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Vaping Epidemic: We Should be Informed

Renee Koski, PharmD, Professor

Ferris State University College of Pharmacy

reneekoski@ferris.edu

February 6, 2020

Objectives

Explain the dangers of vaping

Identify how to keep up with vaping‐related injury statistics

Tobacco Use in the U.S.1

• Chief preventable cause of death

• Associated with cancers, stroke, heart disease, diabetes, COPD, pneumonia, etc.

• Problems not due to nicotine only

• U.S. spends over $300 billion on factors related to tobacco usage

2017

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FDA‐Approved Tobacco Cessation

Therapies2

• Duration should be minimum of 3‐6 months

Product Efficacy Cost (30‐day WAC)

Nicotine Replacement Products

Transdermal Increased smoking cessation rate by 50‐60%

$45

Nasal Spray $330

Gum $60

Lozenge $90

Oral Inhaler $415

Bupropion Doubled smoking cessation rate vs placebo; as effective as NRT

$20

Varenicline More effective than NRT or bupropion; as effective as combination NRT

$450

Electronic Nicotine Delivery Systems (ENDS)2

• E‐cigarettes

• Produce an inhaled aerosol instead of smoke

• Advertised as a safer and socially acceptable alternative to tobacco cigarettes for nicotine delivery

• Studies show mixed results for efficacy vs NRT for smoking cessation

Vaping1

• Inhaling and exhaling vapor produced by an e‐cigarette or personal vaporizer

• Liquid solution is in device

• Battery heats liquid, which is turned into an inhalable vapor

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Generations of E‐Cigarettes3

• First: closed‐system disposable device that resembles a cigarette (cigalike)

• Second: open‐system rechargeable device that is pen‐shaped or larger (vape pen)

• Third: large, refillable, customizable (mod)

• Fourth: open or closed‐system rechargeable device, high‐tech, uses nicotine salts (more rapid delivery of large amount of nicotine), appeals to youth (pod)

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Also Referred to As…

• Cartridges

• Carts

• Water pipe

• Vape pipe/pen

• Juul

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Cig‐a‐likes 1 $ 5 ‐ 60 (Including starter kit prices)

Pod Mods 4 $ 10‐ 50 (Including starter kit prices)

Vape Pens 2 $ 15 ‐ 50

Vape Mods (Box Mods) 3

$ 30 ‐ 100+ (Including Starter Kit Prices)

Cig‐A‐like Pre‐filled Cartridge

$ 1.7‐ 2 per replacement cartridge

Full Disposable E‐cigarettes

$ 6 ‐ 10 dollars per e‐cigarette (Not recommended)

Pre‐filled Nicotine Salt Pods

$ 3‐5 per pod

Nic Salt E‐liquid 30 ml = $ 15 ‐ 20

Regular E‐juice 60 ml = $10 ‐ 25

Regular E‐juice 120 ml $15 ‐ 35

https://www.ruthlessvapor.com/blogs/ruthless‐e‐liquid/nicotine‐salt‐devices‐vape‐pods

E‐Liquid/E‐Juice1

• Main ingredients:

• Nicotine (dissolved in propylene glycol or vegetable glycerin)

• Water‐soluble food flavorings

• Marijuana (THC)

Nicotine

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Dripping4• Labor‐intensive method of vaping where a few drops of liquid are applied directly to exposed heating coil of e‐cig every few puffs

• Produces thicker vapor clouds, giving stronger sensation in throat, making flavors taste better

• Generates higher heating coil temperatures than conventional use of e‐cig, leading to greater emissions of harmful chemicals

• Handling liquid exposes user to direct skin contact with nicotine, which is absorbed rapidly through human skin

Cannabis (THC )4

• Weed vape pens

• Liquid THC or hash oil (concentrated form of plant) is applied to vaping device same way flavored nicotine liquid is

• Liquid turns to vapor, which is then inhaled

• Needs to be heated to higher temp than nicotine to turn to vapor; risk of leaching chemicals from metal heating element

Dabbing4

• Converting marijuana into concentrated form

• Uses highly flammable butane to extract THC from cannabis plant

• Also known as butane hash oil, honey oil, budder, crumble, shatter, or wax

• Marijuana in traditional plant form has THC concentration of ~20%; wax used for dabbing can have concentration of up to 80% (like smoking 20 joints at once)

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Alcohol5

• Ingested alcohol is absorbed through body over time

• Vaped alcohol goes directly into bloodstream• Leads to rapid rush of alcohol to the brain

• Rates of alcohol poisoning are much higher, and there is not a way to “detox” from it

