Hi, my name is Eric Hamberger. I am an
assistant clinical professor of
pediatric pulmonology at UCLA, and I'm
going to talk about e-cigarettes and
lung health today. I have nothing to
disclose, I have no relationships to
disclose for this presentation. So,
e-cigarettes are a group of devices that
allow users to inhale an aerosol, usually
containing nicotine and flavoring, for
recreational use, and I wanted to
emphasize recreational use to
distinguish it from other aerosolized
things like nebulizers, inhalers, which
are prescribed by doctors. They go by a
lot of different names, e-cigarettes, e-cigs,
cigalikes, vapes, vape pens, tanks--some
people just refer to them by the brand
name itself, and they become very popular,
especially in the past decade. In 2014,
they surpassed traditional cigarette use
among adolescents and young adults. The
concept of noncombustible nicotine
delivery has actually been around for
quite a long time. The first patent can
be traced back to the 1920s. In 1927, a
man named Joseph Robinson filed a patent
for what was sort of a prototype of an
electronic cigarette, but it never--they
never used the word cigarette or tobacco.
I'm just going to read a short excerpt
from that patent: "It produces an
extremely simple vaporizer, which
extended use has demonstrated to be of
great effectiveness in the treatment of
afflictions for which its use is
intended." So it was really first intended
to be a medicinal tool. Again, nowhere in
the patent does it say the word
tobacco. In a way, it was described
something like a nebulizer, except it
uses a heated coil. The patent was
granted in 1931, but it was never
commercialized. In 1963, a man named
Herbert Gilbert also attempted to make a
smokeless nontobacco
cigarette, the goal being to replace
burning tobacco with a heated moist
flavored air. Again, that was never
commercialized. One notable product from
the late 1970s was something called the
the Favor. Their slogan was "Do yourself
a favor." It was a smokeless cigarette. It essentially
was just paper soaked in nicotine
containing liquid that the
user would inhale without lighting or
combusting anything, but they were very
expensive, they didn't deliver nicotine
very effectively, and as a result, they
were a massive commercial failure. But
the first modern e-cigarette was
mass-produced in 2003 by a Chinese
pharmacist named Hon Lik, who was the
former deputy director of the Institute
of Chinese Medicine, and the original
intent, as with these other products, was
a smoking cessation tool, and it's even a
statement stated as such in the patent.
It was the first recent innovation that
was mass-produced by a company called
Ruyan. It used something called a
piezoelectric ultrasound emitting
element, which is essentially a power
source that generated electricity. It
made its way to the US markets in 2005, a
lot of sort of copycat devices started
popping up globally, using both this
technology and, later, batteries, and at this
time, it was introduced to the US market.
A couple of years later, in 2007, we saw a
very rapid rise in sales in the United
States, so a company called Plume, which
was renamed to PAX Labs, was
founded by two Stanford grad students
in San Francisco. That company would
later become the company that produced
Joule, and in 2017, Joule actually spun
off into a separate company--again, I
mentioned that in 2015, e-cigarettes
surpassed traditional cigarette use
among youth for the first time, I'll talk
more about that a little bit later--by
2018, e-cigarettes had actually become
a multi-billion dollar industry, so it
was so profitable that tobacco companies
wanted in. So, Altria, the parent company
of Philip Morris, actually purchased a
35% stake in the popular brand Joule in
late 2018, and as you've probably heard,
in 2019, there have been hundreds of
cases of--really, thousands of cases of a
vaping-related illness that started
popping up around the United States--I'll
talk more about that as well a little
bit later. So, what exactly are these
devices? So, this is a modern e-cigarette.
They contain three basic elements.
There's a mouthpiece, so an interface
that's connected to a tank that contains
a heating coil, so that heat aerosolizes
what's called an e-liquid, and
then there's a power source with a
button, usually to--sometimes a button,
sometimes just the active inhaling
initializes the device. Inside the tank,
you have what's called an e-liquid, and
each e-liquid is comprised of really
three main ingredients. So, there's a
solvent--propylene glycol and/or
vegetable glycerin, usually a combination
of both--there is a usually nicotine
involved, although they don't have to
contain nicotine, and usually a flavoring
as well. Some of the flavors that are
currently available--this is from the
Surgeon General's report in 2016--we have
bubblegum, chocolate, cotton candy, grape,
gummy bear, and a lot of states have sort
of caught on to this, and jurisdictions--
Los Angeles, for example, has moved to ban
the sale of flavored e-cigarettes
because of the appeal to children. But
these are some examples of what a lot of
these cigarettes look like now. You'll
notice that they're very compact, they're
simple they share a lot of design
elements with popular tech products. The
product on the right is available from
Joule, sort of like a baby macbook or
iPhone or something. They have these
proprietary things called pods, so this
is the menthol pod, it's still available
through the Joule website. The amount of
nicotine in these pods is about 5% per
weight at maximum, which amounts to about
59 milligrams of nicotine. By comparison,
a cigarette contains about 6 to 12
milligrams, so a pod can contain as much
as 2/3 to one entire pack of
cigarettes, and a user can actually get
through a Joule pod anywhere from a
couple of days to a week, not much than
less than what you would expect for a
pack of cigarettes, but that number can
vary widely, of course, depending on the
user. So, one reason that a lot of people
use e-cigarettes is to help quit smoking,
and there have been sort of a handful of
large randomized control trials
examining the effectiveness of
e-cigarettes and smoking cessation. So,
this was published in 2013 in the
journal
The Lancet. 657 people were randomized to
either nicotine e-cigarettes, nicotine
patches, or placebo e-cigarettes, so
e-cigarettes that don't contain
nicotine. They defined abstinence as not
using combustible cigarettes. What they
found was a rate of 7.3% of e-cigarette
users were abstinent from cigarettes
compared to 5.8% from nicotine
patches and about 4.1% who used
e-cigarettes which didn't contain
nicotine. So, from this study, they
concluded that e-cigarettes were
modestly effective at helping smokers,
similar to nicotine patches, but another
thing I liked about this study was just
simply giving someone something that
they thought contained nicotine--so, a
placebo--could also be effective at
helping people quit cigarettes even
though it's very minimal. Another study
that came out more recently--this is a
randomized control trial that came out
in early 2019 in the New England Journal
of Medicine--so this was nearly 900
participants, they were assigned to
either a combined smoking cessation
group, such as behavioral therapy and
nicotine patches, or an e-cigarette group,
and the primary outcome that they looked
at was, again, sustained abstinence from
from combustible cigarettes for one year.
They actually verified this by measuring
the level of carbon monoxide in the
blood to verify this. E-cigarettes do
work as a modality to quit cigarettes.
