Today we’re going to talk about e-cigarettes and I’ve titled this talk what’s the deal with these electronic cigarettes I’ve met a lot of people that are concerned worried or confused or just have some questions about vaping so today my intention is to give you some of the basics about about e-cigarettes. This is something I cut out of a somewhere I don’t remember about e-cigarettes and and you know we we are learning more and more about the harmful constituents potentially harmful constituents of e-cigarettes so this slide says there’s no way 
they’re dangerous and unless unless I hope and because e cigarettes are a new product and because we we don’t have ingredient list and every single one of them it’s kind of hard to tell are they good are they bad what’s in them and one could get paranoid pretty quick when you don’t know what you’re doing so so anyway that’s what this talk is about to answer that question so we are still in the middle of a public health debate about e-cigarettes and it’s been a very interesting contrast between those are for and against it sort of divided many in the public health and tobacco control community so just a brief overview that you know the debate has to do with the fact that cigarettes and I’ll come right out and say it east cigarettes are less harmful than combustible cigarettes you know I’m an epidemiologist and I’ve been studying public health for thirty years and can safely say that there’s very few things you can do to yourself that’s more harmful than smoking a combustible cigarette with the tar the nicotine the car decisions as well as a long long list of constituents which are found in the cigarette itself and then are also created when when the tobacco is combusted so there there’s a very definite harm reduction strategy and appeal to e-cigarettes in the sense that if we can get people to stop smoking this potently harmful dangerous carcinogenic cigarette and move them to something safer then we can save literally millions of lives and I do think that’s true that is true however however there are still some potential harms related to to e-cigarettes and in in the thing that that I study is a children adolescent and family health so there are some potential harms related to them their harm there they’re less harmful but they’re not harm less and in particular there’s a nicotine in e-cigarettes and nicotine is an addictive substance and my worry is that children will be attractive to the colorful packaging the really interesting advertising and the multitude of flavors there’s there’s thousands of different flavors and kids like to experiment with things so if they try these products they will be exposed to nicotine they might get addicted so there’s a downside to just being addicted to nicotine itself and it differs based on how old you are so when we’re growing up our brains are developing and nicotine has and I’ll talk more about this later nicotine has certain properties that fit well with our brain that can cause problems so lastly the long-term consequences of e-cigarettes are not well known we haven’t been using him long enough so I just give me to talk somewhere and someone came up to the audience afterward and said well when will we know for sure I said well probably in 30 40 50 years he’s like you got to be kidding we can’t wait that long well we’re gonna have to wait that long to have conclusive evidence about the harmful consequences but you know there’s a whole bunch of research studies which are going on that are trying to more more carefully identify the harmful consequences I’m gonna give you the update of what we know as of about January of this year so this animation is not working right I should say there there’s a report in 2018 which came out and they’re their overall message was East cigarettes can’t simply be categorized as either beneficial or harmful you can’t categorize them as beneficial or harmful at this date of time even though I can fairly safely and confidently say they’re less harmful than cigarettes but they’re not completely safe and how can I say that this is the report from the National Academies of Sciences came out in 2018 it’s called the public health consequences of e-cigarettes public health consequences of e-cigarettes if you if you google that they’ll take it to the National Academy of Sciences website and you can download this report right into your computer and you could spend maybe a week because it’s pretty thick report reading it and understanding all this which which I actually did there’s another report that came out in 2016 called East cigarette use among youth and young adults a report from the Surgeon General if you CDC I’m sorry if you if you google CDC East cigarette report it’ll take you to this website and there’ll be a whole bunch of information you could download the report and spend another week reading it there’s a lot of pamphlets and easier to understand summaries of these reports if you go these websites and and most of what I’m going to talk about comes from these two reports when I say that this is a summary of evidence but this talk is divided into four main parts we’re going to go through East cigarette basics what are what do they do we’re gonna talk about what’s in you cigarettes we call it it’s not just vapor we technically need to call it aerosol so when you puff on a cigarette your aerosolizing the liquid contents that you’re inside and it turns into an aerosol that you breathe in we’re going to talk about the health risks at least the ones that we know about today and possible future ones so then we’re going to talk a bit about marketing tactics because again remember this talk is about kids children and adolescents and I will say that most of the research that I do is in takes place in schools and why because most kids are in school particularly elementary school like all kids are in elementary school and almost all of them in middle school and kids don’t start dropping out until high school age so you can learn a lot about kids just by finding them and talking to them they’re talking to teachers and principals and parents of elementary and middle school kids so I know plenty of principles that have a big box full of e-cigarettes that they’ve taken away from their kids in 4th and 5th grade and even more in middle school and a lot more in high school so these kids are using these devices so we’ll talk about how many kids and what the trends are a little bit later on so first let’s talk about the components of an e-cigarette so if you’ve never seen one if you only heard about them this one’s for you it’s composed of three different main parts there’s a battery there’s an