commonly used by youthAppealing flavors; peach schnapps, Pina colada, peppermint, bubble gum, chocolate etc.…More likely to convert to traditional cigarette smoking in the future

A 2018 National Academy of Medicine report found that there was some evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future.E-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking.May lead to vaping marijuana, herbs, wax and oils

Liquid Nicotine: is there a Risk of Poisoning?

Contact of liquid nicotine on skin or swallowed = can poison

Nicotine liquid is lethal in small amounts if swallowed: < 1 tsp

2016 Law required that liquid nicotine must be sold in child-proof packaging

Signs & symptoms of nicotine poisoning:◦ Sweating, dizziness, & vomiting◦ increased heart rate(pulse) ◦ sleepiness ◦ seizures ◦ difficulty breathing

Additional Dangers of E-Cigarettes• Acute nicotine exposure can be toxic- children &

adults have been poisoned by swallowing, breathing or absorbing e-cigarette liquid

• More than half 51% of the calls to poison centers due to e-cigarettes involved young children under age 5

• Approximately 42 % of the poison calls involved people age 20 and older.

American Association of Poison Control Centers(AAPCC): Electronic Cigarettes and Liquid Nicotine Data August 31, 2019

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Year Number of Cases

2011 269

2012 459

2013 1,540

2014 4,011

2015 3,733

2016 2,899

2017 2,470

2018 3,139

2019 YTD 2,961

What's the bottom line?E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.

E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.

While e-cigarettes have the potential to benefit some people and harm others, scientists still have a lot to learn about whether e-cigarettes are effective for quitting smoking.

If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start.

E-cigarettes are not currently approved by the FDA as a quit smoking aid.

Additional research can help understand long-term health effects.

Recent Government Vaping WarningsOn December 18, 2018 Surgeon General Jerome Adams issued a rare advisory—the fourth in

10 years—from his office. “I am officially declaring e-cigarette use [vaping] among youth an epidemic in the United States.”

March 21, 2019 FDA Commissioner Scott Gottlieb might consider temporarily removing all

pod and e-cigarettes from the U.S. market if your e-cigarette use increases this year.

Spring/summer: CDC, FDA and PA Department of Health investigating multistate outbreak of

lung disease associated with E cigarette products.

E cigarettes include a variety of delivery systems but all heat a liquid to produce a aerosol

that users inhale in their lungs –the content can include nicotine, THC, CBD oils and other

additives.

September 11, 2019 Trump says he is concerned about vaping because

'people are dying’

◦ *The Trump administration said on Wednesday that it would ban the sale of

most flavored e-cigarettes

Vaping Related Lung Disease: Epidemic

• There were 53 case patients, 83% of whom were male; the median age of the patients was 19 years. The majority of patients presented with respiratory symptoms (98%), gastrointestinal symptoms (81%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging (which was part of the case definition). A total of 94% of the patients were hospitalized, 32% underwent intubation and mechanical ventilation, and one death was reported. A total of 84% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.

9/6/2019 Wisconsin and Illinois Study

PA & US Laws: e-cigarettesHouse Bill 97 unanimously passed in the Pennsylvania House of Representatives on March 25. The bill would make it illegal for people under 18 years old to purchase or use nicotine-based products, in addition to tobacco products

Proposed PA House Bill 473 If passed, the law would raise the legal age to buy tobacco products in Pennsylvania from 18 to 21. Sen. Scavello says an increased number of teenagers are getting tobacco from 18 year olds and raising the age could stop that. Mar 15, 2019

When FDA's foundational “deeming rule” went into effect on Aug. 8, 2016, it gave the agency's Center for Tobacco Products (CTP) regulatory authority over all ENDS, including e-cigarettes, vapes, e-liquids, e-cigars, e-pipes, and e-hookahs. ... FDA's oversight of these products is a top priority for the agency. Sep 10, 2019

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How do teens get Vapes & how much do they cost?

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VAPING SUPPLIES ARE EASY FOR YOUTH TO PURCHASE ON THE INTRANET

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Vaping Liquid Flavors & Concentrations of Nicotine: Easily Purchased Online With No Age Disclaimer For Purchasing!!!