Vapor6

• Toxic chemicals are formed as e‐liquid heats up to make inhaled aerosol

• Carbonyl compounds

• Volatile organic compounds

• Nitrosamines

• Metals

*Studies also link vaping to fertility problems and

decreased immune system

CDC.gov

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Popcorn Lung1

• Nickname for bronchiolitis obliterans

• Airway scarring due to inflammation of bronchioles

• Sx include cough and shortness of breath

• Can be caused by inhaling heated diacetyl, substance found in ~75% of flavoring chemicals of e‐juices

• Can also be caused by inhaling acetaldehyde, found in e‐juices and marijuana smoke

• Several cases reported from vaping

• Treated with O2, corticosteroids, bronchodilators

E‐cigarette or vaping product use associated lung injury (EVALI)1

• Diagnosis of exclusion (No test exists for diagnosis)

• CDC reported data as of 10/19

• 95% pts experience respiratory sx (cough, chest pain, shortness of breath)

• 77% pts experience GI sx (abdominal pain, NVD)

• 85% pts experience fever, chills, weight loss

• 88% received corticosteroids (82% improved)

• Pulmonary infiltrates on CXR

• Opacities on CT scan

EVALI Stats as of

1/14/201

2,668 hospitalized cases reported to CDC from all states, District of Columbia, Puerto Rico, and U.S. Virgin Islands

60 deaths confirmed in 27 states and District of Columbia (median age 51 yo, 15‐75 yo)

Latest outbreak information updated every Thursday

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EVALI Cases by State1

EVALI Onset1

More EVALI Stats

as of 1/14/201

66% male

76% <35 years old

15% <18 years old

37% 18‐24 years old

24% 25‐34 years old

24% ≥35 years old

Median age 24 years (Range 13‐85 years old)

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More EVALI Stats as of 1/14/201

82% reported using THC‐containing products (33% reported exclusive use of THC‐containing

product)

57% reported using nicotine‐containing products (~14% reported exclusive use of nicotine‐

containing product)

THC Product Source:

16% commercial, 78% informal, 6% both

Nicotine Product Source:

69% commercial, 17% informal, 15% both

Patients with EVALI1

• All reported history of using e‐cigarette or vaping products

• Most reported history of using THC‐containing e‐cigarette or vaping products

• National and state findings suggest products containing THC, especially from informal sources (friends, family, in‐person or online dealers), are linked to most cases and play a major role in the outbreak

EVALI1

Cardiac disease, chronic pulmonary disease, diabetes, increasing age might be risk factors leading to higher morbidity and mortality

Hospitalized patients should be documented as clinically stable for 24–48 hours prior to discharge

Patient should have a follow‐up visit with a primary care provider or pulmonary specialist, optimally within 48 hours of discharge—a shorter follow‐up time than the previous recommendation of 1–2 weeks

Healthcare providers should continue to report cases of EVALI to their local health department

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Vitamin E Acetate1,12

• Found in all bronchoalveolar lavage fluid samples submitted to CDC from 48/51 (94%) patients (from 16 states) with EVALI

• Might be an additive (especially a thickening agent) in THC‐containing e‐cig or vaping products

• Found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables

• Also available as a dietary supplement and in many cosmetic products, like skin creams

• Usually does not cause harm when ingested as supplement or applied to skin

• Previous research suggests when inhaled, it may interfere with normal lung functioning

Other Findings from BAL Testing1,12

• THC identified in 90% of positive samples

• Not found in nicotine‐only samples

• No other toxicants detected, except coconut oil and limonene in 1 patient each

Vitamin E Acetate12

• Ester of vitamin E (alpha‐tocopherol) and acetic acid

• May affect lung surfactant

• When heated, may create ketene, a lung irritant

• Not found in 10/10 samples seized by law enforcement prior to outbreak; found in 20/20 seized samples during/after outbreak

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Case of Double Lung Transplant due to EVALI

• 17‐year‐old male

• Unknown what he vaped

• Presented with pneumonia‐like sx on 9/5/19

• Was sedated on ECMO for over a month

• Put on transplant list on 10/5/19

• Received transplant on 10/15/19

• Will require extensive rehabilitation

Case of Cobalt Lung Disease

• 12/19: 49‐year‐old woman with vaping lung illness resulted in permanent lung damage

• Under microscope, damage looked different than other EVALI cases

• Presence of giant cells

• Found traces of cobalt, aluminum, chromium, lead, nickel, and manganese in vapor