atomizer and there’s a cartridge and as this illustration says it looks just like a cigarette so there’s a lithium-ion battery in the lower portion of it where one would guess this the tobacco isn’t a regular cigarette oftentimes there’s a little LED light at the end that brightens up when you breathe in or take a puff on it there’s an atomization chamber and that’s where the what some people call a juice or a liquid is stored and and then when you when you take a puff it takes the the e-liquid passes it by a coil which is heated up by the battery and then it atomizes the the liquid and into a smoke like form and you breathe it in so that’s what it does and we’re going to talk about each piece in just a little bit so there’s there’s three main types there’s the cig alike and those these are still sold if you go to a gas station today you can probably buy you know one of many different types of ease of siga lights they look just like a cigarette you buy one of them they’re reasonably inexpensive and they’re disposable and can’t be used again so you just puff on it and when you’re done you throw it away most advertising and people that I’ve talked to say that each each cig alight will deliver about a packs worth roughly speaking of cigarettes so it’s like having a whole pack of cigarettes in one you cigarette device and people like them because I mean you don’t have to light it you don’t have to put it out it’s not messy and it doesn’t smell like a cigarette so if you’re a kid it’s perfect because you can sneak away take a puff put it back in your pocket you might smell like a mango but you’re not gonna smell like nasty tobacco smoke and so mom and dad or friends aren’t gonna smell you same thing with your car – it might smell a little bit fruity but you won’t smell the nasty smell like you usually do that we many of us grew up with that are older than 25 so that’s a sigle like and that was the early version and you know people that use those they didn’t in in many of your most cases they didn’t deliver the nicotine levels in the same way as a cigarette so many cigarette users would try them and they just didn’t like them because they didn’t get the same buzz they didn’t get the same throat hit they didn’t get the same feeling from a regular cigarette later as the industry advanced there became the reusable ones with disposable parts I should say the cig likes are still here and they are the the main choice for for many kids or were up until recently to get because they are easy to hide they’re disposable and they’re inexpensive next are reusable system so they’re they’re more advanced they’re a little bit bigger there’s a broader variety of types of devices with it and it might come with a cartridge that you can re or a cartridge that you can just plug into it so you’ll buy the device and then you’ll buy a package of cartridges and you’ll just reuse the cartridges or sorry Bri buy the cartridges so these are called an open system they’re reusable they have a battery that’s rechargeable you charge it just like anything else just plug it in or put it in a laptop or something with a battery in it to do it and then there’s a bit more advanced of this of this type and those are the kinds called advanced personal vaporizer or a mod and it comes with a chamber that you can refill with liquid so instead of buying a cartridge you buy a little bottle filled with the liquids liquids and you put it in the chamber and then it works just like the one I just described these are a bit more expensive and there’s just an incredible variety of them some are big some are small but the main feature is that they have a chamber that you can refill and you go often times you go to the vape shops which I’m sure your sinks are popping up all over the place and you talk to someone about you know the different levels of stuff that you want in your ejuice it could you can alter the type of flavoring you can mix flavorings you can have a little bit of nicotine a medium amount or a lot so you have a lot more control with the apv versus the cig alike and the reusable with disposable cartridges which is more off-the-shelf a PV is usually for an hour experience and surveying kids are not that many kids are using those per se particularly because they’re expensive and you get them from those vape shops instead of convenient stores so anyway first generation I just talked about here’s just a few pictures of them different brands and such blue as a big brand there’s different variations of them some are called an e hookah they’re a little bit larger but the key is that they’re they’re disposable here’s just a few more moving into the next level those with the cartridge I want to make a point here about one that’s just come out in the last couple years is called the jewel and it’s it looks just like a memory stick and you can indeed charge it with your laptop which is the picture that I just showed and they come in different flavors you can buy a package of them for $49 and some school districts 49 bucks is pocket change for some of these kids in other school districts it’s a lot more expensive so the use of joules is going to vary a bit by the the school in the neighborhood and the community in their level of affluence to a certain degree but for 49 bucks you can get your introductory package and so here’s some of the flavors you can get I cut this right off of their website there’s creme brulee there’s fruit medley Virginia tobacco cool mint and mango and one of the first things I want to point out to you is that if you look at the cartridges and I had one right on my desk there’s very little or any product information on the cartridge itself and this is what you see in these different flavors versus the the device in addition if you look up here and I know this a little hard to read so I’ll read it for you each jewel contains ml and 5% nicotine by weight approximately equivalent to one pack of cigarettes or two hundred puffs so in the advertising and I see the similar form of product information and other cigarettes too but think about it for a sec what’s wrong with this picture what’s wrong with this what exactly does ml with 5% nicotine mean in the research world we generally talk about the nicotine content in terms of milligrams per milliliter so Lesley stirs a standard metric to understand it and and I believe this is a calling at seven point seven ml with five percent weight is maybe a little bit confusing possibly misleading anyway so what what does that mean it’s it’s hard to say is this a lot of nicotine errs a little bit so I’m gonna I want to tell you guys a few things about what what it does mean so I found this on a