They do seem to work quite well if 1
in 5 cigarette users are switching to
e-cigarettes versus 1 in 10. It's hard
to argue that they don't work for their
intended purpose. They also saw a 10% to
20% reduction in cough and phlegm
production in these people
compared to nicotine replacement
therapy, but they did find an increase in
the amount of reported mouth irritation
that's been corroborated with others by
other studies, and they didn't see any
significant difference in the incidence
of wheezing or shortness of breath. But
again, I just want to point out this
disclaimer that this was a study done on
active smokers, so these are not never
smokers. So, how much nicotine does an
e-cigarette actually deliver? You can compare the amount of nicotine in a cigarrette or an ounce of liquid, but the more
important measure really is the
plasma-nicotine concentration. So, this is
a study that was published in 2017
comparing plasma and nicotine levels at
steady intervals, at 5, 10, 15, 20, etc.
minutes after the initial use, and I like
this study because it seemed
comprehensive, although it might be a
little bit outdated. It was done
before Joule was really popular--it was
still emerging--so that was not included
in this study. Also, the 11 people that
were studied were so-called experienced
vapers, so they were good at it, which may
or may not represent the general
population. But if we look at the data--so,
the amount of blood nicotine levels
from cigarettes in this study was
clearly the highest--that's this blue
line at the top, so at 5 minutes, it
peaked to a concentration of 18 nanograms
per mL. In close second was a
brand called Views, which is a popular
and later generations considered a
third-generation brand of e-cigarettes.
As we go down, we see that the level of
nicotine approaches about 2/3 to
about 1/2 of what you would find in a
traditional cigarette. But one
interesting finding was that although
they were--this was one so-called drag
from an e-cigarette--what they found was
that although they weren't achieving the
same levels they were taking more puffs
within the same period of time, or even though they were
getting less per puff, they were driven
to take more puffs to achieve a
greater nicotine buzz. The other
conclusion was the fact that later
generation of e-cigarettes delivered
nicotine more efficiently, suggesting
that e-cigarettes as a whole, as an
industry, are really just getting more
and more efficient at delivering
nicotine. A lot of it has to do with the
devices itself. So, before I get into e-cigarettes
and lung danger, I want to talk a
little bit more about nicotine and
general health detriments. These are
from the most recent Surgeon General's
Report. So, cigarettes contain
nicotine, and nicotine is very addictive,
we've known that for a very long time.
Nicotine exposure, especially during
adolescence, when the brain is developing,
they have long lasting consequences. It can have
behavioral or neurological long-term
consequences. We also know that there are
a lot of social and environmental
factors that influence tobacco use. So,
an example--if there's a family member, a
friend, who smokes, you have a greater
risk of smoking, yourself.
We know that nicotine is very dangerous
in pregnancy. It can result in preterm
delivery or stillbirth, it can affect
brain development for fetuses that are
exposed to nicotine in-utero, it can
result in a lot of behavioral disorders,
ADHD, it can result in--it's been linked
to type 2 diabetes, obesity, high blood
pressure. So, what about the lungs? That's
kind of a point of this talk. This was a
very compelling study that was published
in 2016, looking at the potential harm on lung
tissue from e-liquids containing
nicotine. I think this study embodies
some of the more compelling evidence of
the potential harms of nicotine in the
lungs. This was published by a New
York-based group in 2016. They looked
specifically at e-liquids on surface
cells of the airway, to both nicotine- and
non nicotine-containing liquids. They
looked at a variety of outcomes in both
humans and mice. So, the way that they did
this, mice were exposed to either a
control, something called phosphate
buffered saline--it's basically a saline
solution--or an e-liquid containing a
solvent that had either 0 or 18
milligrams per ml for 1 hour per day for
4 months straight, and that
concentration, 18 milligrams per mL, is
similar to what you would find in a
commercial e-liquid. So when
we're looking at these pictures,
these are the little air sacs at the ends of the lungs that
participate in gas exchange or
respiration. You'll notice that these air
spaces in the control group are
relatively small. Similarly, in the lung
tissue exposed to aerosol without
nicotine, you have these very small air
spaces with a lot of lung tissue, and
this is generally a good thing. When
you have smaller air spaces, there's a
lot of room for them
to expand, there's a lot of surface area
for oxygen to diffuse into the blood and
for carbon dioxide to diffuse out. The
tissue itself is very strong and robust.
It's elastic, it can easily expand and
snap back into place. Now, when you
compare that to the image on the right,
you'll notice these very large air sacs
with a lot less lung tissue. When there's
a lot less lung tissue, it means that
there's a lot less surface area for
these lungs to participate in gas
exchange, and in addition, the airways
themselves are weaker. So, this is a
similar finding under a microscope that
you would see in something like a 20
pack, your 30 pack, your adult smoker with
COPD or emphysema, where there are fewer
and larger air sacs for gas exchange.
They're also able to measure lung
function. This is a chart. This chart on
the left is essentially a measurement of
the force of exhalation. If you have
asthma, or if you have a child with
asthma, this is a form of a study called
spirometry, which we perform all the time
in our clinics, and it measures the
strength of flow of air during
inhalation and exhalation. In this
study, they were able to measure
something similar in mice called the FEF 50, or the forced expiratory force at
50%, and what they saw was a significant
reduction in this measurement in mice
exposed to nicotine. Again, this is a
finding similar to what you would see in
obstructive lung diseases, like asthma or
emphysema. Also, in these mice,
they measured the activity of various
enzymes involved in something called
apoptosis, or programmed cell death. So,
this is a protein called caspase, and
what they found is that they were able
to detect significantly higher activity
levels of these enzymes in cells that
were exposed to nicotine compared to
cells that weren't exposed to nicotine,
and the hypothesis is that this increase
in these substance is associated with
destruction of cells in the airway, which
is why we see some of these changes
under the microscope and this image on
the right. They also looked at the
effects of nicotine on human lung cells
by measuring the movement of an
important structure called the cilia. So, in
all of our airways we have these very
tiny microscopic finger-like projections
that serve to sweep out mucus and debris
and infections, and it's important that
these structures move in a very
coordinated and synergistic way to
function properly. What they
found was, when these structures
were exposed to aerosols containing
nicotine, the speed at which these
structures did their job, the so-called
beat frequency, was markedly reduced, in
some cases ceasing to function almost
entirely, making lungs susceptible to
more infections. And this, again, has been
corroborated by other studies, so I think
you see where I'm going for this. It sort
of dispels the notion that nicotine is
addictive and nothing more, you know, an
otherwise benign element in all this.