• Probably leached from heating coil

• Used ZenPen vaping pen with marijuana for 6+ months

THC‐Containing Vape Products Associated

with EVALI1

• 152 different THC‐containing product brands were reported by EVALI patients• Dank Vapes (NE and S): 56%

• TKO (W): 13%

• Smart Cart (W): 13%

• Rove (MW): 12%

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Vaping and Second‐Hand Smoke7

Summary Statistics of PM1 concentrations (μg m−3) before and during vaping session

E‐cig CodeBefore Vaping Session During Vaping Session

p‐ValueAM [SD] Median [IQR] AM [SD] Median [IQR]

1e‐cig_noN 41.27 [19.09] 38.00 [9.00] 79.69 [80.13] 64.00 [12.00] <0.001

1e‐cig_N 43.86 [18.75] 36.00 [8.00] 105.52 [117.10] 89.00 [10.00] <0.001

2e‐cig_noN 21.34 [7.67] 19.00 [4.00] 534.00 [1266.88] 34.50 [309.00] <0.001

2e‐cig_N 18.33 [6.74] 18.00 [2.00] 3428.85 [5857.54] 648.00 [4256.00] <0.001

3e‐cig_1.6Ω‐3.4V_noN 21.56 [6.31] 21.00 [7.00] 789.48 [2300.46] 36.00 [192.00] <0.001

3e‐cig_1.6Ω‐3.4V_N 26.22 [6.58] 25.00 [3.00] 54.39 [179.23] 17.00 [22.00] <0.001

3e‐cig_1.6Ω‐4.8V_noN 21.45 [6.75] 19.00 [7.00] 522.29 [1729.70] 43.00 [99.00] <0.001

3e‐cig_1.6Ω‐4.8V_N 26.22 [13.58] 25.00 [11.00] 1005.81 [4405.06] 22.00 [297.00] <0.001

4e‐cig_0.15Ω‐25W_noN 20.96 [2.74] 20.00 [1.00] 384.53 [1327.67] 39.00 [99.00] <0.001

4e‐cig_0.15Ω‐25W_N 35.44 [6.32] 34.00 [2.00] 963.24 [4605.46] 41.00 [96.00] <0.001

4e‐cig_0.4Ω‐55W_noN 31.67 [8.79] 28.00 [5.00] 74.50 [40.70] 61.00 [29.00] <0.001

4e‐cig_0.4Ω‐55W_N 43.87 [6.23] 43.00 [4.00] 472.93 [1181.44] 66.00 [322.00] <0.001

4e‐cig_0.4Ω‐80W_noN 35.44 [6.32] 34.00 [2.00] 2238.34 [3931.00] 603.00 [2414.00] <0.001

4e‐cig_0.4Ω‐80W_N 41.66 [7.36] 39.00 [6.00] 14,887.00 [25,725.24] 3475.00 [19,658.00] <0.001

4e‐cig_0.15Ω‐50W_noN 41.27 [19.09] 38.00 [9.00] 177.69 [80.61] 144.00 [109.00] <0.001

4e‐cig_0.15Ω‐50W_N 43.55 [7.725] 41.00 [7.00] 5949.16 [15,452.17] 766.00 [2483.00] <0.001

4e‐cig_0.15Ω‐100W_noN 39.28 [17.21] 34.00 [7.00] 5637.34 [19,136.38] 732.00 [1769.00] <0.001

4e‐cig_0.15Ω‐100W_N 43.55 [7.73] 41.00 [7.00] 2572.72 [4301.85] 1610.00 [1292.00] <0.001

4e‐cig_0.15Ω‐150W_noN 41.27 [19.09] 38.00 [9.00] 12,925.34 [31,590.92] 136.00 [4619.00] <0.001

4e‐cig_0.15Ω‐150W_N 44.67 [8.59] 40.00 [5.00] 14,640.47 [32,776.91] 2895.00 [4373.00] <0.001

Secondhand Smoke8,9

• 2013 study found serum cotinine levels to be similar from secondhand e‐cigarette aerosol and combustible cigarette smoke

• 2015 study found levels of other compounds to be lower with e‐cigarettes than with combustible cigarettes

What are teens

smoking?10

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Vaping in Michigan11

• September 2019: Governor signed law to ban flavored e‐cigs• October 2019: Judge blocked ban• Governor plans to appeal to Supreme Court

Vaping in the U.S.

https://time.com/5758004/flavored‐vape‐ban/

Dec. 2019

Gov’t raised legal age to purchase tobacco or vape products from 18 to 21 years

Jan. 2020

President temporarily banned some cartridge‐based flavored e‐cigarettes that are

particularly popular amongst teenagers

Vaping and DrivingNo law specifically addresses vaping while driving, but…

• E‐cigarette treated same as other electronic handheld device• If driver is distracted by it, could face prosecution

