VAPING & E-CIGARETTES - NIKOLINA GOLOB, PHARMD, MBA, PGY1 PHARMACY RESIDENT JEREMY HONDL, PHARMD - ALASKA PHARMACISTS ASSOCIATION
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
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 Dependence1
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 22nd, 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 nicotineNicotine Content 8
THC Content9
– 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 usersMore Discrete
Options 10
– Vaping apparel
– Hoodies
– Backpacks
– Phone cases
– Pens
– Smart watches
– USB Drives1st & 2nd 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 14,15E-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 17Adult 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 productsSafety
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 31,2016Health 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 Concern24,25 – 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
Vaping & Pregnancy
E-cigarettes & Smoking
CessationCan e-cigarettes help with
smoking cessation? 23
SHORT ANSWER:
NO
But… Maybe?? Available studies give mixed reviews.
– Not FDA approved as a smoking cessation aid
– U.S Preventative Services Task Force concluded “evidence is insufficient to
recommend e-cigarettes for smoking cessation in adults, including pregnant
women”E-cigarettes & Smoking Cessation 3,23,26
– Cochrane Review September 2016
– “Found evidence from 2 randomized controlled trials that e-cigarettes with nicotine can help smokers
stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes”3,7
– CDC Study published April 2017
– Confirmed many adults use e-cigarettes to help quit smoking
– However, many report “dual use”
– 2019 U.K. National Health Service study
– Individuals assigned to either Nicotine Replacement Therapy (NRT) or e-cigarette starter pack
– E-cigarettes were more effective for smoking cessation
– However, most e-cigarette users were still smoking e-cigarettes at a one year follow up
– Difficult to make concrete recommendation
– Safety and efficacy lacking, diverse products, quality variation, lack of regulationNRT & E-cigarettes – Not enough randomized controlled trials – No official guidelines – Assess patient need and vaping habits – All NRT therapy is appropriate – Multiple case studies showing effective smoking cessation
FDA, CDC, & Alaska
What is the FDA doing? 27
– “In January 2020, FDA issued an enforcement policy on unauthorized flavored
cartridge-based e-cigarette products, including fruit and mint flavors, that
appeal to kids”
– Manufactures are required to comply with the FDA’s Tobacco Regulations
– Manufactures include anyone who “makes, modifies, manufactures, fabricates,
assembles, processes, labels, repacks, relabels or imports any ‘tobacco product’”
– Nicotine addictiveness warning statement on packages and advertisements
– On December 20, 2019, sale of tobacco products legal age changed from 18 to
21E-cigarette or Vaping Product Use-
Associated Lung Injury (EVALI) 28-30
– EVALI: name given by the Centers for Disease Control and Prevention (CDC) for the newly
identified lung disease linked to vaping
– First recognized June 2019, number of cases peaked in September but have since declined
– Vitamin E acetate, an additive in some THC e-cigarettes, is most closely associated with EVALI
– Study published December 20, 2019
– Bronchoalveolar-Lavage Fluid (BAL) collected from 51 patients in 16 states and 99 healthy participants
– Performed isotope dilution mass spectrometry measure the following toxicants: vitamin E acetate, plant
oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes
– Vitamin E was identified in 48 of 51 EVALI cases but not in the healthy group
– Possible risk factors leading to higher morbidity and mortality
– Cardiac disease, chronic pulmonary disease, diabetes, and increased ageCDC Latest Outbreak Info 30 – As of December 27, 2019, there have been 2,561 reported cases of EVALI – In 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and the U.S. Virgin Islands) – Of the 2,561 diagnosed, there have been 55 deaths – Demographics – 67% males – 78% under age 35 – 78% non-Hispanic white – Median age 52 years (range 17 through 75) – Patients that died, were older than the overall population diagnosed – 2 deaths occurred in patients under 25 years of age
Patient Exposure 30