We're starting to learn more and more
that nicotine is a very real culprit in
lung damage associated with e-cigarette
use. What about the solvent? So, propylene
glycol and vegetable glycerin. This was just
an image that I got from Amazon of these
solvents. There have been studies that suggest
that in small doses, up to 28 days,
they're safe when they're ingested by
animals, but beyond that, they are
associated with toxic byproducts with
free radical productions, which can be
carcinogenic. A lot of this has to
do with the the so-called PG/VG ratio, so
that 70/30 propylene glycol to vegetable
glycerin is considered sort of the
safer ratio, so a lot of independent
vendors will sort of stick to that ratio.
As far as the flavorants, a lot of this
depends on the flavor.
Many of these flavor compounds are
derived, not surprisingly, from the flavor
source, so for example, cinnamon is
derived from cinnamon. I mentioned
cinnamon because it does--it's sort of
gotten a reputation as one of the
worst compounds. It does contain
several highly bioactive compounds.
Flavors, as you may have heard, are also
implicated to be the driving
factor for vaping initiation in youth,
and this has, again, been backed up by
numerous studies. Most flavorants
contain compounds that are in
general maybe safe to eat but not to
inhale, so some other toxic byproducts
that have been detected in e-cigarettes--
diethyl phthalate,
which has been detected in nearly half
of e-liquids. According to a study in 2015,
that's been associated with premature
puberty. It's also possibly
carcinogenic. This has gotten a lot of
press--diacetyl (DIE-uh-see-tuhl) or diacetyl (die-AH-si-teel), however
you choose to pronounce it, has been
used in various e-liquids and associated
with something called popcorn lung. The
technical term is bronchiolitis
obliterans. It's really irreversible
destruction of small airways, and the
only cure is a lung transplant. And then
finally, formaldehyde and acetaldehyde
are possible carcinogenic
byproducts. These are more likely to
form in devices that are higher voltage
or higher heat, and the reason this is
important, there are still some places where
custom flavors and independent vape
shops have the ability to basically
commercially extract any product
that they want directly from the source,
and I think we're seeing a lot
more of these so-called homebrew with
things like cannabis oil, things that
have that have been shown very recently
to have very catastrophic effects when
inhaled, and probably a large factor in
the recent outbreak of vaping-related
illnesses. There have been several
studies looking at immune function. I
already mentioned the effects of
nicotine on ciliary function, but there
have been a handful of studies
looking at the effects on local immune
function. So, one study showed that nasal
scrapings from humans--of e-cigarette
users--had large alterations in over 50
immune regulatory genes. Other studies
have shown an increase in molecules
associated with inflammation, so sort of
creating a pro-inflammatory
environment. It's also been shown to
increase the expression of
pro-inflammatory molecules, and in
general, many teens just don't know what
they're inhaling. A large portion don't
even know that they contain nicotine,
that they're just so called--they're just
flavored water--a lot of teens have
reported that, but I started this talk by
presenting evidence that e-cigarettes
are an effective smoking cessation tool
in adults. I put this in now because I
wanted to contrast this with evidence
that it actually has the opposite effect
in adolescents and young adults.
So, over the past few years have been a
slew of studies, one after the other
concluding that never smokers--so those
who had never even tried a cigarette--
during adolescence, if they tried
e-cigarettes, they were more likely to
initiate combustible cigarettes--so,
traditional cigarettes--later on, and the
likelihood of this happening
kind of depended on the location and the
actual study, but time and again, these
studies are coming to the same
conclusion, that vaping, that e-cigarette
use itself is a significant risk factor
for regular cigarette use. So, going back
to the Surgeon General's Report, the data
for e-cigarettes in this report go
back to 2011, and I'll show you more
recent data shortly, but the good news is
that in the last twenty years, there has
been a significant decline in just
combustible tobacco use. So, you can see
in 2011, 14% of middle school
students had ever used tobacco. That's
reduced pretty significantly, and that
trend continues to decrease and
eventually sort of plateau around 5% as of this year.
By contrast, you'll notice that
e-cigarette use--so, either e-cigarette only
use or combustible and e-cigarette use--
surpassed traditional cigarette
use somewhere between the data
collection of 2014 and 2015, and again,
similarly, that trend continues to 2019.
This is national data from the
Monitoring the Future database of 2017,
which is a survey of over 43,000
students in the United States that looks
at every manner of substance use from
8th graders through young adults. The
earliest data in the study on
e-cigarettes dates back to 2014. Some of
the important findings--so, vaping had a
higher 30-day prevalence than all
tobacco products among
eighth, tenth, and twelfth graders,
and the 30-day prevalence among
these among 12 graders is the highest. In
2017, 11% of 12th graders report
recent--so, within 30-day use--which is
pretty staggering. And one thing I want
to note with these arrows here is that
this cohort is the same as this cohort,
so you can see that the jump from
8th to 10th grade from 2015 to 2017 is
pretty staggering for ever use. You can
also notice that from 10th to
12th grade--so this cohort is the same as
this cohort--there is still an increase
from 10th to 12th grade for e-cigarette
use. And then this is the National Youth
Tobacco Survey from the CDC reported
last year. This is only getting worse.
Basically, e-cigarette use is still on
the rise with, as of last year, 3.5
million middle and high school students
engaging in active past 30-day cigarette
use, which is more than double what it
was a year before that at 1.5 million.
And you'll notice that past 30-day use
has increased from 11% to 21%, so
really, 1 in 5 are reporting past 30-day
use as of 2018. They cited nicotine
flavoring as the major reason for this.
So, after this report came out in
November of last year--so, one year ago--
the FDA proposed to address this by
revisiting the flavoring policies. The
proposal from the FDA's Center for
Tobacco Products called for a ban in
flavors in e-cigarettes except from
mint and menthol, which are
suggested to help adult smokers quit
using combustible cigarettes. They also
suggested age verification for online
sales. So, a lot of local ordinances are
taking this into their own hands before
this starts to take effect in
2022, especially in California, but on
November 6, 2019, the most
recent data from the National Youth
Tobacco Survey reported a jump from 21% to 27% of high school
students who use e-cigarettes and
10.5% of middle schoolers
who use e-cigarettes in the last 30 days.
About 1/3 of them use e-cigarettes
more than 20 days per month.
Compare that to combustible cigarette
use, which continues to decline
from 2011 through 2019.
You notice that it's about 5% to 6% of
high schoolers are using cigarettes
compared to 27.5% of high schoolers that
are using electronic cigarettes, and that
continues those trends continue to this day.
So finally, I wanted to talk about the
outbreak of vaping-related illnesses in
2019. It goes by a few different names.
The CDC has dubbed it E-cigarette or
Vaping-Associated Lung Injury. I think
it's pronounced EVALI.
