understanding & preventing youth vaping › wp-content › uploads › understanding-an… ·...

Understanding & Preventing Youth Vaping

Bonnie Halpern-Felsher, PhD

Bonnie.halpernfelsher@Stanford.edu

Professor of Pediatrics

PAUSD

January 22, 2019

What I Will Cover

• An introduction to e-cigs/vaping– What they are

– How they work

– What is in them

• National usage rates

• Health effects

• Why youth are using vapes

• What you can do!

Take Home Points

• This is BIG TOBACCO 2.0

• Nicotine is extremely addictive, more addictive than heroin

• Really important to keep your kids from getting addicted before their frontal cortex is fully formed, so they don’t have a predisposition towards addiction for the rest of their lives

• The people behind these vaping companies are great marketers who are targeting our kids and actively trying to cloud the narrative around these facts.

• These vaping companies are using tools and practices that many of us don’t understand and don’t see. We need to be vigilant, stay informed, and stay active!

Good News…

McKelvey & Halpern-Felsher, 2017

Changing Landscape of Tobacco Use

Bad News:

Terminology

E-Cigarettes (Formal/Scientific)Vapes (Colloquial, from Industry)

1st Generation 2nd Generation 3rd Generation Pod-Based Devices

Electronic Smoking Devices

E-Cigarettes&VapePensGenerations

VapePens

Thesehavebatteriesthatcan

reachhighertemperatures,haverefillablee-liquidcartridges,andallowuserstoregulatethefrequencyofinhalations.

Mods

Largesize,modifiablee-

cigarettesallowformoreaerosol,

nicotine,andotherchemicalstobebreathedintothelungs,atafasterrate.

Pod-Based

Thesee-cigarettesare

shapedlikeUSBsandcontain

podswithhigheramountsofnicotinethanprevious

generations.

Variations

Variationsonthefirste-cigarettesincluded

productslikee-hookahandrechargeableversions.

Cig-a-Like

E-cigarettescameontothemarketaround

2007.

Mostdeliverednicotineand

weredisposable.

TobaccoPreventionToolkitDivisionofAdolescentMedicine,StanfordUniversity

Formoreinformationgoto:www.tobaccopreventiontoolkit.stanford.edu

E-Juice/E-Liquid

Pod-Based E-cig Devices

Pod-Based E-cig Devices

National Rates of E-cigarette Usage

National Rates of E-cigarette Usage

14

Trends in 30-Day Prevalence of Use for Grades 8, 10, and 12 Combined

NIDA. "Teens using vaping devices in record numbers." National Institute on Drug Abuse, 17 Dec. 2018, https ://www.drugabuse.gov/news-events/news-releases/2018/12/teens-us ing-vaping-devices-in-record-numbers. Accessed 21 Dec. 2018.

5.4 5.4

3.4

12.0

14.5

3.64.6

5.5

2.7

19.2

14.6

5.7

0

5

10

15

20

25

30

Cigarettes Cigarillos Hookah Vaping Marijuana Vaping MJ

Per

cen

t

Adolescent Use in 2018

2017

2018

Cigarettes Blunts Hookah Vapes with Nicotine

Marijuana

Dramatic Increase in Youth E-Cigarette Use: 2017-2018

• High school students’ e-cig use increased by 78%• 1 in 5 high school students currently use e-cigarettes

• Middle school students’ e-cig use increased by 48.1%• 1 in 20 middle school students currently use e-cigarettes

Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR MorbMortal Wkly Rep 2018;67:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6745a5.

What are E-Cigarettes?

How Do E-cigs Work?What is in E-cigs?

BatteryAtomizer/coil

Absorbent material/cotton:Nicotine

Propylene glycol

Vegetable glycerin

Flavorants

Nicotine aerosol

Anatomy of an E-Cigarette

Image Credit: Dr. Gideon St. Helen

Anatomy of a Pod-Based System

Cartridges/Pods

Devices with Rechargeable Battery

Covers

tobaccopreventiontoolkit.stanford.edu

PHIX

JUUL

These cartridges/pods do contain NICOTINE!