On-line loose disclaimer….. !" Must be 18 years of age or older and of legal age to purchase and use vaping products

within your location. Our products are not intended for anyone; pregnant, nursing, underage, with or at for risk heart disease, diabetic, asthmatic, or sensitive to vaping byproducts including e-liquid vapors or ingredients and nicotine. Nicotine is addictive and may be dangerous to your health. Keep vape products away from of children and pets. By purchasing from this website you automatically agree to assume all responsibility including liabilities, harm or damages that may occur as a result from the use of our products. Use at your own risk. Please Recycle -

Copyright © 2019 VAPES.

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Where do teens get Vapes in our community?

Wawa’s

King of Prussia Mall

Online….iPhone/Droid

Signs to look for: It can be hard for parents to tell if their child/teen is vaping, since there's no smoke or telltale smell.

"Pens" that aren't pens

New scents: the vapor can be flavored (fruit punch, bubble gum)

Typical signs of marijuana use: red eyes, lethargic, increase cravings for snacks, confusion, anxiety, lack of focus/coordination, unusually talkative, dropping studies or usual activities, change of friends, and/or secretiveness

Increase of water intake: Propylene glycol attracts and holds water molecules from its environment. This can lead e-cig users to have a constant state of dry mouth.

Some e-cigarettes users develop a sensitivity to caffeine, and curb their caffeine intake

Nose bleeds. The water-holding effect of e-cig vapor can also dry out the nasal passages

Containers of butane

Talk to our child/teens….As a parent, you have the power to influence your teen’s decisions. Many parents don’t talk to their kids about drugs, addiction, smoking or drinking, but for those who do, the results are positive.

Teens whose parents talk to them about these difficult subjects make better choices

When talking about vaping, play it casual. Ask them if they have heard of it and what they know.

Keep it open-ended. Teenagers will look for any chance to answer a question with a yes or no. What do you think about vaping?

Today's teens are more health-savvy. Teach your teen about e-cigarettes and regular cigarettes.

Talk about the uncertainty of e-cigarette safety and about the definite possibility of addiction to nicotine that goes along with vaping

Stress the seriousness of vaping as a decision to not just make on a whim, but one with potential consequences of lifelong problems

Be the message. If you don't want your kids to vape, don't vape, either.

Children of people that use products like vaping and nicotine products are more likely to use them

Clinical signs in primary or acute care setting

PA Department of Health: “Severe Acute Pulmonary Disease Associate with Vaping”

◦ First report 8/16/19: most cases THC containing products with unidentified chemical

constituents in the products

Carful history and physical regarding substances, amount and frequency of vaping

Identify type of device, E-liquid, THC, CBD etc..

9/26/19: If you become aware of cases that involve severe lung injury related to

vaping, fax “ Lung Injury Associate with E-Cigarette Product Use or Vaping Initial

Suspect Case Report Form” to PA DOH.

Call PA DOH at 1-877-PA-HEALTH for any questions

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New: PA DOH Lung Injury Associated with E-cigarette Product Use or Vaping Suspect Case Report Form

References for Parents/Guardians/Clinicians 1. Center for Disease Control(CDC) E-cigarettes and Youth: What Parents Need to Know: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/resources/index.html

2. American Lung Association: The Vape Talk Conversation Guide and facts on vaping: https://www.lung.org/stop-smoking/vape-talk/

3. NIH: National Institute on Drug Abuse: What to Do If You Have a Problem with Drugs: For Teens and Young Adults: https://www.drugabuse.gov/related-topics/treatment/what-to-do-if-you-have-problem-drugs-teens-young-adults

4. US Surgeon General: The Facts of e-cigarette use among youth and young adults; https://e-cigarettes.surgeongeneral.gov/getthefacts.html

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References:NIH: National Institute on Drug Abuse: Electronic Cigarettes (E-cigarettes)

CDC: E-Cigarettes https://www.cdc.gov/.../e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids...

U.S. Department of Health and Human Services: E-Cigarettes Use Among Youth and Young AdultsSurgeon General Report: Know the risks of E-Cigarettes and young people: https://e-cigarettes.surgeongeneral.gov/resources.html

Center for Addiction: https://www.centeronaddiction.org/e-cigarettes/about-e-cigarettes

www.media.pa.gov/Wolf Administration Discusses Dangers of E-Cigarettes with StudentsNational Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettesExternal. Washington, DC: The National Academies Press.

2019 National Youth Tobacco Survey- PA statistics: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm625917.htm

Questions ????????????