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Vaping & the Use of E-Cigarettes in Our Community Kern County Network for Children Larry E. Reider Education Ctr. 2000 K Street, Room 101 Bakersfield,

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Presentation on theme: "Vaping & the Use of E-Cigarettes in Our Community Kern County Network for Children Larry E. Reider Education Ctr. 2000 K Street, Room 101 Bakersfield,"— Presentation transcript:

1 Vaping & the Use of E-Cigarettes in Our Community Kern County Network for Children Larry E. Reider Education Ctr. 2000 K Street, Room 101 Bakersfield, CA 93301 November 5, 2014 Presentation materials borrowed from Dr. Phil Gardiner and authorized to be used for public education only.

2 From Whence E-cigarettes 2003: Chinese pharmacist, Hon Lik, is credited with conceptualizing and producing the first modern Electronic Cigarette

3 E-Cigarettes Nicotine Addiction: The Next Generation – Vaporizes liquid nicotine among other chemicals – Varying degrees of nicotine potency delivered – Long term health Impact still to be determined – Potential Life Saving Cessation Device – Explosion in popularity; emergence of a subculture; the new “in thing” in Hollywood – The Tobacco Vapor Electronic Cigarette Association estimates that there are more than 3.5 million e- cigarette users in the United States alone.

4 Component Parts

5 E-Cigs

6 Nicotine Inhaler

7 Hookah and E-Hookah

8 E-Pens; E-Hookah Pens Cherry, Chocolate, Vanilla, Bubblegum

9 E-Cigars Swisher Sweets E-cigars (Swisher International) Westenberger, 2009; Goniewicz et al 2013)

10 E-Cigars

11 Vaporizers

12 E-Cig Style

13 New Bluetooth E-Cigarette Lets You Vape AND Receive Calls, Listen to Music

14 Stanford Research into the Impact of Tobacco Advertising The Stanford School of Medicine has developed an online compendium of some 2000 e-cigarette ads, including a comparison of e-cig vs. cigarette ads highlighting the revival of long-banned advertising methods. ecigs.php?token=fm_ecigs_mt036.php

15 The E-Cigarette Explosion Market Size Continues to Increase – retail sales are over $1B currently; – ~$1.8B by the end of 2013; – $10B by 2017. – U.S. comprises 30% of the $6B global market E-cigs could surpass consumption of conventional cigs within the next decade (by 2023). (Herzog, 2013)

16 E-Cigarette Explosion: Youth Uptake Case in Point Among Middle and High School Students: – E-cigarette use rose from 4.7 percent in 2011 to 10.0 percent in 2012 (ever used) – E-cigarette use rose from 1.5 percent to 2.8 percent (past 30 days) – In 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes – 76.3 percent of who used e-cigarettes within the past 30 days also smoked conventional cigarettes in the same period. (MMWR,CDC, 2013)

17 Enter the tobacco industry Lorillard (LO) –Acquired the blu e-cigs in April 2012 for $135M. Reynolds American (RAI) –Vuse supposedly has technology that improves the consistency of vaping experience, unique design features and will be manufactured in the U.S. Altria Group (MO) –Launched MarkTen this year. –May acquire an existing e-cig company such as NJOY. NJOY (privately held) –One of the first retail entrants to the e-cig market; personnel includes several ex- Altria execs. –#2 brand in the c-store channel in terms of dollar sales and #4 in the take-home channel (Adapted from Herzog, 2013)

18 Lorillard Jumps Out First Lorillard in 2012 acquired E-Cigarette Company Blu- Blu adBlu ad > 40% E-Cig Market (non-internet)

19 Reynolds: Technologically Superior R.J. Reynolds has test marketing Vuse since 2011; purported to be technological advanced Vuse ad Reynolds Vapor Co.

20 Altria Joins the Fray Altria Group – Test Marketing now in Arizona – Altria still may acquire an existing company – Altria first-quarter U.S. sales volume fell by 5.2% – Marlboro sales fell by 5.5%, 2013)

21 NJOY: Hanging Tough NJOY – One of the first retail entrants to the e-cig market; personnel includes several ex-Altria execs. – #2 brand in the e-cigarette market behind Blu – Ex-Surgeon General Carmona; PM, Altria Executives – Feels Like the First Time Feels Like the First Time

22 NJOY: A Healthier (sic) Product? “Friends Don’t Let Friends Smoke” NJOY

23 E-Cigarette Liquid

24 E-Cigarette Liquid: The “Juice” E-Cigarette Liquid contains: – Nicotine, extracted from tobacco leaves Large variation in content between and within brands (Cheah et al 2012; Trtchounian et al 2011; Goniewicz et al 2013) Lethal if ingested; 60 mg Adult; 6 mg Children Detrimental to fetuses (Martz, 2009) Tobacco specific nitrosamines (TSNAs) (Laugesen, 2008; Westenberger, 2009; Goniewicz et al 2013)

