E-CIGARETTES AND VAPING: What We Know and What We Don't
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
3/23/2021
E-CIGARETTES AND VAPING:
What We Know and What We Don’t
Judith S. Gordon, PhD
Professor and Associate Dean for Research, College of Nursing
Professor, Family & Community Medicine
1
USAGE RIGHTS
Do not cite or use these materials without
permission of the author
2
1
3/23/2021
FINANCIAL DISCLOSURE
I have no financial conflicts of interest to disclose.
3
OVERVIEW
• Prevalence of use
• Vaping hardware
• Constituents of e-liquids
• General health consequences
• Oral health effects
• Safety of e-cigarettes
• Use of e-cigarettes for cessation
• Evidence-based cessation resources
• Vaping prevention
• Q&A
4
2
3/23/2021
E-CIGARETTES
• Also known as electronic nicotine delivery system
(ENDS), vapes, juuls, puffs, etc.
• Tobacco companies major players
• E-liquid is heated which produces
aerosol (vapor)
• Use is called “vaping”
• Aerosol contains many chemicals
• Nicotine
• THC or CBD
• Many short-term health consequences, some serious
and life-threatening
• Nothing is known about long-term health consequences
5
PREVALENCE OF E-CIGARETTE USE
IN THE UNITED STATES - ADULTS
Adults (%) 2018 2019
Nicotine Last 30 Days 3.2 4.5
Nicotine Last 12 months 16.0
5.7 22.0
Marijuana Vaping
(18+) (18-22)
Smoking Cigarettes 13.7 14.0
Centers for Disease Control: Behavioral Risk Factors Surveillance Survey; Tobacco Use Survey
National Institute on Drug Abuse Monitoring the Future Study
6
3
3/23/2021
PREVALENCE OF E-CIGARETTE USE
IN THE UNITED STATES - YOUTH
12th Grade (%) 2018 2019 2020
Nicotine Last 30 Days 20.9 27.5 19.6
Nicotine Last 12 months 34.0 35.3 34.5
Marijuana Vaping 13.1 20.5 22.1
Smoking Cigarettes 8.1 6.0 4.6
Centers for Disease Control: Behavioral Risk Factors Surveillance Survey; Tobacco Use Survey
National Institute on Drug Abuse Monitoring the Future Study
7
PATTERNS OF USE AMONG CURRENT
E-CIGARETTE USERS - 2015
Regular Former Never
Smokers Smokers Smoker
Age (%) (%) (%)
Overall 60 29 11
45+ 69 30 1
25-44 60 32 8
18-24 42 18 40
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.mm6542a7
8
4
3/23/2021
THE JUUL PHENOMENON
• Sleek high-tech design
• Better nicotine delivery
• Savvy marketing
• 70% market share
• 40% Altria (Philip
Morris) ownership
9
Instagram
Twitter
Magazine
ad
Promotional
Event
10
5
3/23/2021
VAPE CULTURE
11
VAPING HARDWARE 1.0
12
6
3/23/2021
VAPING HARDWARE 2.0
13
VAPING HARDWARE 3.0
DISPOSABLES
14
7
3/23/2021
COMPONENTS OF VAPE SYSTEMS
1.0 2.0
Heating
15
E-LIQUIDS 1.0
16
8
3/23/2021
E-LIQUID CARTRIDGES 2.0
17
FLAVORS (3.0)
18
9
3/23/2021
CONSTITUENTS OF E-LIQUIDS
• Nicotine (1.0) or Nicotine salts (2.0)
• THC/CBD
o Vitamin E acetate
• Ultrafine particles (2.0)
• Propylene Glycol and/or Vegetable Glycerin
o Propylene oxide
• Water
o Minor component
• Volatile Organic Compounds (VOCs)
o Benzene, Acrylamide, Formaldehyde, Acetone, Acetyladehyde
• Microbial Contaminants
o Glucan (fungi), Endotoxin (microbial agent)
o Asthma, reduced lung function, inflammation
19
CONSTITUENTS OF E-LIQUIDS
• Flavor additives
o Diacetyl – all flavors
o Ethyl maltol – mint/menthol
o Cinnamaldehyde – cinnamon
o Ethylvanillin – vanilla
o Benzaldehyde – cherry
o Sucrose
o Sucralose
• Tobacco specific nitrosamines
• Heavy metals
o Nickel, tin, chromium, lead
• Plastics
• Myclobutanil
o Fungicide that transforms into hydrogen cyanide when burned
20
103/23/2021
NICOTINE IN E-CIGARETTES
Product Type # of Puffs Avg. Nicotine
Cigarettes 10 1.0 mg
E-cigarettes 10 0.3 mg
Pod mods (e.g., Juul) 10 0.8 – 2.0 mg
Product Type Average Nicotine Concentration
E-Cigarettes 24 mg/ml
Juul 56 mg/ml
21
SHORT-TERM HEALTH CONSEQUENCES
OF E-CIGARETTE/VAPING
• Nicotine addiction • heart rate
• Mouth/throat irritation • airway resistance
• Dry cough • inflammation
• respiratory infections • Cell damage
• asthma sx • Acute pulmonary damage
• Pneumonia • E-cig/Vaping Assoc Lung
• Alveolar hemorrhage Injury (EVALI)
• Respiratory failure • Vapers 5x risk of COVID-19
• Seizures • Vaping = COVID-19 cases
• O2 saturation