website where they characterize you know zero to three milligrams 6 to 12 12 to 18 so in the packaged where the the disposables and the package types of e-cigarettes it can vary from you know from very little to 12 to 18 those are in metric some of them will poke over into 24 milligrams per milliliter so its measured by by this expression mg 4 ml some of the liquid will come as high as 42 or 56 milliliter per ml and if you didn’t know anything about you cigarettes you could say well 0 2 3 doesn’t sound like a whole lot of nicotine in 56 sounds like a lot but that’s not exactly descriptive in a way that I find useful so I started poking around and while I was poking around I found that last year the European Union limited the amount of nicotine to 20 milligrams per milliliter so remember I just showed you that we’ve got zero to three 6 to 12 12 to 18 commonly advertised and now the maximum in the EU is 20 milligrams and then I found and took from a vaping website which is talking about the finding the right strength of nicotine and this is what they said that is a very low point 6 lobe medium is high and 2 is very high so 20 milligrams and that’s the that’s the test for whether or not you can you can sell them in the disposable e-cigarette packages in the European Union so that that’s what’s considered the high end so that gave me a little bit type of information to help make an assessment as to how much is enough so I went and I found different types of devices and a juices that were very low and low and medium and high and very high and here’s the EU and here’s the thing the Joule comes in at 59 milligrams for milliliter that’s really high in fact that’s the the highest one I was able to find just by looking around the internet there there might be higher ones because I can’t say I looked at every single one of them but it’s very high and it’s the most popular device used by teenagers so we have little problem here even though I said early in the presentation that e-cigarettes are less harmful for the regular cigarettes the Joule device is delivering quite possibly and probably more nicotine than a regular cigarette so when the kids are taking a puff off of that they’re getting a significant bolus of nicotine and they’re reporting that you know you can catch a pretty big buzz from from smoking and jool you cigarette so I would say and here’s a conundrum if you’re a heavy smoker the Joule might be the right thing for you if you’re smoking one to three packs a day you might need the Joule to be satisfied but if your teenager you probably shouldn’t start out at three packs a day right so we have a little problem Houston with the Joule device so I started doing more poking around and I found these are just Google searches when I searched Joule and nicotine teenagers say Joule is a discrete way to vaping class talked a lot of teachers and a lot of kids they put them on a chain put it underneath your shirt you can just vape in the middle of class no problem doesn’t smell bad I’ve heard complaints from from parents to say their kids don’t want to go the bathroom anymore because the kids are are smoking in the bathroom on blowing big clouds of smoke they don’t smell like cigarettes but their people are nervous because I don’t know what’s in them you can buy it through PayPal a lot of people that purchase things will have a PayPal account for eBay and for other places so you just buy them on a PayPal account and have them delivered on whatever interval that you want here’s a website the H the best eight best THC cartridges on the market and I found one for the jewel and and called a friend of mine in California who happens to know this stuff a little bit and said yes he did find and know about jewel cartridges which have THC and instead of marijuana I was not able to confirm that I wish I could have but other than a friend of mine I guess who was a stoner in California but but anyway and then hash oil and jewel – so here’s a package picture that I did find using Google Images called a hood rat at 5% strength in marijuana at 5% strength you know in Texas we do not sell marijuana either medicinally or recreationally so I couldn’t find anyone who had Joule marijuana cartridges where I live I just heard about in California so so anyway here’s with a warning they say with the Joule this product contains nicotine nicotine is an addictive chemical well let’s talk a little bit more about that and then here’s just some guy I found that I thought I would share this picture with you another form of advertising for the Joule before I get into addiction there’s a whole bunch of different kind devices and you can see that the variety of them there there’s many different varieties you can imagine and then there’s a whole bunch of different types of ejuice as I said I think there’s up to 8,000 different combination flavors this one is called unicorn milk this one is called schism ninja God’s milk coming at 4% now we know what 4% means that means a lot of nicotine 1% means not that much serial killer is another one and I just saw it and then the French dude vape French Roast just lots of different kinds there’s another one to the right of the little french toast guy with different apples on it and and I heard reports from younger kids and elementary in early Middle School that say well it can’t be bad for you look it’s just an apple fruit flavor so kids are a little bit confused try to remember when you were kid or if you have kids you know that some things think and some things don’t here’s another one blueberry ejuice at 3 6 12 and 18 and 24 milligrams or here they are showing it at 30 60 and 240 milliliters not nicotine but just the size of the bottle so that they come in but the the nicotine the mg per ml milligram per milliliters is is labeled and that 24 is beyond the European standard but you can get it at 3 if you want to do it and I’ve met and talked to a whole bunch of people that start off at the higher level and then they sort of titrate down just like trying to cut the number of cigarettes you smoke until we get to an easier place with your level of addiction so that you can quit and so I a lot of people say that’s worked for them just want to make sure the you know you hear I’ve heard at least that nicotine is just as bad as caffeine well no it’s not there’s there’s a lot of reasons why read those reports that I mentioned the beginning of the talk if you want to get the full answer on it I also hear that it’s just water vapor right it’s vapor vapor comes from water boiling its water vapor well no no it’s not it’s contained for a variety of different things that’s propylene glycol its nicotine it’s a