25 E-Cigarette Liquid: The “Juice” E-Cigarette Liquid contains: – Propylene Glycol - the vapor; the fog FDA approved food additive (humectant, solvent for colors and flavors), cosmetics, and medicines. Short term exposure causes eye, throat, and airway irritation (Wieslander et al 2001; Vardavas et al 2012,) Long term exposure can result in children developing asthma. (Choi et al 2010) Chemical composition changes when heated (Henderson et al, 1981)

26 E-Cigarette Liquid: The “Juice” E-Cigarette Liquid contains: – Glycerin: A humectant used instead of or in combination with propylene glycol in EC fluids for aerosol production. – FDA Approved for ingestion. – Slightly hazardous in case of skin and eye contact, ingestion, and inhalation; prolonged exposure may cause organ damage. – Metals – Tin Particles found in E-liquid (Williams et al., 2013)

27 E-Cigarette Liquid: The “Juice” E-Cigarette Liquid contains: – Flavorants. Key one Menthol; Candy flavoring Anesthetic effects, mimics bronchial dilatation, increases salivary flow; transbuccal absorption; greater cell permeability Allows the poison to go down easier! – 100s of candy flavors; appeals to kids (bubblegum, strawberry, gummy bears, etc.) – Exotic for adults (Sex on the Beach, Aces and 8’s) Mix your Own (ala roll your own)

28 Combustion; Heating; Aerosolizing Cigarettes burn tobacco at ~ 900˚ Celsius Heated Tobacco Products E-Cigarettes aerosolize nicotine laced propylene glycol at 40 – 65˚ Celsius

29 The Aerosol: Its not just Water Vapor E-Cigarette Aerosol Vapor Contains: – Propylene glycol, glycerol, flavorings, and nicotine, which are found in the e-liquid, are also found in the e-vapor – Volatile Organic Compounds: Benzene and Toluene – Carbonyl Compounds: Formaldehyde, acetaldehyde, and acrolein – Metals: tin, silver, iron, nickel aluminum, sodium, chromium, copper, magnesium, manganese, lead, potassium and silicate nanoparticles – Tobacco specific nitrosamines (TSNAs) carcinogenic compounds found in tobacco and tobacco smoke. (Schripp et al, 2012: Westenberger 2009; Goniewicz et al, 2013; Williams et al, 2013)

30 Propylene glycol glycerin Flavorings (many) NicotineNicotine NNNNNN NNKNNK NAB NAT EthylbenzeneEthylbenzene BenzeneBenzene P,m, xylene TolueneToluene AcetaldehydeAcetaldehyde FormaldehydeFormaldehyde NaphthaleneNaphthalene StyreneStyrene Benzo(b)fluorantheneBenzo(b)fluoranthene Benzo(ghi)perylene AcetoneAcetone AcroleinAcrolein Silver NickelNickel Tin Sodium Strontium Barium Aluminum ChromiumChromium Boron Copper SeleniumSelenium ArsenicArsenic Aerosol composition CadmiumCadmium Silicon Lithium LeadLead Magnesium Manganese Potassium Titanium Zinc Zirconium Calcium Iron Sulfur Vanadium CobaltCobalt Rhubidium yellow Compounds in yellow are from FDA 2012, Harmful and Potentially Harmful Substances – Established List Chlorobenzene CrotonaldehydeCrotonaldehyde PropionaldehydePropionaldehyde Benzaldehyde Valeric acid Hexanal Fluorine Anthracene Pyrene Acenaphthylene Acenapthene Fluoranthene Benz(a)anthraceneBenz(a)anthracene ChryseneChrysene Retene Benzo(a)pyreneBenzo(a)pyrene Indeno(1,2,3- cd)pyreneIndeno(1,2,3- cd)pyrene

31 The Aerosol: Its not just Water Vapor E-Cigarette Vapor – Concentrations of pollutants less than in cigarettes – Carcinogens, less than in cigarettes – Great variation across products; no product standards – Intermediate and long term health effects unknown – Maybe safer, but this doesn’t mean safe

32 Peering Through the Mist... (Burstyn, 2013) “an analysis of current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces.