That's how I'm gonna choose to pronounce
it. It's been referred to also as
Vaping-Associated Lung Injury (VALI),
Vaping-Related Pulmonary Illness,
basically any combination of those words,
but basically, it describes a sudden
respiratory illness that can take hours
to days. It might be life-threatening, and
it can mimic other causes of acute
respiratory failure, so, for example,
pneumonia. A vast majority of these
patients report respiratory symptoms, so
95% report things like
cough, shortness of breath, chest pain--but
a very large number of these patients
actually reported GI symptoms, and a lot
of the time these GI symptoms--things
like nausea, vomiting, diarrhea, abdominal
pain--can actually precede the
respiratory symptoms. Other signs and
symptoms are very nonspecific, so things
like body aches, fever, weight loss over
the course, diminished appetite, you know--
failure to respond to antibiotic therapy,
I think, is a key finding. Remember,
this is not an infection, so antibiotics
aren't going to fix this. But a lot of
these things are very nonspecific and
very difficult to detect, so I think a
strong index of suspicion should be had
by parents as well as providers if
someone comes in with acute respiratory
failure without a specific explanation
in an otherwise healthy person. So, as of
October 2019, there have been 1,299 cases.
Just recently, on November 5th,
the number of cases grew to over 2,000
cases of Vaping-Associated Lung Injury
in the United States. I mean, 49 states, the District of
Columbia, and the US Virgin Islands--I think
the one state was Alaska that hasn't
reported any vaping-related illnesses.
There have been--there were 21 reported
deaths a few weeks ago that has risen to
39 reported deaths, and the vast
majority of these cases have occurred
within the last 4 months. The median
age is 24, with 80% less than
the age of 35.
70% of these cases have been in
males, and the median age of death is 49
years old, with a very wide range of 17
to 75. So, even though the cases are more
prevalent in young adults, they tend to
be more resilient than older patients,
who are more susceptible, really, to
death from this vaping-related illness.
There has been at least one double lung
transplant in response to a patient who
was injured by vaping. That patient was a
minor, he was 17 years old and was, in my
opinion, extremely lucky to have even
been considered for a lung transplant,
since substance abuse and active
nicotine use is taken into strong
consideration when lungs are
allocated for donation. So, the CDC has
been actively investigating the cause of
this recent outbreak. They have reported
that 76% of patients reported
using THC--so, a byproduct of marijuana or
cannabis-containing products--but
13% still report not using
THC-containing products, but a very recent
report suggested that a derivative of
vitamin E acetate was found in
lung fluid in 100% of these cases, so
they looked at the lung fluid of 29
patients, and this vitamin E acetate
derivative was actually found in every
single one of these samples. So, why do
they--why do I bring this up? It's, you
know, it's very tempting to say that this
is sort of an isolated incident or this
was a bad batch or something. In this case, I
agree, I think it's very reasonable to
make that conclusion, but a few points I
want to make. One is that we don't really have any
idea how long this outbreak is going to
last. The numbers keep rising, every
report that comes out seems to indicate
that this product, this problem, is just
getting worse, and we really don't know
if it's gonna happen again. We don't know
if there are any other culprits in this,
and we still haven't detected anything
else. And so they say that this is
somehow proof that since commercial
vaping products are not the culprit in
this, they must be safe, that if it
doesn't cause lung injury, then then it
isn't harmful to your lungs, and the
truth is we still don't know about the
long-term effects of e-cigarettes, and
when you compare them to cigarettes, it
might be important for active adult
smokers, but that comparison kind of
loses its substance to
healthy lungs that are naive to the
effects of a foreign substance. One final
point I want to make just before--just be
careful when you're trying to seek
information, when using the internet, when
you look for information about vaping.
If it starts with something like, "Debunking the
myths about vaping," I would just stay
away. They're not really debunking
anything, they're really just trying to
preserve their industry, and just be
aware where you're getting the
information from. I think less is more, in
this case. A great starting point is the
CDC website. There's information about
vaping in general, the recent vaping
related illness outbreak, which is
updated weekly, the latest news and
resources, and you really can't go wrong
by starting there. Some other really
great resources--PAVE, so Parents Against
Vaping E-cigarette, is an advocacy
group. It's sort of geared more
toward parents, what to look for in
their children who are vaping. And then,
of course, drugfree.org is another
great resource. So, that's it. I will--at
this point, I'm going to open it up to
some questions from the audience.
Okay, so the first question I have is "Are e-cigarettes more dangerous
than traditional cigarettes?" So, I sort of
touched on this in my presentation. I
think, you know, the short answer is
we don't know.
I think, logically, anything combustible
is probably worse for you than
electronic cigarettes, but really, I think
the important point to take from this is
that when you're comparing traditional
cigarettes to electronic cigarettes, the
only people that that's actually
relevant to are active adult smokers. If
you saw my data earlier on the trends of
traditional cigarette use, if you're
looking at youth, if you're looking at
8th, 10th, 12th graders who are using
e-cigarettes, many of them--at least 94%
of them--probably wouldn't have
touched a cigarette to begin with, so you
shouldn't really be comparing cigarettes
to e-cigarettes in that population. You
should be comparing a cigarette to
nothing, and there's a lot of evidence
that suggests that e-cigarettes are
harmful in the short term and the long
term, but again, we don't know
the long-term effects of vaping.
"Is vitamin E acetate found in all vaping
liquids?" It is not. It is not a common
ingredient. From what I understand, it's
not included in commercial e-cigarettes.
I don't think the CDC has identified the
first source of this, whether it was
an intentional additive, whether it was a
bad batch of something, but no, it is not
a common ingredient in e-liquids,
although it seems to be more prevalent
in liquids that contain derivatives of
cannabis, so marijuana-containing
e-liquids. "Is vaping healthy as long as
there's no nicotine?" I think that's kind
of an interesting question. You know,
my stance as a pulmonologist is,
I would say, similar to the question of
cigarettes compared to e-cigarettes, you
know, you're not comparing one
thing to the other, you're comparing
something to not putting something into
your lungs. And I think, really, the only
thing that should go into your lungs is air, really,
oxygen, or if you have a medication
that's prescribed by a pulmonologist
or a primary care doctor, that those are
generally better for you than doing
something recreational that can be very
harmful to your lungs. "What about the
argument that everything's fine in
moderation? Does that apply here?" So I do
agree that everything is fine in
moderation. It really depends on how you
define moderation. In the case of
e-cigarettes, I would define moderation
as almost nothing. The reason for that is
we know that e-cigarettes--most
e-cigarettes contain nicotine, and once
you start using nicotine, it's very, very
difficult to quit, even with a small
amount of use, so I would say
"everything's fine in moderation" probably
doesn't apply to e-cigarettes. The other
argument I would make is that many of
these cases of e-cigarette use-related
lung injury are in patients who had
never even used an e-cigarette before, so
maybe not necessarily heavy users, so one
time can actually be catastrophic in
some cases, especially in these sort of
third-party homebrew applications of
electronic cigarettes. "How does one
combat smoking addiction and now
e-cigarette smoking addiction?" Again,
there are a lot of great resources on
the CDC. There are smoking cessation
programs that have been very helpful;
they've been demonstrated to be very
helpful. Nicotine replacement therapy
that's prescribed by a doctor, as long as
it's used correctly, can be very
effective. There are certain medications,
sort of off-label use medications that
can be very effective in nicotine
addiction and have been shown to be very
beneficial for active smokers and for
people who are addicted to nicotine. And
I think that's it. Were there anything else? Okay,
well, I hope you learned something today.