flavoring and vegetable oil those are the four main ingredients in the ejuice and and the one to two of them to pay attention to is the nicotine level as well as the flavoring because that different flavoring compounds are shown to have different harmful exposures to a person’s lungs so if you look at that 2018 report it’s only six weeks old just a few of the conclusions there’s there’s about 40 or 50 different conclusions from this report but just a couple of them pertain to kids there is substantial evidence that e-cigarette use increases the risk of ever using combustible tobacco cigarettes among youth and young adults so it appears as if that kids who do not use tobacco combustible tobacco once they start east cigarettes that eventually they graduate to at least trying to use a regular cigarette now these studies are still fairly new and young young in terms of how long they’ve been operating you know three years maybe possibly four years and measurement of e-cigarette use amongst kids is a little bit tricky too so I’m talking about having ever tried a cigarette you’re much more likely to try a cigarette if you had previously tried an e-cigarette so that means you might take you down the path of becoming a combustible user the evidence is still not quite there yet so this is a speculative in the sense of like the whole population yes you would expect it as the e-cigarette rate goes up that the tobacco use rate would go up to however I would guess that that’s going to be lagged by three or four years I mean we haven’t had three or four years that with big numbers being measured just yet so we’re gonna have to wait on the answer for this a little bit further if we see a spike in combustible tobacco use amongst kids then my hypothesis might be true here’s a node one among youth and young adult users who use combustible who use her ever used combustible tobacco use if they add in cigarettes there is moderate evidence that means there’s some is it’s going in this direction it’s not conclusive yet that e-cigarette use increases the frequency intensity into duration of subsequent tobacco use that just means if your current cigarette smoker you add in east cigarettes these are for kids mind you you tend to smoke more regular cigarettes so that that’s a bit worrying too and then there’s insufficient evidence from randomized control trials that e-cigarettes are effective as a smoking cessation tool now a lot of people who could talk and will argue with me on this and I will say that there is evidence from non randomized trial that these cigarettes might be effective so the best we have is maybe they’re effective to the highest quality evidence in RCTs randomized trials shows that they’re not effective there are plenty of anecdotes out there that say and this is with adults here now now I’m talking about adults plenty of evidence that says that I’m sorry anecdotes to say that that will work but the jury is still out on this so I wish it was a more robust finding and we’d feel more confident about talking about e-cigarettes but today it’s just not from the CDC report a couple years ago nicotine exposure during adolescence can cause addiction and harm the developing brain the hazardous compounds that have been found in ecig arete s– could and include formaldehyde acetyl hide-and acrolein which are known cancer producing toxicants nicotine can cross the placenta and is known which is known to have serious consequences fetal and postnatal development and then during pregnancy there is a direct relationship between nicotine use or sorry combustible tobacco use in the nicotine is the suspected agent in combustible tobacco that leads to sudden infant death syndrome altered corpus callosum which is that thick nerve that connects the two left and right hemispheres of the brain direct link with auditory processing which means that children have a slower onset of speech and have some difficulties early on in school and even obesity – so let me just say if you’re a pregnant woman it’s not a good idea to smoke e-cigarettes are they safer than regular cigarettes that’s not easy to say it’s really just not easy to say you know I studied very hard the literature on this and it appears is that if it’s the nicotine that’s causing most of the birth defects and birth related problems but we haven’t done the studies yet it’s it’s I mean how are we going to do these studies and when it’s brand-new we can’t randomize women to smoking and non-smoking or smoking in East cigarette conditions however what I will say is you can do this with mice so you can’t do with humans but you can do it with mice or other mammals that would simulate our own human response and the evidence is pretty clear that it’s nicotine that are causing these things so it’s not a far-fetched idea to say that nicotine will cause it in humans – so if you’re a pregnant woman I I don’t think you should smoke anything really cigarettes or e-cigarettes but but I in terms of the harm reduction I’m not certain you get as big a bang for the buck switching to e-cigarettes from combustibles as you do if you’re just switching in general for other health issues like lung cancer your baby’s going to suffer either way I think with combustible and non combustible tobacco other things from the report is that youth and young adults are uniquely vulnerable to the detrimental consequences from nicotine exposure including reduce impulse control mood dysfunction and deficits inattention in cognition so now we’re leaving pregnant women and going into you know kids who start to smoke and remember our brains don’t fully form and connect let’s say you know from almost from a wiring perspective the different parts of the brain do not complete themselves until until about age 25 or so so the younger you start becoming exposed to nicotine the the greater the chance that you’re going to have problems with it so so that this is an issue for young people like in sixth grade they’re 11 years old and sixth grade approximately even younger than that so you’re you’re well into the way of your brain formation and anyone who’s hung out with kids or remember where you were when you were little you have some issues with impulse control and that’s in part because our prefrontal cortex is the last part of our brain which which controls our our reasoning and our ability to self-regulate ourselves and that doesn’t that doesn’t come online until a little bit later in our early 20s so interfering or messing with that is what nicotine does and I wish I could say more specifically what Messing means but it is a pretty complicated process here again our rat models our mice models help us understand