– All EVALI patients reported a history of using e-cigarette, or vaping, products
– Vitamin E acetate was identified as a chemical of concern
– Most EVALI patients admitted to THC-containing products
– THC is present in most samples tested by FDA to date
– “Black market” products are linked to most of the EVALI cases
– CDC has analyzed THC containing products reported by EVALI patients
– 152 different brands were reported
– Most commonly reported products: Dank Vapes (56%), TKO (15%), Smart Cart (13%),
and Rove (12%)CDC Statements & Recommendations 30 – “While it appears that vitamin E acetate is associated with EVALI, there are many different substances and product source that are being investigated, and there may be more than one cause” – CDC recommends not to purchase THC-containing products from informal sources – Vitamin E acetate should not be added to any vaping product – Best way to prevent EVALI is by discontinuing use of all e-cigarette, or vaping products
Clinical Evaluation for EVALI 30 – Patient history – Respiratory symptoms (95%): cough, chest pain, SOB – GI issues (77%): abdominal pain, nausea, vomiting, diarrhea – Fever, chills, weight loss (85%) – Important information to gather – Type of substance (i.e. THC, cannabis [oil, dabs], nicotine, modified products, home-made) – Product source, brand, and name – Duration and frequency of use – Deliver system – Method of use (i.e. aerosolization, dabbing, or dripping)
Clinical Evaluation for EVALI 30 – Physical examination – Tachycardia (55%), tachypnea (45%), O2 saturation
32
Why was AK seemingly unaffected from this vaping illness until now? – Illnesses too mild – Misdiagnosis – Did not meet CDC EVALI diagnosis – Happenstance – AK population is low compared to other states – Black market THC products (or chemicals) may not have made it to AK in large quantities – “A review of ingredient lists, the state’s Marijuana Control Board determined that vitamin E acetate did not show up in any approved products in the regulated Alaska Market” – per vice chair of the board Loren Jones
Questions? Nikolina Golob: ngolob@scf.cc Jeremy Hondl: jhondl@scf.cc
References
1. Benowitz NL. Nicotine Addiction. N Engl J Med. 2010 Jun 17;362(24):2295–303.
2. Zhang G et al. Safety Assessment of Electronic Cigarettes and Their Relationship with Cardiovascular Disease. Int J Environ Res Public Health. 2018;15(75).
3. E-cigarettes: Facts, stats and regulations. Truth Initiative. https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations. Published November 11, 2019. Accessed January 6, 2020.
4. Health CO on S and. Smoking and Tobacco Use; Electronic Cigarettes [Internet]. Centers for Disease Control and Prevention. 2018. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
5. Historical Timeline of Electronic Cigarettes [Internet]. CASAA. 2015. Available from: http://www.casaa.org/historical-timeline-of-electronic-cigarettes/
6. CDC. Quick Facts on the Risks of E-cigarettes for Young People [Internet]. Centers for Disease Control and Prevention. 2018. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-
and-Young-Adults.html
7. The Tobacco Prevention Toolkit. Stanford Medicine. https://med.stanford.edu/content/dam/sm/tobaccopreventiontoolkit/documents/ecigarettes/E-Cigarettes and Vape Pen Generations.pdf. Accessed December 20, 2019.
8. Jewell T. How Much Nicotine Is in a Cigarette, Cigar, and E-Cigarette? Healthline. https://www.healthline.com/health/how-much-nicotine-is-in-a-cigarette#nicotine-in-other-products. Published November 18, 2019. Accessed January 6, 2020.
9. Johns Hopkins Medicine. "Vaping cannabis produces stronger effects than smoking cannabis for infrequent users." ScienceDaily. ScienceDaily, 4 December 2018. .
10. Schimelpfening N. 6 Vaping Products Disguised as Everyday Items. Healthline. https://www.healthline.com/health-news/teens-and-disguised-vaping-devices. Published October 15, 2019. Accessed January 6, 2020.
11. Chai C. What is 'dripping?' Scientists warn of dangerous e-cigarette hack teens are trying. Global News. https://globalnews.ca/news/3232815/what-is-dripping-scientists-warn-of-dangerous-e-cigarette-hack-teens-are-trying/. Published February 7, 2017. Accessed
January 6, 2020.
12. 5 Vape Apps You Should Try for Mobile Devices. Vaping360. https://vaping360.com/lifestyle/vape-apps-tools/. Accessed January 6, 2020.