Please feel free to call the pulmonary
office at UCLA if you have any other
questions.
assistant clinical professor of
pediatric pulmonology at UCLA, and I'm
going to talk about e-cigarettes and
lung health today. I have nothing to
disclose, I have no relationships to
disclose for this presentation. So,
e-cigarettes are a group of devices that
allow users to inhale an aerosol, usually
containing nicotine and flavoring, for
recreational use, and I wanted to
emphasize recreational use to
distinguish it from other aerosolized
things like nebulizers, inhalers, which
are prescribed by doctors. They go by a
lot of different names, e-cigarettes, e-cigs,
cigalikes, vapes, vape pens, tanks--some
people just refer to them by the brand
name itself, and they become very popular,
especially in the past decade. In 2014,
they surpassed traditional cigarette use
among adolescents and young adults. The
concept of noncombustible nicotine
delivery has actually been around for
quite a long time. The first patent can
be traced back to the 1920s. In 1927, a
man named Joseph Robinson filed a patent
for what was sort of a prototype of an
electronic cigarette, but it never--they
never used the word cigarette or tobacco.
I'm just going to read a short excerpt
from that patent: "It produces an
extremely simple vaporizer, which
extended use has demonstrated to be of
great effectiveness in the treatment of
afflictions for which its use is
intended." So it was really first intended
to be a medicinal tool. Again, nowhere in
the patent does it say the word
tobacco. In a way, it was described
something like a nebulizer, except it
uses a heated coil. The patent was
granted in 1931, but it was never
commercialized. In 1963, a man named
Herbert Gilbert also attempted to make a
smokeless nontobacco
cigarette, the goal being to replace
burning tobacco with a heated moist
flavored air. Again, that was never
commercialized. One notable product from
the late 1970s was something called the
the Favor. Their slogan was "Do yourself
a favor." It was a smokeless cigarette. It essentially
was just paper soaked in nicotine
containing liquid that the
user would inhale without lighting or
combusting anything, but they were very
expensive, they didn't deliver nicotine
very effectively, and as a result, they
were a massive commercial failure. But
the first modern e-cigarette was
mass-produced in 2003 by a Chinese
pharmacist named Hon Lik, who was the
former deputy director of the Institute
of Chinese Medicine, and the original
intent, as with these other products, was
a smoking cessation tool, and it's even a
statement stated as such in the patent.
It was the first recent innovation that
was mass-produced by a company called
Ruyan. It used something called a
piezoelectric ultrasound emitting
element, which is essentially a power
source that generated electricity. It
made its way to the US markets in 2005, a
lot of sort of copycat devices started
popping up globally, using both this
technology and, later, batteries, and at this
time, it was introduced to the US market.
A couple of years later, in 2007, we saw a
very rapid rise in sales in the United
States, so a company called Plume, which
was renamed to PAX Labs, was
founded by two Stanford grad students
in San Francisco. That company would
later become the company that produced
Joule, and in 2017, Joule actually spun
off into a separate company--again, I
mentioned that in 2015, e-cigarettes
surpassed traditional cigarette use
among youth for the first time, I'll talk
more about that a little bit later--by
2018, e-cigarettes had actually become
a multi-billion dollar industry, so it
was so profitable that tobacco companies
wanted in. So, Altria, the parent company
of Philip Morris, actually purchased a
35% stake in the popular brand Joule in
late 2018, and as you've probably heard,
in 2019, there have been hundreds of
cases of--really, thousands of cases of a
vaping-related illness that started
popping up around the United States--I'll
talk more about that as well a little
bit later. So, what exactly are these
devices? So, this is a modern e-cigarette.
They contain three basic elements.
There's a mouthpiece, so an interface
that's connected to a tank that contains
a heating coil, so that heat aerosolizes
what's called an e-liquid, and
then there's a power source with a
button, usually to--sometimes a button,
sometimes just the active inhaling
initializes the device. Inside the tank,
you have what's called an e-liquid, and
each e-liquid is comprised of really
three main ingredients. So, there's a
solvent--propylene glycol and/or
vegetable glycerin, usually a combination
of both--there is a usually nicotine
involved, although they don't have to
contain nicotine, and usually a flavoring
as well. Some of the flavors that are
currently available--this is from the
Surgeon General's report in 2016--we have
bubblegum, chocolate, cotton candy, grape,
gummy bear, and a lot of states have sort
of caught on to this, and jurisdictions--
Los Angeles, for example, has moved to ban
the sale of flavored e-cigarettes
because of the appeal to children. But
these are some examples of what a lot of
these cigarettes look like now. You'll
notice that they're very compact, they're
simple they share a lot of design
elements with popular tech products. The
product on the right is available from
Joule, sort of like a baby macbook or
iPhone or something. They have these
proprietary things called pods, so this
is the menthol pod, it's still available
through the Joule website. The amount of
nicotine in these pods is about 5% per
weight at maximum, which amounts to about
59 milligrams of nicotine. By comparison,
a cigarette contains about 6 to 12
milligrams, so a pod can contain as much
as 2/3 to one entire pack of
cigarettes, and a user can actually get
through a Joule pod anywhere from a
couple of days to a week, not much than
less than what you would expect for a
pack of cigarettes, but that number can
vary widely, of course, depending on the
user. So, one reason that a lot of people
use e-cigarettes is to help quit smoking,
and there have been sort of a handful of
large randomized control trials
examining the effectiveness of
e-cigarettes and smoking cessation. So,
this was published in 2013 in the
journal
The Lancet. 657 people were randomized to
either nicotine e-cigarettes, nicotine
patches, or placebo e-cigarettes, so
e-cigarettes that don't contain
nicotine. They defined abstinence as not
using combustible cigarettes. What they
found was a rate of 7.3% of e-cigarette
users were abstinent from cigarettes
compared to 5.8% from nicotine
patches and about 4.1% who used
e-cigarettes which didn't contain
nicotine. So, from this study, they
concluded that e-cigarettes were
modestly effective at helping smokers,
similar to nicotine patches, but another
thing I liked about this study was just
simply giving someone something that
they thought contained nicotine--so, a
placebo--could also be effective at
helping people quit cigarettes even
though it's very minimal. Another study
that came out more recently--this is a
randomized control trial that came out
in early 2019 in the New England Journal
of Medicine--so this was nearly 900
participants, they were assigned to
either a combined smoking cessation
group, such as behavioral therapy and
nicotine patches, or an e-cigarette group,
and the primary outcome that they looked
at was, again, sustained abstinence from
from combustible cigarettes for one year.