this and it does appear that nicotine is the culprit with exposing rats to this so clearly everyone knows that nicotine is addictive everyone knows that tobacco is addictive that’s why it’s hard to quit that’s why once you do become addicted you tend to want to continue to use it and you know everybody knows that there’s not much debate but I had to I had to look a little closer at this and try and figure out why so if you look there’s there’s the cocido culling receptors in our brain there’s nicotinic receptors to see the Coulomb receptors all over our brain which have an action on : journey areas of the brain in these areas control muscle movement breathing heart rate memory and motivation so that’s a long list of things that it that is related to and has some control over so that’s why when we take a you know I was a former smoker I’ll admit that I did that for 10 years both my parents died from smoking young because I was born in 1958 before the first Surgeon General came out and prior to that doctors would advertise tobacco and medical journals as being a health promoting thing to reduce anxiety and stress so if nicotine has this interesting property that will relax you when you’re agitated but when you’re feeling a little bit either tired or depressed you can smoke it and it’ll it’ll bring you up so bring you up and take you down depending on where you are it’ll increase your heart rate will increase your breathing so anyway there’s a number of actions to take place but the biggest one is the neurotransmitters and hormones that have an impact on all of these different brain neuro chemicals acetylcholine norepinephrine but bingo its dopamine dopamine serotonin and these other factors that that mean that in particular dopamine is is you know the main pathway for pleasure and reward so nicotine causes a pleasurable response you start smoking it and you feel good you feel pleasurable when you get addicted you smoke to stave off the withdrawal symptoms in that sense it’s just like heroin people love heroin at the beginning of their addiction and then they start getting sick when they don’t have it so they’re in a perpetual state of feeling sick until they get more heroin so it’s not too far away with with nicotine two of those not not quite as impactful but in a health perspective it’s it’s really really damaging to smoke cigarettes for cancer and other cardiovascular disease reasons so there’s very strong biologic plausibility these are words that we use in epidemiology that nicotine is related to impulse control deficits and attention and cognition and mood disorders now I’m not gonna sit here and lie to you guys and say that it’s a whopping big effect these are modest effects somewhere if you’re if you’re you’re like statistics in the range of you know to times the risk so not quite double the risk but you know the evidence is there and we can’t ignore it that nicotine has some impact and if you smoke you’re probably a regular person you’re just fine in so many different ways you might have a nagging feeling that gee I wish I hadn’t a smoke but I wonder if I would be less impulsive alright wonder if I had different levels of mood swings or I’m under you know there’s a lot of things that a modest effect will still keep you very nicely functioning in society but still cause you not to reach your full brain capacity and potential that my friends is what I’m worried about so what’s propylene glycol colorless liquid at room temperature is what’s used as the base to put the nicotine in to heat up and then become analyzed and it’s generally recognized as safe now this is a technical term that they use in the food industry or in other type of toxicant industries however it’s generally recognized as safe in cosmetics because the base of some cosmetics is a propylene glycol and so you can smear it on your face and it doesn’t do much this sounds bad doesn’t it smear in your face so if you put makeup on some of it a lot of it lipstick included will have propylene glycol but we don’t know about breathing it in it’s in a lot of food too so people eat it all the time and it passes through the digestive system without any particular problems and is generally recognized as safe but we’re still churning through the literature I’m sorry churning through experiments to figure out whether it’s bad for you to put into your lungs their lungs are a whole other organ set with a different set of properties and and there needs to be careful attention paid and there is so let me just say there’s a long list of things which are in that have been found coming out the other end of a vape pen so that’s in the cloud let’s say that you’re breathing in these are all the different things they’ve been found in e-cigarettes aerosol or clouds then those in yellow have been known to be carcinogenic the issue is is how much so it’s it’s tricky to say how much there is because it depends on you know the liquid you use the vaporizer that you use and how deeply you inhale and how frequently you inhale so there’s there’s safe limits for these things many of which I will say that these cigarettes fall into the the safe use category they’re not in that strongly related carcinogenic so however it does depend on the type of things that you use so it gets a little bit tricky to understand what I will say is that that the the higher the temperature the higher the voltage of the device which means we’re in those sort of aficionado devices that are more expensive the the greater the likelihood that you’ll get an increased level of toxic exposure to these things that I just showed you yes and by the way so there’s some engineers that were using the wrong cord trying to get ECX to explode and they reliably got them to explode if you put different current levels into the into the batteries and do what your not supposed to do so follow the instructions there has been a number of cases of e-cigarettes exploding however I would probably say there’s a net gain in switching to e-cigarettes when compared to falling asleep with a cigarette in your mouth and burning your house down so so anyway just beware there’s a number of photos if he does Google East cigarettes exploding you’ll see little videos of this case is blowing up in someone’s purse in this case it blew up in a kid’s face but you know he survived and he’s still talking about it also there’s poison control issues you can see over time there’s an increase in our decreasing level of poison control ish and these are with little kits like infants and toddlers and things just somehow fine a juice bottle laying around and they drink it so moms and dads get concerned the kids not happy might have