33 Peering Through the Mist... (Glantz Blog, 2013 on Threshold Limit Values, TLVs) “TLVs are for occupational exposures; occupational exposures are generally much higher than levels considered acceptable for ambient or population-level exposures Same approach to risk assessment as those conducted for secondhand smoke by those affiliated with the tobacco industry decades ago Occupational exposures also do not consider exposure to sensitive subgroups, such as people with medical conditions, children and infants, who might be exposed to secondhand e-cigarette emissions.”

34 Secondhand Exposure to Vapors From Electronic Cigarettes (Czogala et al, 2013) The average concentration of nicotine resulting from smoking tobacco cigarettes was 10 times higher than from e-cigarettes (31.60±6.91 vs. 3.32±2.49 µg/m 7xs more Particulate matter Still, in a room of 5 to or more e-cigarette users, nicotine and particulate matter levels are above healthy levels

35 Second Hand Vaping: The Take Home Message “Overall, the e-cigarette is a new source of VOCs and ultrafine/fine particles in the indoor environment. Therefore, the question of “passive vaping” can be answered in the affirmative. However, with regard to a health- related evaluation of e-cigarette consumption, the impact of vapor inhalation into the human lung should be of primary concern” (Schripp, et al., 2012).

36 Short Term Pulmonary Effects A team of scientists found that only after 5 minutes of use, e-cigarettes had immediate adverse physiologic effects, similar to some of the effects seen with tobacco smoking, including decreased FeNO. FeNo, or Fractional exhaled Nitric Oxide, shows the retardation of lung function; this measure is often used in assessing persons with asthma (Vardavas, et. al., 2012)


38 E-Cigs and Cessation: The Promise vs. The Reality: Dual Use Proof of concept study in 40 smokers not wanting to quit; Followed up at 24 weeks – 33% sustained a 50% reduction in cigarette consumption – 13% sustained an 80% reduction in cigarette consumption – 23% sustained complete abstinence Polosa et al 2011 BMC Public Health, 11(1): 786

39 E-Cigs and Cessation: The Promise vs. The Reality: Dual Use In another study comparing three different groups, 2 using different strengths of e- cigarette “juice” and one group not receiving nicotine cartridges, found that “there were significant reductions in Cigs/day comparing baseline to week 52: – Group A: 19 to 11 – Group B: 21 to 10 – Group C : 22 to 12 (Caponnette, et al., 2013).

40 E-Cigs and Cessation: The Promise vs. The Reality: Dual Use Four Country Survey Comparing Wave 7 and Wave 8 – 85% (n=146) of current ENDS users stated that they used ENDS as a tool to help them quit smoking, although only 11% of current ENDS users report having quit since Wave 7. – Quitting did not differ between users and non-users of e- cigarettes – After a year of using e-cigarettes as a cessation devise, the vast majority, 89%, had not quit and were still using regular cigarettes. (Atkison, et al., 2013).

41 E-Cigs and Cessation: The Promise vs. The Reality: Dual Use A 6-state Quitline survey collected data on 2758 treatment seekers at baseline and then again a 7 moths. The authors found that: – E-cigarette user groups were significantly less likely to be tobacco abstinent at the 7-month survey compared with participants who had never tried e-cigarettes. – The bottom line is that e-cigarette users, while using these products to quit, were not any more likely to have been successful if that had used them at all. – (Vickermann, et al., 2013)

42 From De-normalization to Renormalization From the 21 st Century to the 1950’s: Vaping is not only technologically up to date, it is everything a “girl” could want! – Vuse Ad Vuse Ad – Blu ad Blu ad

43 The Downside of Dual Use In a study of of 23 521 men and 19 201 women, aged 35–49 years, screened for cardiovascular disease risk factors in the mid 1970s and followed throughout 2002. “smoking 1–4 cigarettes per day was associated with a significantly higher risk of dying from ischemic heart disease and from all causes, and from lung cancer in women” (Bjartveit and Tverdal, 2005).

44 Renormalization


46 Need We Say More

47 Renormalization

48 Electronic Nicotine Delivery Device & Other Drugs Poisonings from E-Cigarettes and Synthetic Pot Are Surging (Spice, Black Mamba, K2, MOJO, White Widow, Hash Oil…) SeizuresHallucinations VomitingPsychosis Extreme anxietyPermanent brain damage SuicidalitySevere kidney damage Reduced blood flow to heartTachycardia Heart attackSudden cardiac arrest StrokeDelirium

49 Electronic Nicotine Delivery Device & Other Drugs New legal synthetic drug trend among young adults- a synthetic cigarette liquid known as "Blue Blossoms." Blue Blossoms fragrance is even labeled, "Not for human consumption" and "Product is not for sale to minors.” The effects of Blue Blossoms include, but are not limited to: distorted sense of time, bursts of euphoria, lowered awareness, and elevated heart rate.