• Vaping = COVID-19 deaths
22
113/23/2021
EVALI
6/2019-2/2020 vaping contributed to >2,800 EVALI
hospitalizations & >68 EVALI deaths in the US
Healthy Lungs “EVALI” Lungs
23
ORAL HEALTH EFFECTS
OF VAPING
• Initial reports show effects of e-cigarettes on
periodontal tissues similar to conventional cigarettes
• Some vaping formulations may be highly cariogenic,
especially sweet flavors
• Research shows several key ingredients and
hardware have potential impact on oral health
o Microbiome
o Propylene Glycol
o Vegetable Glycerin & Flavorings
o Nicotine
o Lithium Batteries
Yang I, Sandeep S & Rodriguez J. (2020) The oral health impact of electronic cigarette use: a systematic
review, Critical Reviews in Toxicology, 50:2, 97-127, DOI: 10.1080/10408444.2020.1713726
24
123/23/2021
SHORT-TERM EFFECTS ON MICROBIOME
• Study of immunoinflammatory responses and microbial
dynamics in oral ecosystems of systemically and periodontally
healthy individuals
• Examined subgingival plaque samples from 5 groups: current
smokers, nonsmokers, e-cigarette users, former smokers turned
vapers, and dual users
• Vaping for at least 3 months related to changes similar to severe
periodontitis, including:
o pathogen overgrowth
o higher microbial virulence signatures
o robust proinflammatory signal
• Long-term current/former smokers had worsened oral profiles
after 3 - 12 months of vaping
• Increased hairy tongue vs. smoking
• Increased candidiasis vs. non-smoking or non-vaping
Ganesan, S. M., et al. (2020). "Adverse effects of electronic cigarettes on the disease-naive oral microbiome."
Science Advances 6(22): eaaz0108.
Yang I, Sandeep S & Rodriguez J. (2020) The oral health impact of electronic cigarette use: a systematic
review, Critical Reviews in Toxicology, 50:2, 97-127, DOI: 10.1080/10408444.2020.1713726
25
PROPYLENE GLYCOL
• Toxic to enamel &
soft tissue
• Hygroscopic
• Leads to:
o Xerostomia
o Caries, gum disease
& other oral health
issues
Perio-ImplantAdvisory.com, January 10, 2019
Irusa, KF, Vence, B, Donovan, T. Potential oral health effects of e-cigarettes and vaping: A review and case
reports. J Esthet Restor Dent. 2020; 32: 260– 264. https://doi.org/10.1111/jerd.12583
26
133/23/2021
VEGETABLE GLYCERIN & FLAVORINGS
• Sucrose, sucralose and ethyl maltol
• Increases in microbial adhesions to enamel & biofilm
formation
• Decreased enamel hardness
• Leads to:
o Caries
o Increases in
Oxidative stress
Pro-inflammatory responses
Pro-senescence responses (DNA damage)
o Dysregulated repair of tissues of the oral cavity
Sundar IK, Javed F, Romanos GE, Rahman I. E-cigarettes and flavorings induce inflammatory and pro-
senescence responses in oral epithelial cells and periodontal fibroblasts. Oncotarget. 2016;7(47):77196-77204.
doi:10.18632/oncotarget.12857
27
NICOTINE
• Vasoconstrictor
• Reduces immmune cell
function
• Decreases connective
tissue turnover
• Leads to gum disease &
tooth loss
• Throat irritation vs. non-
nicotine or NRT
Saunders 2009 Elsevier, Inc.
• Nicotine stomatitis higher in
e-cigarette users
Yang I, Sandeep S & Rodriguez J. (2020) The oral health impact of electronic cigarette use: a systematic
review, Critical Reviews in Toxicology, 50:2, 97-127, DOI: 10.1080/10408444.2020.1713726
28
143/23/2021
LITHIUM BATTERIES
• Explosive
• Causes tooth &
tissue damage
Perio-ImplantAdvisory.com, January 10, 2019
Yang I, Sandeep S & Rodriguez J. (2020) The oral health impact of electronic cigarette use: a systematic
review, Critical Reviews in Toxicology, 50:2, 97-127, DOI: 10.1080/10408444.2020.1713726
29
EXPOSURE TO AEROSOL (VAPOR)
• Secondhand aerosol contains the same chemicals
as those inhaled/exhaled by the person vaping
• >33% of middle and high school students report
being exposed to secondhand aerosol
• Thirdhand aerosol is deposited on surfaces
• Aerosol is heavier than smoke and settles quickly
• E-liquids containing nicotine can be toxic if
absorbed through the skin or ingested
o Refillable cartridges pose a risk for dermal
exposure and toxicity
o In US 2013-2017, est. 4,145 children3/23/2021
HOW SAFE ARE E-CIGARETTES?