Chemicals Found in E-Cig/Vape Pen Aerosol

Compounds in yellow are from FDA 2012, Harmful and Potentially Harmful Substances – Established List

• Propylene glycol

• Glycerin

• Flavorings (many)

• Nicotine

• NNN

• NNK

• NAB

• NAT

• Ethylbenzene

• Benzene

• Xylene

• Toluene

• Acetaldehyde

• Formaldehyde

• Naphthalene

• Styrene

• Benzo(b)fluoranthene

• Cadmium

• Silicon

• Lithium

• Lead

• Magnesium

• Manganese

• Potassium

• Titanium

• Zinc

• Zirconium

• Calcium

• Iron

• Sulfur

• Vanadium

• Cobalt

• Rubidium

• Benzo(ghi)perylene

• Acetone

• Acrolein

• Silver

• Nickel

• Tin

• Sodium

• Strontium

• Barium

• Aluminum

• Chromium

• Boron

• Copper

• Selenium

• Arsenic

• Nitrosamines

• Polycyclic aromatic

hydrocarbons

• Chlorobenzene

• Crotonaldehyde

• Propionaldehyde

• Benzaldehyde

• Valeric acid

• Hexanal

• Fluorine

• Anthracene

• Pyrene

• Acenaphthylene

• Acenapthene

• Fluoranthene

• Benz(a)anthracene

• Chrysene

• Retene

• Benzo(a)pyrene

• Indeno(1,2,3-

cd)pyrene

What’s in Vape?

Diacetyl

(butter flavor)

Benzene

(gasoline)

Cadmium

(batteries)Formaldehyde

(dead tissue preservative)

Lead

(car batteries)Nickel

(cheap jewelry)

Toluene

(paint thinner)

N-Nitrosonornicotine

(pesticides)

Nicotine

(tobacco)

What’s in that Pod?

• Salt-based Nicotine

• Benzoic Acid

• Glycerol

• Propylene Glycol

• Natural Oils

• Extracts and Flavors

• ???

Why Should We Be Concerned?

Why Should I Care about Vapes?

Amount Equivalent

1 pack cigarettes 20 cigarettes(contains 8mg per cigarette, but only inhale 1mg)

1 JUULpod 0.7 mL pod"5% nicotine by volume"

1 PHIX pod 1.5 mL pod"5% nicotine by volume"

1 Suorin pod 2 mL cartridge"5.4% nicotine by volume "

NOTE: ALL SALT-BASED E-JUICE/LIQUID CONTAINS NICOTINE!

Nicotine Levels in Pod-Based Products

The Body on Nicotine

The Body on Nicotine

Brain development

Nicotine Effects

➢ Highly addictive substance

➢ Causes changes in brain chemistry –

stimulates pleasure centers, alters

normal brain function

➢ As nicotine levels in brain drop, brain

craves nicotine to feel pleasure and

relieve feelings of anxiety and stress

(withdrawal)

Nicotine Effects

❖ Nicotine addiction

❖ Slows development of learning, memory,

attention and behavior

❖ Mood disorders like anxiety and

depression

❖ Permanent lowering of impulse control

❖ Increased risk of other addictions

Until about age 25 the brain is still growing

“My parents just think it’s a flash drive”

Why Youth are Vaping

• Flavors

• Changing social norms and misperceptions

• Marketing

• Cost

Why Youth are Vaping

• Flavors

• Changing social norms and misperceptions

• Marketing

• Cost

Flavors of Vapes

JUUL Flavors

Role of Flavors in Tobacco Usage

“Oh, I used that all day. I’d just keep it with me in my pocket and when I felt like having a taste of something flavor-y or something, I’d just take a hit… when you smell like blue raspberry and green apple, no one is going to question why you smell like that.”

Ramos, Ramamurthi, Roditis, & Halpern-Felsher, In progress

Why Youth are Vaping

• Flavors

• Changing social norms and misperceptions

• Marketing

• Cost

From the Teens Themselves

“…It's really hyped up, like, ‘No nicotine.’ That's what

everybody's saying. ‘There's no nicotine.’ ‘It's good for you.

Cuz it's vapor.’ The water vapor...”

Roditis & Halpern-Felsher, 2015, JAH

E-Cigs are Cool

E-Cigs are Cool

From the Teens Themselves

“I like that I didn’t have to always go outside to smoke a

cigarette or have to light it or deal with ash and the harsh odor

on yourself. Cigarette smoke stays on you and the e-

cigarettes don’t at all because there’s no scent on them really.”