some symptoms of nicotine poisoning you know tachycardia nausea throwing up and other things headaches and this typically was counted to not having childproof safety devices on there and I will say the industry has done a reasonably good job at it making the the ejuice cartridges tamper proof as well as the bottles that you get so we’re seeing a reduction in the calls to poison control centers but you know back in 2014 it was a little bit off the chain people saying look at this kids are getting them I’m one of my staff members found them empty cartridges which still had liquid in it in a daycare playground so some dumb-dumb I guess just threw it in there anyway so this paper just came out in 2018 they’re trying to express how the the relative safety of cigarettes and e-cigarettes based on a bunch of different types of things so the green is ambient air the light pinkish is a nicotine inhaler here we’ve got East cigarettes variable power organic only here’s one subset that was used in a particular set of studies by an investigator Ghana wheats here’s the heat not burn devices here which are brand new in the marketplace or reasonably new not quite yet in America but in other countries tobacco smoke over here so if we index at 10 to the zero power the relative cancer potential of tobacco then you look at as you go down to the negative exponent of it this illustrates you know it’s a little hard to understand but it does illustrate the the relative safety some of these devices those mods which have variable power and if you get the wrong one and you heat it to high you’re exposing yourself to those carcinogenic chemicals that relatively high level such almost comparable to tobacco use that just means if you’re smoking these things know how to use your device and don’t don’t drip on the coil and make sure it’s working properly and make sure you charge it with the proper equipment so here we’re saying on the right tobacco smoking is not good for you standing next to someone smoking is not good for you they do have an assessment of the heat not burn so in terms of harm reduction heat not burn is is less harmful than tobacco but still in the ballpark of being harmful if we go all the way down here we can see that there’s a variety of e-cigarettes and in most of them in terms of cancer potential are much safer than the regular cigarettes from a cancer perspective but remember cigarette smoking doesn’t just cause cancer is the number one cause of heart disease to stroke etc so we still have to learn a lot more I can’t say they’re safe this clearly illustrates that they’re that they’re safer but not completely safe as regular ambient air okay this is a bit more precise with regard to a few more different types and so here we’ve got formaldehyde acetyl I’d acrolein and Tolu and night tobacco-specific nitrosamines carcinogen during the curing process so so just to make a long story short not to get too deep into this we look at the comparison toxic ins emitted by tobacco versus east cigarettes we see that tobacco emits nine times more formaldehyde i’m make sure I’m reading this right in terms of a ratio there there’s less there’s 450 times less a caseta lied in an e-cigarette compared to a regular cigarette nine times for formaldehyde so some are large differences where you can reasonably clearly say that e-cigarettes are safe in comparison to regular cigarettes based on these numbers 381 29 and 15 is getting a little bit closer and that that explains some of this variation here down on the bottom I’m not going to go into this too much just to give you a peek at the types of studies which are coming out this one compares cellular toxicity and levels of released inflammatory mediators inflammatory mediators is it now talking about not just a cancer but cardiovascular disease so if you put if you put some lung cells in a petri dish and you blow if you blow a cigarette smoke on it and you look at it by the different flavors this is tobacco this is pina colada is menthol coffee strawberry and and a reference you can see that in terms of cell metabolic activity that there’s a difference the whole point is that there’s a difference based on the flavor so here’s cell viability the cells die faster with strawberry than they do with the tobacco flavor interesting enough so again if you want to look us up give the slides and can find that yourself from tobacco control a couple years ago but just illustrates that different flavors have different potential harmful effects and we’re still trying to figure it out in fact a lot of manufacturers have voluntarily taken off cinnamon off of their flavor list because turns out that’s that’s pretty bad to put in your lungs it’s cinnamon so we’re moving near the end here let’s talk about marketing tactics we’re seeing similar marketing tactics to regular cigarettes so you can just see that there’s an appeal for adventurousness freedom there’s a sex appeal sort of thing blue in particular here we’re going with menthol and sort of an African American hip-hop theme so anyway kids are attracted to images like this there are thousands of flavors there they’re highly attracted to the flavors we’ve been studies that say that they wouldn’t even try cigarettes that they weren’t flavored so there there are some discussions of limiting the number of flavors that are available through e-cigarettes to keep kids to not want them and you can debate that – but the fact remains that the kids are using e-cigarettes because they they want to experiment with the flavours as much as the feeling the buzz you get from them from the nicotine anyway I just want to put you cigarettes in context a little bit this is the 2000 data from the monitoring the future study it’s done every year from the University of Michigan and estimates the national rates of tobacco use so here it is eighth grade 10th grade 12th grade about 10% of kids are users of cigarettes that is they answer the question yes when they were asked have you used a cigarette or smoked a cigarette in the last 30 days you can see that East cigarettes commented about 17% so more kids use these cigarettes today than regular tobacco combustible cigarettes you can see that you know a sizable proportion or vaping marijuana 8th grade 10th grade 12th grade so 5% are vaping some form of marijuana in their vaporizing devices now you put it right next to being drunk so you know kids like to drink – who knew it huh so even as young as in eighth grade so we’ve got almost 20% of kids 20% of American 12th graders report having been drunk in the last 30 days and if you look at marijuana use it’s even higher and this is just ever you so they puffed on