They actually verified this by measuring
the level of carbon monoxide in the
blood to verify this. E-cigarettes do
work as a modality to quit cigarettes.
They do seem to work quite well if 1
in 5 cigarette users are switching to
e-cigarettes versus 1 in 10. It's hard
to argue that they don't work for their
intended purpose. They also saw a 10% to
20% reduction in cough and phlegm
production in these people
compared to nicotine replacement
therapy, but they did find an increase in
the amount of reported mouth irritation
that's been corroborated with others by
other studies, and they didn't see any
significant difference in the incidence
of wheezing or shortness of breath. But
again, I just want to point out this
disclaimer that this was a study done on
active smokers, so these are not never
smokers. So, how much nicotine does an
e-cigarette actually deliver? You can compare the amount of nicotine in a cigarrette or an ounce of liquid, but the more
important measure really is the
plasma-nicotine concentration. So, this is
a study that was published in 2017
comparing plasma and nicotine levels at
steady intervals, at 5, 10, 15, 20, etc.
minutes after the initial use, and I like
this study because it seemed
comprehensive, although it might be a
little bit outdated. It was done
before Joule was really popular--it was
still emerging--so that was not included
in this study. Also, the 11 people that
were studied were so-called experienced
vapers, so they were good at it, which may
or may not represent the general
population. But if we look at the data--so,
the amount of blood nicotine levels
from cigarettes in this study was
clearly the highest--that's this blue
line at the top, so at 5 minutes, it
peaked to a concentration of 18 nanograms
per mL. In close second was a
brand called Views, which is a popular
and later generations considered a
third-generation brand of e-cigarettes.
As we go down, we see that the level of
nicotine approaches about 2/3 to
about 1/2 of what you would find in a
traditional cigarette. But one
interesting finding was that although
they were--this was one so-called drag
from an e-cigarette--what they found was
that although they weren't achieving the
same levels they were taking more puffs
within the same period of time, or even though they were
getting less per puff, they were driven
to take more puffs to achieve a
greater nicotine buzz. The other
conclusion was the fact that later
generation of e-cigarettes delivered
nicotine more efficiently, suggesting
that e-cigarettes as a whole, as an
industry, are really just getting more
and more efficient at delivering
nicotine. A lot of it has to do with the
devices itself. So, before I get into e-cigarettes
and lung danger, I want to talk a
little bit more about nicotine and
general health detriments. These are
from the most recent Surgeon General's
Report. So, cigarettes contain
nicotine, and nicotine is very addictive,
we've known that for a very long time.
Nicotine exposure, especially during
adolescence, when the brain is developing,
they have long lasting consequences. It can have
behavioral or neurological long-term
consequences. We also know that there are
a lot of social and environmental
factors that influence tobacco use. So,
an example--if there's a family member, a
friend, who smokes, you have a greater
risk of smoking, yourself.
We know that nicotine is very dangerous
in pregnancy. It can result in preterm
delivery or stillbirth, it can affect
brain development for fetuses that are
exposed to nicotine in-utero, it can
result in a lot of behavioral disorders,
ADHD, it can result in--it's been linked
to type 2 diabetes, obesity, high blood
pressure. So, what about the lungs? That's
kind of a point of this talk. This was a
very compelling study that was published
in 2016, looking at the potential harm on lung
tissue from e-liquids containing
nicotine. I think this study embodies
some of the more compelling evidence of
the potential harms of nicotine in the
lungs. This was published by a New
York-based group in 2016. They looked
specifically at e-liquids on surface
cells of the airway, to both nicotine- and
non nicotine-containing liquids. They
looked at a variety of outcomes in both
humans and mice. So, the way that they did
this, mice were exposed to either a
control, something called phosphate
buffered saline--it's basically a saline
solution--or an e-liquid containing a
solvent that had either 0 or 18
milligrams per ml for 1 hour per day for
4 months straight, and that
concentration, 18 milligrams per mL, is
similar to what you would find in a
commercial e-liquid. So when
we're looking at these pictures,
these are the little air sacs at the ends of the lungs that
participate in gas exchange or
respiration. You'll notice that these air
spaces in the control group are
relatively small. Similarly, in the lung
tissue exposed to aerosol without
nicotine, you have these very small air
spaces with a lot of lung tissue, and
this is generally a good thing. When
you have smaller air spaces, there's a
lot of room for them
to expand, there's a lot of surface area
for oxygen to diffuse into the blood and
for carbon dioxide to diffuse out. The
tissue itself is very strong and robust.
It's elastic, it can easily expand and
snap back into place. Now, when you
compare that to the image on the right,
you'll notice these very large air sacs
with a lot less lung tissue. When there's
a lot less lung tissue, it means that
there's a lot less surface area for
these lungs to participate in gas
exchange, and in addition, the airways
themselves are weaker. So, this is a
similar finding under a microscope that
you would see in something like a 20
pack, your 30 pack, your adult smoker with
COPD or emphysema, where there are fewer
and larger air sacs for gas exchange.
They're also able to measure lung
function. This is a chart. This chart on
the left is essentially a measurement of
the force of exhalation. If you have
asthma, or if you have a child with
asthma, this is a form of a study called
spirometry, which we perform all the time
in our clinics, and it measures the
strength of flow of air during
inhalation and exhalation. In this
study, they were able to measure
something similar in mice called the FEF 50, or the forced expiratory force at
50%, and what they saw was a significant
reduction in this measurement in mice
exposed to nicotine. Again, this is a
finding similar to what you would see in
obstructive lung diseases, like asthma or
emphysema. Also, in these mice,
they measured the activity of various
enzymes involved in something called
apoptosis, or programmed cell death. So,
this is a protein called caspase, and
what they found is that they were able
to detect significantly higher activity
levels of these enzymes in cells that
were exposed to nicotine compared to
cells that weren't exposed to nicotine,
and the hypothesis is that this increase
in these substance is associated with
destruction of cells in the airway, which
is why we see some of these changes
under the microscope and this image on
the right. They also looked at the
effects of nicotine on human lung cells
by measuring the movement of an
important structure called the cilia. So, in
all of our airways we have these very
tiny microscopic finger-like projections
that serve to sweep out mucus and debris
and infections, and it's important that
these structures move in a very
coordinated and synergistic way to
function properly. What they
found was, when these structures
were exposed to aerosols containing
nicotine, the speed at which these
structures did their job, the so-called
beat frequency, was markedly reduced, in
some cases ceasing to function almost
entirely, making lungs susceptible to
more infections. And this, again, has been
corroborated by other studies, so I think
you see where I'm going for this. It sort
of dispels the notion that nicotine is
addictive and nothing more, you know, an
otherwise benign element in all this.
