Vaping & E-cigarettes Nikolina Golob, PharmD, MBA, PGY1 Pharmacy Resident Jeremy Hondl, PharmD
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 nicotine
Nicotine 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 users
More Discrete
Options 10 – Vaping apparel
– Hoodies
– Backpacks
– Phone cases
– Pens
– Smart watches
– USB Drives
1st & 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 14,15
E-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 17
Adult 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 products
Safety
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 31,2016
Health 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 <6 years old
Vaping & Pregnancy
E-cigarettes & Smoking
Cessation
Can 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 regulation
NRT & 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
21
E-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 age
CDC 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 <95% (57%)
– Pulmonary findings on auscultation exam – unremarkable
– This is consistently true even for those with severe lung injury
– Laboratory Testing
– Guided by clinical findings
– Imaging
– CXR: pulmonary infiltrates
– CT Scan: opacities on chest
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
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