Geoff Wilson, LCSW, CADC The Ridge Behavioral Health

Cigarette smoking is the leading cause of preventable disease and mortality in the United States, and is usually initiated in adolescence. That makes what happens in adolescence particularly important!

Four in every ten American young people (40%) have tried cigarettes by 12th grade, and nearly one in six (17%) 12th graders is a current smoker. Even as early as 8th grade, one in six (16%) has tried cigarettes, and 1 in 20 (5%) has already become a current smoker. In 2012, cigarette use reached the lowest levels recorded in the life of the MTF study

By 2012 levels of perceived risk were the highest ever observed, but they leveled after that. There is a clear age effect: by the time most youngsters fully appreciate the hazards of smoking, many already have initiated the behavior.

By 2014, 30-day prevalence levels were down from peak levels by 81%, 77%, and 63% in grades 8, 10, and 12, respectively. An increase in 2009 in federal taxes on cigarettes (from $0.39 to $1.01 per pack) may have contributed to the recent decline in use.

Since 1996, availability has declined considerably, especially among 8th and 10th graders. Some 47% of 8th graders and 69% of 10th graders now say that cigarettes would be very easy or fairly easy to get, reflecting declines of 39% and 24%, respectively

 In 2012, 6.7% of middle school and 23.3% of high school students currently used tobacco products, including cigarettes, cigars, hookahs, snus, smokeless tobacco, pipes, bidis, keteks, dissolvable tobacco, and electronic cigarettes

In 2012, 1.78 million U.S. teens tried e-cigarettes and 160,000 of them were non-smokers! 6 th -12 th grades: ever use of e-cigarettes increased 3.3% to 6.8% (more than doubled) High school students: ever-use increased 4.7% to 10% Dual use: 76% of middle and high school students who had used e-cigs in the past 30 days had also smoked conventional cigarettes in the same time period

In 2014 more teens used e-cigarettes in the past 30 days than traditional tobacco cigarettes or any other tobacco product. MTF is the first national study to document this finding. Specifically, 30-day prevalence of e-cigarette use was 8.7%, 16.2%, and 17.1% in 8th, 10th, and 12th grade. The corresponding prevalence for tobacco cigarette use was 4.0%, 7.2%, and 13.6%. Note that in 8th and 10th grades e- cigarette prevalence is more than twice the prevalence of regular cigarettes. E-cigarettes have the lowest perceived risk for regular use than any other drug in the survey, including alcohol.

Products that look like pens or highlighters can easily be hidden by students in schools and classrooms. Teachers may not recognize e-cigs, and smoke detectors won’t catch the aerosol.

In 2012, the Kentucky Regional Poison Control Center of Kosair Children's Hospital reported a 333 percent increase in calls attributed to e-cigarette cartridges. E-cig sales in participating Kentucky retail outlets increased from $8,392 in 2011 to nearly $1.7 million in 2012 (excludes online sales). Nationally, poison control centers have seen a 161 percent increase in calls from people with concerns about these devices.

Hookah- water pipes that are used to smoke specially made tobacco that comes in different flavors, such as apple, mint, cherry, chocolate, coconut, licorice, cappuccino, and watermelon In the US it has become more popular among teens and young adults and in college towns, seen as a “popular social activity”

The hookah device consists of four parts: A base, or smoke chamber, which is partially filled with water A bowl, which contains tobacco and the heating source A pipe that connects the bowl to the base and dips into the water in the base A hose, a second tube in the pipe that does not dip into the water but opens into air in the base and allows users to inhale the hookah smoke When a smoker inhales through the tube, a pressure difference forces air past the heating source and heats the tobacco, which gives off smoke. The smoke is pulled away from the tobacco and passes through the water and into the smoke chamber — from which it is inhaled by the smoker.

The World Health Organization noted in a report from 2011 that the smoke inhaled in a typical one-hour hookah session can equal 100 cigarettes or more. The WHO report also stated that even after it has been passed through water, the tobacco smoke in a hookah pipe contains high levels of cancer-causing chemicals.

 As with cigarette smoking, hookah smoking is linked to lung and oral cancers, heart disease and other serious illnesses.  Hookah smoking delivers about the same amount of nicotine as cigarette smoking does, possibly leading to tobacco dependence.