E-cigarettes might be safer than conventional
cigarettes, but they are not safe
They do not include any health warnings
E-liquid products not consistent in labeling/content
Emerging evidence on short-term health effects
No research yet on long-term health effects
FDA has not approved electronic cigarettes as an
effective and safe smoking cessation treatment
due to lack of evidence
Considered an “alternative smoking device”
31
PERCEPTIONS OF SAFETY
Agreement with Statements About E-Cigarettes
(% Strongly/Somewhat Agree)
Total 23-38
Flavored e-cigarettes are less damaging
21% 29%
to your health than non-flavored e-cigs
You can’t get addicted to e-cigarettes 20% 24%
E-cigarettes are harmless 16% 24%
Huang J, Feng B, Weaver SR, et al. JAMA Netw Open. 2019;2(3):e191047.
doi:10.1001/jamanetworkopen.2019.1047
32
163/23/2021
FEDERAL & STATE REGULATION
• Increase in age to buy tobacco products to 21
• Some states have imposed bans on e-cigarette sales
& stores no longer selling e-cigarettes
• Ban on in-person sales of certain flavors
• Federal probes of deceptive marketing practices at
Juul and other manufacturers
• CDC warning not to vape, particularly THC
33
WHAT SHOULD AN
E-CIGARETTE USER KNOW?
• They are not harmless
• The contents vary widely and are not regulated
• Products safe for eating may not be safe when
heated and inhaled
• Many questions remain about e-cigarettes’ safety
• Don’t use black market or “home-made” products
• Encourage users to quit e-cigarettes
• Use same effective (approved) treatments for
cessation as you would for smoking
• Stop vaping of all medical marijuana products and
use other (non-combustible) forms
Rigotti, Annals of Internal Med. 2018
34
173/23/2021
WHAT SHOULD A SMOKER KNOW
ABOUT E-CIGARETTES?
• Not a safe alternative to smoking
• Not approved for smoking cessation
• Recommend using approved treatments first
• If smoker insists and has failed with other methods
o Express concern regarding safety of e-cigarettes
o Recommend only temporary, short-term use of e-cigs
o Switch completely to e-cigarettes (no dual use)
o Don’t vape THC/CBD or buy black market products
o Make a plan to stop e-cigarettes (taper off) as you
would with approved treatments
o Create a quit plan and follow up on progress
o Switch to approved treatments if still vaping
Rigotti, Annals of Internal Med. 2018
35
MOST E-CIGARETTE USERS
WANT TO QUIT
• Recent survey of 1800 people who used
e-cigarettes regularly
• Over half were also smoking conventional
cigarettes
• Almost 67% said they had plans to quit
e-cigarettes someday
• About 50% planned to quit in the next year
• 25% had tried to quit in the past year
• Few used social support and FDA-approved
cessation aids
Rosen RL & Steinberg ML, Interest in Quitting E-cigarettes Among Adults in the United States, Nicotine
& Tobacco Research, ntz062, https://doi.org/10.1093/ntr/ntz062
36
183/23/2021
FDA-APPROVED CESSATION
PHARMACOTHERAPY OPTIONS
• Over-The-Counter (OTC) Nicotine Products
o Nicotine Patch
o Nicotine Gum
o Nicotine Lozenge
• Prescription Medications
o Nicotrol Inhaler
o Nicotine Nasal Spray
o Zyban/Wellbutrin (Bupropion)
o Chantix (Varenicline)
• Age restrictions (18+) on purchase of OTC
• Physician can prescribe for3/23/2021
PREVENTION AMONG YOUTH
• Prevention efforts must focus on youth before they
begin using any type of tobacco product
• Large jumps in use 7th, 9th and 12th grade
• Start talking about e-cigarettes at age 12
• Focus on:
• Similarities to cigarettes
• E-cigarettes are owned by tobacco companies
• Market for cigarettes is decreasing, so they are looking
for new customers through vaping
• Marketing products as “safe” and “cool”, but they are
manipulating youth
• Kids who vape are 4 times more likely to smoke
cigarettes
• Vaping is very addictive and not safe
39
THANK YOU!
Contact Info:
Judith Gordon, PhD
judithg@email.arizona.edu
40
20You can also read