marijuana in the last 30 days so if you’re trying think about the relative problems of things I would have to go with being drunk is a problem if you’re a teenager because you really do stupid things when you’re drunk invites sort of the opportunity for unwanted sexual advances there’s drunk driving there’s a fighting there’s you know all sorts of problems with being drunk is such a younger young age a marijuana use well it’s illegal for one there there’s a whole host of studies which I can’t get into but you cite about why it’s not a good idea to be getting high all the time when your teenager particularly for in a training mode like high school and college so I thought you might be interested in this I’m just going to finish up by saying that you know there’s there’s a – back family tobacco and smoking Control Act in 2000 we’re still waiting on rules for how to interpret these things so the regulation is in the pipeline let’s say with regard to e-cigarettes and there’s opinions on all different sites in Texas in 2015 we said that the age of sail and and the use on schools is is not allowed with a cigarette so here’s a bit more things tobacco has some sorry the FDA is some authority over the constituents so they could if they want to regulate the number of flavors in the amount of nicotine I mean they could say just like the European Union no more than 20 milligrams per per milliliter if they wanted to and actually I think that’s probably a good idea why I have such an addictive device out there but the laws in Texas and in many other states are similar is prohibits the sale purchase or use retailers must post a sign that containers must be child resistant retailer must supervise and train people to make sure they don’t sell it school districts you can’t do it anywhere in school this is Texas law so then here’s some sample from from a school district for actually the school district my son goes to West Lake they put this in their their handbook if you want that as an example you can you can look at this afterwards and then finally I mean there is a penalty if you’re caught selling to a minor in this state it’s a thousand dollars per violation I want to mention one last thing if you’re if you work at a school or at a school district or for your parent my group has my group meaning here at the University of Texas School of Public Health has created a program an awareness program called catch my breath that if you google catch my breath you well you’re gonna end up finding a song I forget by who the woman’s name is but if you type catch my breath east cigarettes you’ll find us at the catch global foundation and CVS Pharmacy has graciously racially agreed to support implementation of this program in any school that wants so call us we’ll give you this program it’s for sessions long it’s designed to tell kids about what’s what we know and don’t know about e-cigarettes and have them have a conversation hopefully get them to think twice before they use them it’s called catch my breath you can get it free of charge as long as CBS helps us out she’ll thank you CBS so I just want to talk for a minute about what these cigarettes look like you might not you might not know much about it so do you believe that your kids I call them knuckleheads would would want to do this does this look attractive and it’s a whole group of people this is a smoke blowing contest these are happening all over the United States so here’s the one I mean very big thick smoke clouds that these kind of clouds are kind of hard to do with the siga likes and the cartridge thing so that you you need a higher voltage to be able to do this so here’s another one there’s contests for the type of smoke rings I talked to a dad who said that yeah what’s wrong with that I’m buying zero nicotine for my kids so dad told me he’s going to a vape shop buy and his son these things and his son is just sort of walking around and blowing smoke rings you know without the nicotine there there is less of a concern however we still have the concern with the cell viability and other things of that nature which so we just don’t know I still wouldn’t recommend it anyway so there’s some people dressing up and smoking there’s all sorts of different ways to sort of sexualize it you can see on the internet and in advertising this one too so yes that’s attractive you know to young men in this case and there’s one you know advertises for from women too but here’s the reality kids sitting in a car and just blow and smoke because they’re kids and they feel like blowing smoke so should we encourage that should we discourage that that’s the whole point of this talk I find this one a little bit amazing but but could you believe a group of kids would do that well probably with a case of beer they might do that I can imagine that too in different places that yeah I can imagine that as well so in this case yeah that’s a bit extreme so I’m gonna end here and I hope you’ve been typing some questions in the Q&A part of it and I’ll try to answer your questions but anyway thank you all for listening to me and hanging in here for the for this long there’s a lot to talk about these cigarettes so if you have questions just type them in the box and I’ll try to answer them oops I see there’s some let me get my glasses one are our hookahs and hookah bars delivering the same substances so I will say that you know there is a variety of different types of shisha or different types of tobacco and and flavors that go into hookahs so I’m not talking about those kind of hookahs so it’s sort of a misnomer when we call an e-cigarette device a hookah it’s just a name that they put on it so so it is different and when you’re in a hookah bar you’re usually smoking nicotine and tobacco and some other different flavorings that go into it I will say that it’s it’s really easy to get an overdose of nicotine in a hookah bar if you puff on it a lot it delivers a very high bolus of nicotine and the carcinogens that are typically found in combusted tobacco smoke so if you look it up it’s it’s it’s it’s not healthy that’s for sure smoking hookah in a hookah bar see will you be sending out a recording of this we’re not going to send it out but you can find it on our website at the Michael and Susan Dell Center you can see some of the places here MSD Center org at the very bottom of here we will put probably put it up either today or tomorrow so pretty soon ah yes it is by Kelly Clarkson oh you’re right about that thank you Omega re cigarettes tax the same as cigarettes not not yet that’s part of the regulatory process so at this stage to my knowledge they are not taxed based on your experience you recommend