E-CIGARETTES & PERSONAL VAPES

 Electronic cigarette: smokeless, battery operated device used to deliver nicotine with flavorings or other chemicals to the lungs.  Vaporizer pen “vape pen”: hand-held device used to generate an inhalable vapor from a solid, semi- solid, or liquid substance. Specifically designed to vaporize THC.  Both use the same technology, leave no detectable odor, and are similar in appearance.

"Butane honey oil" is a super-potent type of hash that has surged on the marijuana market. The "dabs" of oil can be vaporized and inhaled without the pungent smell of weed, and produce a soaring high for even longtime cannabis smokers with a strong tolerance for the drug. But it has also blown up in the faces of those making it, sending at least 17 people with catastrophic injuries to burn centers in Southern California in the last 14 months.

“disposable hookah” “hookah pen” “e-hookah” “vape pipe” “vape pen” Note. Some e-cigs connect to other electronic devices to play music and answer calls

E-Pipes E-Cigars E-Hookah E-?

 E-cigarettes have been around since the 1960s.  Started to take off in the last decade with more than 250 brands and flavors like watermelon, pink bubble gum and Java.  Estimated 4 million Americans use them, according to the Tobacco Vapor Electronic Cigarette Association.  Researchers compared e-cigarettes to nicotine patches and other smoking cessation methods and found them statistically comparable in helping smokers quit over a six-month period  According to a CDC study: nearly 1.8 million young people had tried e- cigarettes and the number of U.S. middle and high school students e- smokers doubled between 2011 and 2012.

 E-cigarettes can increase nicotine addiction among young people and may lead kids to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death  The products may contain ingredients that are known to be toxic to humans  Conducted a preliminary analysis on some samples of electronic cigarettes and components from two leading brands.

Sottera Inc. v. Food & Drug Administration, , U.S. Court of Appeals, District of Columbia Circuit (Washington) FDA wanted to regulate e-cigarettes as electronic nicotine delivery device, but… Judge ruled in favor of Sottera (maker of N-Joy) that e-cigarettes are a tobacco product. E-cigarette industry advocating for less regulation than with other tobacco products.

E-cigarettes emit harmful chemicals, some of which are known to cause cancer (formaldehyde, metals [cadmium, lead, nickel], nitrosamines). These chemicals are contained in visible aerosol consisting of condensed submicron liquid droplets. The Hazards of E-cigarettes by Offermann, ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Journal, June 2014

 DPA's analysis revealed the following: Diethylene glycol was detected in one cartridge at approximately 1%. An ingredient used in antifreeze and is toxic to humans. Certain tobacco-specific nitrosamines which are human carcinogens were detected in half of the samples tested. Tobacco-specific impurities suspected of being harmful to humans The electronic cigarette cartridges that were labeled as containing no nicotine had low levels of nicotine present in all cartridges tested, except one. Three different electronic cigarette cartridges with the same label were tested and each cartridge emitted a markedly different amount of nicotine with each puff. The nicotine levels per puff ranged from 26.8 to 43.2 mcg nicotine/100 mL puff. One high-nicotine cartridge delivered twice as much nicotine to users when the vapor from that electronic cigarette brand was inhaled

E-smoking gives off aerosol, not water vapor. The aerosol contains a mix of toxic gases and tiny particles: propylene glycol (lung and eye irritant); formaldehyde and β -nicotyrine (cause cancer); metal & silicate particles (toxic to human cells); and nicotine (addictive and harmful to unborn babies). Not FDA-approved as a quit aid. Nevertheless, e-cigs marketed as cessation aids, either overtly or covertly. E-cigs may encourage dual use vs. switching altogether.

E-cigs give off tiny particles that can be inhaled deep into the lungs. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers by Schober, Szendreia, Matzena, Osiander-Fuchs, Heitmann, Schettgend, Jörres,and Fromme, International Journal of Hygiene and Environmental Health, The size & number of particles emitted from e-cigarettes are similar to conventional cigarettes. E-Cigarettes: A Scientific Review by Rachel Grana, Neal Benowitz and Stanton A. Glantz, Circulation, The e-cigarette aerosol also contains metals and silicate particles. Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol by Williams, Villarreal, Bozhilov, Lin & Talbot, PLOS, 2013.