50 % of stores that sell e-cigarettes in the Central Valley (HSHC 2013)

51 European Union E-Cigarettes Regulation Starting in 2016 Advertising Banned Graphic Health Warning Labels Child-Proof Nicotine Limited to 20mgs Outlawing Menthol Cigarettes (4-year delay) Indoor and Outdoor use NOT Regulated

52 FDA Regulation (or lack thereof) No FDA Regulation – Blocked imports in 2008 – Launch toxicological studies 2009 – Seized NJOY shipments 2009 – NJOY sued the FDA, claiming the e-cigarettes should be regulated like cigarettes, not a medicine – 2010, both the lower and applet court agreed with NJOY – 2013, FDA “poised” to announce regulations in October

53 Regulation (or lack thereof) No FDA Regulation – No Product Standards – No Minimal or maximum of nicotine or other chemical constituents – No Indoor Air Regulations – No Minor Restrictions – No Advertising Restrictions – The Wild, Wild, West

54 Only California State Wide Law As of 2011, CA law makes it unlawful for a person to sell or otherwise furnish an electronic cigarette to persons less than 18 years of age. – CAL. HEALTH AND SAFETY CODE § 119405 (West 2013). E-Cigs CodeE-Cigs Code

55 Corbett 648 (Died a Horrible Death) Summary: Would extend the restrictions and prohibitions against the smoking of tobacco products to include electronic cigarettes. – 04/17/2013 Senate Health (Y:6 N:2 A:1) – 04/30/2013 Senate Judiciary (Y:4 N:2 A:1) – 05/24/2013 Senate Floor (Y:21 N:10 A:8) – 06/25/2014 Assembly Governmental Organization Committee – 08/06/2014Assembly Appropriations-Failed, but 17 voted Y and 0 N for reconsideration

56 Thank You Bee Sacramento California Democrats accepting more campaign cash from tobacco industry By Laurel Rosenhall Read more here: Rosenhalllrosenhall@sacbee.com Editorial: Democrats choose tobacco money over public health By the Editorial Board Read more here: Editorial Board

57 Cities Move to Regulate E-Cigarettes in California RichmondMill ValleyMorgan Hill Long BeachMountain ViewOroville Los AngelesPetalumaSan Bernardino San FranciscoSanta Clara CountySanta Maria Contra Costa CountySeal BeachSebastopol ArcataSolana BeachTemecula Beverly HillsTiburonUnion City CampbellWalnut CreekDel Mar CarlsbadEurekaFairfax FremontMarin CountyArvin

58 Kern County Board of Supervisors- Addressing Illegal sales of ENDDs 6/24/2014- BOS amended Chapter 8.60.010 of the Kern County Ordinance code relating to Tobacco Retailer Permits to include electronic smoking devices and paraphernalia in the definitions. The amended ordinance would require retailers selling electronic smoking devices and paraphernalia to obtain an Environmental Health Permit. These retailers would also be included in the Division’s compliance check process to ensure children are not sold tobacco products & ENDDs.

59 Definitions??? Definitions are the keys to making changes in the existing laws: Chapter 8.60.010 Section D: "Tobacco product" means any product that contains tobacco, is derived from tobacco, or contains synthetically produced nicotine and is intended for human consumption. "Tobacco product" includes electronic smoking devices(s) and electronic smoking device paraphernalia, but does not include any product specifically approved by the United States Food and Drug Administration for use in treating nicotine or tobacco dependence. Section I: "Smoking paraphernalia" means tobacco paraphernalia, electronic smoking devices, and electronic smoking device paraphernalia. Section J: "Electronic smoking device" means an electronic and/or battery-operated device, the use of which may resemble smoking, which can be used to deliver an inhaled does of nicotine or other substance. "Electronic smoking devices" include any such electronic smoking device, whether manufactured, distributed, marketed, or sold as an electronic cigarette, an electronic cigar, an electronic cigarillo, an electronic pipe, an electronic hookah, or any other product name or descriptor. "Electronic smoking device" does not include any product specifically approved by the United States Food and Drug Administration for use in the mitigation, treatment, or prevention of disease. Section K: "Electronic smoking device paraphernalia" means cartridges, cartomizers, e-liquid, smoke juice, tips, atomizers, electronic smoking device batteries, electronic smoking device chargers, and any other item specifically designed for the preparation, charging, or use of electronic smoking devices.

60 Thank You! Nsele M Nsuangani, MPH Health Educator-Project Director Tobacco Education Program Environmental Health Division Kern County Public Health Services Department Phone: (661) 862-8751 Email:

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