We're starting to learn more and more
that nicotine is a very real culprit in
lung damage associated with e-cigarette
use. What about the solvent? So, propylene
glycol and vegetable glycerin. This was just
an image that I got from Amazon of these
solvents. There have been studies that suggest
that in small doses, up to 28 days,
they're safe when they're ingested by
animals, but beyond that, they are
associated with toxic byproducts with
free radical productions, which can be
carcinogenic. A lot of this has to
do with the the so-called PG/VG ratio, so
that 70/30 propylene glycol to vegetable
glycerin is considered sort of the
safer ratio, so a lot of independent
vendors will sort of stick to that ratio.
As far as the flavorants, a lot of this
depends on the flavor.
Many of these flavor compounds are
derived, not surprisingly, from the flavor
source, so for example, cinnamon is
derived from cinnamon. I mentioned
cinnamon because it does--it's sort of
gotten a reputation as one of the
worst compounds. It does contain
several highly bioactive compounds.
Flavors, as you may have heard, are also
implicated to be the driving
factor for vaping initiation in youth,
and this has, again, been backed up by
numerous studies. Most flavorants
contain compounds that are in
general maybe safe to eat but not to
inhale, so some other toxic byproducts
that have been detected in e-cigarettes--
diethyl phthalate,
which has been detected in nearly half
of e-liquids. According to a study in 2015,
that's been associated with premature
puberty. It's also possibly
carcinogenic. This has gotten a lot of
press--diacetyl (DIE-uh-see-tuhl) or diacetyl (die-AH-si-teel), however
you choose to pronounce it, has been
used in various e-liquids and associated
with something called popcorn lung. The
technical term is bronchiolitis
obliterans. It's really irreversible
destruction of small airways, and the
only cure is a lung transplant. And then
finally, formaldehyde and acetaldehyde
are possible carcinogenic
byproducts. These are more likely to
form in devices that are higher voltage
or higher heat, and the reason this is
important, there are still some places where
custom flavors and independent vape
shops have the ability to basically
commercially extract any product
that they want directly from the source,
and I think we're seeing a lot
more of these so-called homebrew with
things like cannabis oil, things that
have that have been shown very recently
to have very catastrophic effects when
inhaled, and probably a large factor in
the recent outbreak of vaping-related
illnesses. There have been several
studies looking at immune function. I
already mentioned the effects of
nicotine on ciliary function, but there
have been a handful of studies
looking at the effects on local immune
function. So, one study showed that nasal
scrapings from humans--of e-cigarette
users--had large alterations in over 50
immune regulatory genes. Other studies
have shown an increase in molecules
associated with inflammation, so sort of
creating a pro-inflammatory
environment. It's also been shown to
increase the expression of
pro-inflammatory molecules, and in
general, many teens just don't know what
they're inhaling. A large portion don't
even know that they contain nicotine,
that they're just so called--they're just
flavored water--a lot of teens have
reported that, but I started this talk by
presenting evidence that e-cigarettes
are an effective smoking cessation tool
in adults. I put this in now because I
wanted to contrast this with evidence
that it actually has the opposite effect
in adolescents and young adults.
So, over the past few years have been a
slew of studies, one after the other
concluding that never smokers--so those
who had never even tried a cigarette--
during adolescence, if they tried
e-cigarettes, they were more likely to
initiate combustible cigarettes--so,
traditional cigarettes--later on, and the
likelihood of this happening
kind of depended on the location and the
actual study, but time and again, these
studies are coming to the same
conclusion, that vaping, that e-cigarette
use itself is a significant risk factor
for regular cigarette use. So, going back
to the Surgeon General's Report, the data
for e-cigarettes in this report go
back to 2011, and I'll show you more
recent data shortly, but the good news is
that in the last twenty years, there has
been a significant decline in just
combustible tobacco use. So, you can see
in 2011, 14% of middle school
students had ever used tobacco. That's
reduced pretty significantly, and that
trend continues to decrease and
eventually sort of plateau around 5% as of this year.
By contrast, you'll notice that
e-cigarette use--so, either e-cigarette only
use or combustible and e-cigarette use--
surpassed traditional cigarette
use somewhere between the data
collection of 2014 and 2015, and again,
similarly, that trend continues to 2019.
This is national data from the
Monitoring the Future database of 2017,
which is a survey of over 43,000
students in the United States that looks
at every manner of substance use from
8th graders through young adults. The
earliest data in the study on
e-cigarettes dates back to 2014. Some of
the important findings--so, vaping had a
higher 30-day prevalence than all
tobacco products among
eighth, tenth, and twelfth graders,
and the 30-day prevalence among
these among 12 graders is the highest. In
2017, 11% of 12th graders report
recent--so, within 30-day use--which is
pretty staggering. And one thing I want
to note with these arrows here is that
this cohort is the same as this cohort,
so you can see that the jump from
8th to 10th grade from 2015 to 2017 is
pretty staggering for ever use. You can
also notice that from 10th to
12th grade--so this cohort is the same as
this cohort--there is still an increase
from 10th to 12th grade for e-cigarette
use. And then this is the National Youth
Tobacco Survey from the CDC reported
last year. This is only getting worse.
Basically, e-cigarette use is still on
the rise with, as of last year, 3.5
million middle and high school students
engaging in active past 30-day cigarette
use, which is more than double what it
was a year before that at 1.5 million.
And you'll notice that past 30-day use
has increased from 11% to 21%, so
really, 1 in 5 are reporting past 30-day
use as of 2018. They cited nicotine
flavoring as the major reason for this.
So, after this report came out in
November of last year--so, one year ago--
the FDA proposed to address this by
revisiting the flavoring policies. The
proposal from the FDA's Center for
Tobacco Products called for a ban in
flavors in e-cigarettes except from
mint and menthol, which are
suggested to help adult smokers quit
using combustible cigarettes. They also
suggested age verification for online
sales. So, a lot of local ordinances are
taking this into their own hands before
this starts to take effect in
2022, especially in California, but on
November 6, 2019, the most
recent data from the National Youth
Tobacco Survey reported a jump from 21% to 27% of high school
students who use e-cigarettes and
10.5% of middle schoolers
who use e-cigarettes in the last 30 days.