Found in antifreeze, de-icing agents in cars, planes, and boats.

 Pneumonia  Congestive heart failure  Disorientation  Seizure  Low blood pressure  Chest pain  Second degree burns to face  Loss of vision  Possible infant death from choking on EC  Physically ill  Poisoning

Where’s the disconnect?

 Nicotine causes a dopamine release in the brain’s limbic system.

Large amounts of nicotine are lethal (60 mg adult, 6 mg children) Is also an insecticide and toxicant The number of poisoning cases linked to e- cigarettes liquids was 1,351 in 2013, a 300% increase from 2012 According to the National Poison Data System, these number are on pace to double in 2014

 E-cigarette users exhale – passive vaping like secondhand smoke does happen.  This chemical aerosol is not “just” water vapor.  Studies so far show it contains: nicotine propylene glycol fine & ultrafine (UF) particles low levels of toxins known to cause cancer nanoparticles of chromium, nickel, tin volatile organic compounds (VOCs)

Research has been so limited, but new trends are emerging

 A study examining the biological effects of e-cigarettes found “strikingly similar” gene mutations in lung cells exposed to e-cig vapor as those found in smokers. This means that although e-cigarette vapor is tobacco and tar-free and that the device does not require combustion, it could potentially increase a user’s risk of cancer.  Another study published in Germany examined secondhand emissions from several e-cigarettes in a human exposure chamber. While the e-cigarette produced lower levels of toxins in the air for nonsmokers to breathe than the conventional cigarette, there were still elevated levels of acetic acid, acetone, isoprene, formaldehyde and acetaldehyde, averaging around 20% of what the conventional cigarette put into the air. Putting detectable levels of several significant carcinogens and toxins in the air

 In 2012 a Florida man suffered severe injuries from an electric cigarette that exploded in his mouth. Knocked out all of his teeth and part of his tongue. The event also set fire to the room. 

 Increased risk of addiction to cocaine and other drugs Nicotine greatly enhanced the effect of cocaine in mice Cocaine dependence greater in heavy smokers (>100 cigarettes before using cocaine) Nicotine acts as a gateway drug with the effects of addiction, especially in adolescents

We’ve already fought this battle with Big Tobacco…

-Keep smoking -Take back your “right to smoke” -Rebellion -It’s not about quitting

Not a safe alternative but may be less harmful than conventional cigarettes Nicotine addiction  a possible gateway to conventional smoking Majority of e-cig users still use conventional cigarettes. This “dual-use” undermines or eliminates potential health benefits of quitting.

Even if less harmful, will they…. Keep smokers smoking (bridging and/or using methods that are not evidence- based)? Attract youth users who progress to conventional cigarettes? Lure former smokers back into smoking?

E-cigarette aerosol contains toxic gases and tiny particles that are emitted into the air. For this reason, they should be covered under smoke- and tobacco-free policies. Workers and patrons are exposed to secondhand aerosol from e-cigarettes. E-smoking creates a dense mix of aerosol and fine particles that looks like tobacco smoke. If exempt from tobacco-free policies, the ‘smoky look’ creates confusion with enforcement. Note: Electronic cigarettes are not approved as a quit aid by the FDA!

 Nicotine free school campuses- school policies  Keeping the price of nicotine products high  Restricting nicotine devices’ marketing and other activities  Mass media campaigns to reduce initiation  Reinforcing a tobacco/nicotine-free norm  Kids' perceptions of how many people are smoking is a major factor in whether they decide to smoke

Kentucky Center for Smoke-free Policy Thank you to Amy Barkley, Campaign for Tobacco-free Kids for allowing me to adapt some of her slides, Electronic Cigarettes: What They Are, How They’re Marketed, & How We Can Protect Our Youth, 11/20/13, Richmond VA.

The presenter would like to credit: Ellen J. Hahn, PhD, RN, FAAN Kentucky Center for Smoke-free Policy University of Kentucky College of Nursing And The Prevention Department Tri- County Mental Health Services 3100 NE 83 rd St. Suite 1001 Kansas City, MO 6411