a cigarettes as a method of harm reduction strategy for tobacco prevention no I don’t well and I say that because prevention implies kids and I just don’t think we should recommend a cigarettes to kids because there’s there’s too much potential downside to get them addicted to the nicotine however in terms of tobacco prevention I would say that a cigarette prevention belongs right next to tobacco prevention programs so if I were going into school I would talk about the dangers of combustible tobacco I would be honest and say that these cigarettes are less harmful than combustible tobacco but they are not harmless and you shouldn’t do either one so and here’s the reason why that there’s nicotine in e-cigarettes so that’s that’s my opinion on that let’s see what about purchasing mail-order liquids are there restrictions or reasons young people purchase them from out of state well you know I’ve looked at a number of different websites and really all you have to do is click and say that you’re of a certain age and then you’ll be able to get them so that’s a little problem the industry I think needs to work out if they if they don’t want regulation and they need to work it out sooner or later it probably will become regulated so yeah that’s why I said you can buy these Joule cartridges you can get on the monthly plan just use your PayPal and get it delivered to your house so yeah kids are gonna lie about that we know that there needs to be better ways to tell the jewels credit I did see in a new updated version which came out last week on their website that they have some kind of method to figure out if you’re of age I do not know what that method is so if it works then hats off to you guys at Jewel I do jewel if you’re listening wish that you would do a better job of letting people know how much nicotine is in your devices and while clearly you say that there’s a strong throat hit and a buzz that goes along with it it’s it’s it I mean you guys are really high in nicotine and I think you’re great for the heavy smoker but you’re bad for the teenagers so to hear more from you about about what you’re doing and I notice you’re you’re toying around with the idea of providing schools with a cigarette prevention stuff so we probably shouldn’t talk if you want to send me an email anyway kids surveyed for e-cigarettes ecigs beer drinking are they nationwide or Texas so the numbers I showed you we’re from the monitoring the future and so they’re national you know in Texas it’s probably close to the the national average a little bit lower a little bit higher that’s going to vary by community in socioeconomic status and and other factors too but I would say Texas has as big a problem as the rest of the country with these cigarettes yeah what would require for the FDA to require twenty milligrams like the UK I can be really snarky about this question but I’m not gonna I mean it just means that we we need to have more politicians with the backbone that will agree that this is a problem and the it needs to go through the FDA regulatory control process that usually is a very slow process it’s an open process in the sense that there would likely be a comment period and individuals that think this is a bad idea would have a chance to have their say and people that think it’s a good idea would have a chance to say but it really the authority belongs to the authority belongs to the FDA to do that are there specific policy strategy you suggest in relation to e-cigarettes well there’s always lots of different policy actions that one can take so if you’re a local school I would say let everyone know post signs and let parents know that first of all it’s illegal to use in your state maybe you know take advantage of this catch my breath program it’s free we have a digital online platform you can just start using it if you want to spend a little bit more time and energy as a policy in in substance abuse prevention not just east cigarettes but as I showed you we need to talk about marijuana we need to talk about alcohol with our kids and and you know research is very clear that if we can delay the onset of any of these substance oriented behaviors you have someone who’s less addicted less prone to be having problems with these substances you make better choices if you wait a little bit longer there’s other policies they could remove menthol from the list of flavors you could do that with tobacco too so there’s there’s lots of different things that could happen it takes a long time the policies at the state level most of them are in place which is restricting the age of sale to 18 and over you could raise that to 21 I suppose there’s a number of places who are doing that and also having it restricted at schools to make it outlawed at school that’s another statewide or it could be a district policy along those lines so yeah there’s a number of things that you could do I guess we got one minute or one more question all right we’re gonna close up soon I can’t quite read them our you schools no information curriculum or any mention about e-cigarettes school be beneficial or just some of our youths mentioned too much exposure make them actually want to try you know that that is a very good point there is what’s called unintended negative consequences of telling kids about it and that’s why I worry about starting prevention programs like an elementary school you need to be careful when you’re delivering messages across the age ranges of kids so I think you know we’ve done a good job of generally of creating general anti cigarette anti tobacco norms like smoking sake with little kids in kindergarten you don’t need to spend six week program with the kindergarten you just need to let them know that no you don’t smoke adults tell you what’s in charge when they move into middle school and the reasoning capacity and the peer influence starts growing then you start need to talk about decision making and you need to be careful not to make it look too much fun actually like I did with those pictures at the end of my talk so yes there’s a problem with that most programs in the area of these sensitive topics like a tobacco alchemy tamaco regular tobacco and alcohol prevention HIV STD pregnancy prevention if you look at the last 25 years of research this unintended negative consequences not happen very much at all you get a bigger bang for the buck in the prevention side as opposed to you know stimulating someone for doing it where I worry most is with advertising Public Health advertising campaigns what you’re exposing you know all kids or most kids to something and it could go wrong.
E cigarettes and Vape Pens – What You Nedd to Know