Ramos et al., In Progress

From the Teens Themselves

“I guess after I tried the actual cigarette I felt like I wanted

something, but not something harmful, that harmful at least,

so I went to the vape store with my friend. We went to the

smoke shop…and they were able to let us try out some of

them and they recommended a model and they let us try it.”

Ramos et al., In Progress

From the Teens Themselves

“People always tell you smoking's bad, and cigarettes and

tobacco's bad, but if you just smoke regular with just water,

it's not bad. Because you take out the tobacco and the

cigarette stuff. That's what people think. It's better than

smoking.”

Roditis & Halpern-Felsher, 2015, JAH

PAUSD Students’ Perceptions of HarmCompared to Cigarettes if use

Occasionally

Aaaa Grade 7 Grade 9 Grade 11

Great/moderate harm

72% 69% 64%

Slight/no harm

28% 30% 36%

PAUSD Students’ Perceptions of HarmCompared to Cigarettes if use

Several Times a Day

Grade 7 Grade 9 Grade 11

Great/moderate harm

86% 80% 80%

Slight/no harm

15% 20% 20%

Why Youth are Vaping

• Flavors

• Changing social norms and misperceptions

• Marketing

• Cost

JUUL Nation

Who’s the Target Audience?

Why Youth are Vaping

• Flavors

• Changing social norms and misperceptions

• Marketing

• Cost

Cost and Accessibility

JUUL

• JUUL Device: $34.99; 4 JUULpods: $15.99

• Cigarettes: $9.55 per pack x 4 = $38.20

• $15.99 vs. $38.20

JUULpods cost LESS than cigarettes!!!

JUUL

• JUUL Device: $34.99; 4 JUULpods: $15.99

• Cigarettes: $9.55 per pack x 4 = $38.20

• $34.99 vs. $19

JUULpods cost LESS than cigarettes!!!

What about Access?

• PAUSD students’ perception of ease of obtaining e-cigarettes:–Grade 7: 19% easy or very easy to obtain–Grade 9: 46% easy or very easy to obtain–Grade 11: 67% easy or very easy to obtain

What YOU Can Do?

What YOU Can Do?

Parents/Caregivers…

• Stay informed

• Talk to your children

• Be an advocate

• Talk to healthcare providers

• Drug testing

• Talk to your children

Stay Informed…

Behavioral Indicators

• Change in clothing

• Depression and withdrawal

• Moodiness and irritability

• Reduced communication with family members

• Deterioration in school performance and/or truancy

• Physical changes

Talk to Healthcare Providers

• Treatment/referrals

– Nicotine replacement therapy (off-label)

– Cognitive behavioral therapy (CBT)

• Drug testing– Providers CANNOT drug test your child unless child gives

permission (sensitive service laws)

– You can test at home

• Subject to false positives and false negatives

• Talk!

– See our discussion guides

Starting the Conversation

• Goal: to have a conversation, not a lecture

– Find the “right time”

– Be patient and ready to listen

– Avoid criticism and encourage open dialogue

• Avoid “we need to talk,” instead “What do you think about…”

• Avoid “you don’t vape, right…”

• Use the right words! (vaping, Juuling)

• Continue the conversation

⎻ In-person, or via text/email, etc.

• Sharing articles is a great way to stay engaged

Stay Informed, Stay Active

• https://www.parentsagainstvaping.org

Stay Informed, Stay Active

Submit a public comment!

The Tobacco Prevention Toolkit

Interactive

Online

Free

Tobaccopreventiontoolkit.Stanford.edu

Stay Informed, Stay Active

• Bonnie.halpernfelsher@Stanford.edu

• Follow us to stay up to date with relevant news, curricula

updates, and new activities at:

• www.facebook.com/TobaccoPrevToolkit/

• www.twitter.com/StanfordTPT

Take Home Points

• This is BIG TOBACCO 2.0

• Nicotine is extremely addictive, more addictive than heroin

• Really important to keep your kids from getting addicted before their frontal cortex is fully formed, so they don’t have a predisposition towards addiction for the rest of their lives

• The people behind these vaping companies are great marketers who are targeting our kids and actively trying to cloud the narrative around these facts.

• These vaping companies are using tools and practices that many of us don’t understand and don’t see. We need to be vigilant, stay informed, and stay active!