13. Nicas J, Tsang A. Apple to Ban Vaping Apps From Its Store. The New York Times. https://www.nytimes.com/2019/11/15/business/apple-vaping-apps.html. Published November 15, 2019. Accessed January 7, 2020.
14. Zhu S, Sun JY, Bonnevie E, et al Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation Tobacco Control 2014;23:iii3-iii9.
15. Neal M. There Are Now 7,700 Flavors and 460 Brands of E-Cigarettes. Vice. https://www.vice.com/en_us/article/wnjxjx/there-are-now-7700-flavors-and-460-brands-of-e-cigarettes. Published June 17, 2014. Accessed January 7, 2020.
16. E-cigarette Ads and Youth. Centers for Disease Control and Prevention. https://www.cdc.gov/vitalsigns/ecigarette-ads/index.html. Published March 23, 2017. Accessed January 7, 2020.
17. QuickStats: Cigarette Smoking Status Among Current Adult E-cigarette Users, by Age Group — National Health Interview Survey, United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1177. DOI: http://dx.doi.org/10.15585/mmwr.mm6542a7external icon
18. Walker, Bill, et al. Alaska Tobacco Facts - 2018. http://dhss.alaska.gov/dph/Chronic/Documents/Tobacco/PDF/2018_AKTobaccoFacts.pdf.
19. Wang TW. Tobacco Product Use Among Adults — United States, 2017. MMWR Morb Mortal Wkly Rep [Internet]. 2018. 67. Available from: https://www.cdc.gov/mmwr/volumes/67/wr/mm6744a2.htm
20. July 7 ES|, 2016. Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes [Internet]. American Lung Association. Available from: https://www.lung.org/about-us/blog/2016/07/popcorn-lung-risk-ecigs.htm
21. Products Ingredients and components. Vaporizers, E-Cigarettes, and other ENDS. U.S. Food and Drug Administration. https://www.fda.gov/tobacco-products/products-ingredients-components/vaporizers-e-cigarettes-and-other-electronic-nicotine-delivery-
systems-ends. Published January 3, 2020. Accessed January 7, 2020.
22. Electronic Cigarette Fires and Explosions in the United States 2009-2016. U.S. Fire Administration. https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf. Published July 2017. Accessed January 3, 2020.
23. About Electronic Cigarettes (E-Cigarettes). Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html#seven. Published January 3, 2020. Accessed January 7, 2020.
24. E-Cigarettes and Liquid Nicotine . American Association of Poison Control Centers (AAPCC) - E-Cigarettes and Liquid Nicotine. https://aapcc.org/track/ecigarettes-liquid-nicotine. Accessed January 10, 2020.
25. Govindarajan P, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. E-Cigarette and Liquid Nicotine Exposures Among Young Children. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/early/2018/04/19/peds.2017-3361. Published
May 1, 2018. Accessed January 10, 2020.
26. Hajek P, Drazen JM, Borrelli B, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy: NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1808779. Published February 14, 2019. Accessed January 7,
2020.
27. Products Cfor T. Manufacturing Tobacco Products. U.S. Food and Drug Administration. https://www.fda.gov/tobacco-products/compliance-enforcement-training/manufacturing. Published November 25, 2019. Accessed January 7, 2020.Can electronic cigarettes
help people stop smoking, and are they safe to use for this purpose? [Internet]. Available from: /CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose
28. E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). Yale Medicine. https://www.yalemedicine.org/conditions/evali/. Accessed January 7, 2020.
29. Blount BC, Cabo Rde, Mattson MP, et al. Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI: NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1916433#article_references. Published December 26,
2019. Accessed January 7, 2020.
30. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Published December 31, 2019. Accessed
January 7, 2020.
31. Siegel, David A, et al. “Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-Cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019.” Centers for Disease Control and Prevention,
Centers for Disease Control and Prevention, 17 Oct. 2019, https://www.cdc.gov/mmwr/volumes/68/wr/mm6841e3.htm.
32. Krakow, Morgan. “First Case of Vaping-Related Illness in Alaska Confirmed by State Health Department.” Anchorage Daily News, Anchorage Daily News, 4 Dec. 2019, https://www.adn.com/alaska-news/2019/12/03/first-case-of-vaping-related-illness-in-alaska-
confirmed-by-state-health-department/.You can also read