• Must obey laws on visibility through windshields• The smoke could obstruct visibility

• If caught trying to fill a device while driving, a careless driving charge could result

https://vapingdaily.com/blog/vaping‐and‐driving/

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Lithium Battery

• 2015‐17: >2000 cases of e‐cig burns/explosion‐related injuries; 2 deaths

• Lithium ion battery 18650

• Mostly used in modifiable e‐cigs

• Explosion while being used or incorrectly stored

• Due to overcharged or damaged battery

• Don’t use damaged, exposed to extreme temps, or wet battery

• Avoid putting device near metal, like keys, cell phones, or in cluttered area

• Don’t store battery in pocket or bag; use protective case for storage

• Do not leave batteries on charger longer than necessary

f h d kl f

nbcnews.com

CDC Recommendations1

Avoid using e‐cigarette or vape products with THC, especially from informal sources

Avoid using all e‐cigarette or vape

products

Don’t add vitamin E or other substances to e‐cigarettes not intended

by manufacturer

Adults using e‐cigarettes to quit smoking should not go back to smoking; they should weigh

risks and benefits and consider utilizing FDA‐approved smoking

cessation products

Adults who continue to use an e‐cigarette or vaping product should carefully monitor themselves for symptoms and see a

healthcare provider immediately if they develop symptoms like those reported in the

outbreak

More CDC Recommendations1

E‐cigarette or vape products should never be used by youths, young adults, or pregnant women

Adults who don’t currently use tobacco products should not start using e‐cigarette or vape products; There’s no safe tobacco product. All tobacco products, including e‐cigarettes, carry a risk.

THC has been associated with a wide range of health effects, particularly with prolonged frequent use; The best way to avoid potentially harmful effects is to not use THC‐containing e‐cigarette or vape products; Persons with marijuana use disorder should seek evidence‐based treatment by a health care provider

People who have significant impairment or distress from ongoing problematic use of THC‐containing e‐cigarette or vape products should seek evidence‐based behavioral treatment and recovery services for cannabis use disorder

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www.cdc.gov• About e‐cigarettes

• Quick facts about e‐cigarettes

• Outbreak of lung injury associated with the use of e‐cigarette, or vaping, products

Any Questions?

References1. Smoking and vaping facts. Found at https://www.cdc.gov/tobacco/basic_information/e‐cigarettes/severe‐lung‐disease.html, accessed

11/20/19

2. Drugs for smoking cessation. The Medical Letter. July 15, 2019;61(1576):105‐10.

3. Walley SC, Wilson KM, Winnickoff JP, et al. A public health crisis: electronic cigarettes, vape, and JUUL. Pediatrics. 2019 Jun;143(6). pii: e20182741. doi: 10.1542/peds.2018‐2741.

4. THC and vaping. Found at: https://weedmaps.com/learn/products‐and‐how‐to‐consume/vape/, accessed 11/20/19.

5. Is it safe to smoke alcohol? Found at: https://www.healthline.com/health/vaping‐alcohol#impact‐on‐body, accessed 11/20/19.

6. Lukasz GM, Jakub K, Michal G, et al. Levels of selected carcinogens and toxicants in vapor from electronic cigarettes. Tob Control. 2014 March;23(2):133‐9.

7. Protano C, Avino P, Vivaldi V, et al. Environmental electronic vape exposure from four different generations of electronic cigarettes: airborne particulate matter levels. Int J Environ Res Public Health. 2018 Oct; 15(10): 2172.

8. Flouris AD, Chorti MS, Poulianiti KP, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol, 2013 Feb;25(2):91‐101.

9. Glasser AM, Collins L, Pearson JL, et al. Overview of electronic nicotine delivery systems: a systematic review. Am J Prev Med. 2017;52(2):e33‐e66.

10. Youth Tobacco use: results from the national youth tobacco survey. Found at: https://www.fda.gov/tobacco‐products/youth‐and‐tobacco/youth‐tobacco‐use‐results‐national‐youth‐tobacco‐survey, accessed 11/20/19.

11. Vaping in Michigan. Found at: https://www.michigan.gov/mdhhs/0,5885,7‐339‐71550_2955_2973_94238‐‐‐,00.html, accessed 11/20/19.

12. Blount BC, Karwow MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar lavage in EVALI patients. N Engl J Med December 2019;

More information can also be found at: https://e‐cigarettes.surgeongeneral.gov/

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