About 1/3 of them use e-cigarettes
more than 20 days per month.
Compare that to combustible cigarette
use, which continues to decline
from 2011 through 2019.
You notice that it's about 5% to 6% of
high schoolers are using cigarettes
compared to 27.5% of high schoolers that
are using electronic cigarettes, and that
continues those trends continue to this day.
So finally, I wanted to talk about the
outbreak of vaping-related illnesses in
2019. It goes by a few different names.
The CDC has dubbed it E-cigarette or
Vaping-Associated Lung Injury. I think
it's pronounced EVALI.
That's how I'm gonna choose to pronounce
it. It's been referred to also as
Vaping-Associated Lung Injury (VALI),
Vaping-Related Pulmonary Illness,
basically any combination of those words,
but basically, it describes a sudden
respiratory illness that can take hours
to days. It might be life-threatening, and
it can mimic other causes of acute
respiratory failure, so, for example,
pneumonia. A vast majority of these
patients report respiratory symptoms, so
95% report things like
cough, shortness of breath, chest pain--but
a very large number of these patients
actually reported GI symptoms, and a lot
of the time these GI symptoms--things
like nausea, vomiting, diarrhea, abdominal
pain--can actually precede the
respiratory symptoms. Other signs and
symptoms are very nonspecific, so things
like body aches, fever, weight loss over
the course, diminished appetite, you know--
failure to respond to antibiotic therapy,
I think, is a key finding. Remember,
this is not an infection, so antibiotics
aren't going to fix this. But a lot of
these things are very nonspecific and
very difficult to detect, so I think a
strong index of suspicion should be had
by parents as well as providers if
someone comes in with acute respiratory
failure without a specific explanation
in an otherwise healthy person. So, as of
October 2019, there have been 1,299 cases.
Just recently, on November 5th,
the number of cases grew to over 2,000
cases of Vaping-Associated Lung Injury
in the United States. I mean, 49 states, the District of
Columbia, and the US Virgin Islands--I think
the one state was Alaska that hasn't
reported any vaping-related illnesses.
There have been--there were 21 reported
deaths a few weeks ago that has risen to
39 reported deaths, and the vast
majority of these cases have occurred
within the last 4 months. The median
age is 24, with 80% less than
the age of 35.
70% of these cases have been in
males, and the median age of death is 49
years old, with a very wide range of 17
to 75. So, even though the cases are more
prevalent in young adults, they tend to
be more resilient than older patients,
who are more susceptible, really, to
death from this vaping-related illness.
There has been at least one double lung
transplant in response to a patient who
was injured by vaping. That patient was a
minor, he was 17 years old and was, in my
opinion, extremely lucky to have even
been considered for a lung transplant,
since substance abuse and active
nicotine use is taken into strong
consideration when lungs are
allocated for donation. So, the CDC has
been actively investigating the cause of
this recent outbreak. They have reported
that 76% of patients reported
using THC--so, a byproduct of marijuana or
cannabis-containing products--but
13% still report not using
THC-containing products, but a very recent
report suggested that a derivative of
vitamin E acetate was found in
lung fluid in 100% of these cases, so
they looked at the lung fluid of 29
patients, and this vitamin E acetate
derivative was actually found in every
single one of these samples. So, why do
they--why do I bring this up? It's, you
know, it's very tempting to say that this
is sort of an isolated incident or this
was a bad batch or something. In this case, I
agree, I think it's very reasonable to
make that conclusion, but a few points I
want to make. One is that we don't really have any
idea how long this outbreak is going to
last. The numbers keep rising, every
report that comes out seems to indicate
that this product, this problem, is just
getting worse, and we really don't know
if it's gonna happen again. We don't know
if there are any other culprits in this,
and we still haven't detected anything
else. And so they say that this is
somehow proof that since commercial
vaping products are not the culprit in
this, they must be safe, that if it
doesn't cause lung injury, then then it
isn't harmful to your lungs, and the
truth is we still don't know about the
long-term effects of e-cigarettes, and
when you compare them to cigarettes, it
might be important for active adult
smokers, but that comparison kind of
loses its substance to
healthy lungs that are naive to the
effects of a foreign substance. One final
point I want to make just before--just be
careful when you're trying to seek
information, when using the internet, when
you look for information about vaping.
If it starts with something like, "Debunking the
myths about vaping," I would just stay
away. They're not really debunking
anything, they're really just trying to
preserve their industry, and just be
aware where you're getting the
information from. I think less is more, in
this case. A great starting point is the
CDC website. There's information about
vaping in general, the recent vaping
related illness outbreak, which is
updated weekly, the latest news and
resources, and you really can't go wrong
by starting there. Some other really
great resources--PAVE, so Parents Against
Vaping E-cigarette, is an advocacy
group. It's sort of geared more
toward parents, what to look for in
their children who are vaping. And then,
of course, drugfree.org is another
great resource. So, that's it. I will--at
this point, I'm going to open it up to
some questions from the audience.
Okay, so the first question I have is "Are e-cigarettes more dangerous
than traditional cigarettes?" So, I sort of
touched on this in my presentation. I
think, you know, the short answer is
we don't know.
I think, logically, anything combustible
is probably worse for you than
electronic cigarettes, but really, I think
the important point to take from this is
that when you're comparing traditional
cigarettes to electronic cigarettes, the
only people that that's actually
relevant to are active adult smokers. If
you saw my data earlier on the trends of
traditional cigarette use, if you're
looking at youth, if you're looking at
8th, 10th, 12th graders who are using
e-cigarettes, many of them--at least 94%
of them--probably wouldn't have
touched a cigarette to begin with, so you
shouldn't really be comparing cigarettes
to e-cigarettes in that population. You
should be comparing a cigarette to
nothing, and there's a lot of evidence
that suggests that e-cigarettes are
harmful in the short term and the long
term, but again, we don't know
the long-term effects of vaping.
"Is vitamin E acetate found in all vaping
liquids?" It is not. It is not a common
ingredient. From what I understand, it's
not included in commercial e-cigarettes.
I don't think the CDC has identified the
first source of this, whether it was
an intentional additive, whether it was a
bad batch of something, but no, it is not
a common ingredient in e-liquids,
although it seems to be more prevalent
in liquids that contain derivatives of
cannabis, so marijuana-containing
e-liquids. "Is vaping healthy as long as
there's no nicotine?" I think that's kind
of an interesting question. You know,
my stance as a pulmonologist is,
I would say, similar to the question of
cigarettes compared to e-cigarettes, you
know, you're not comparing one
thing to the other, you're comparing
something to not putting something into
your lungs. And I think, really, the only
thing that should go into your lungs is air, really,
oxygen, or if you have a medication
that's prescribed by a pulmonologist
or a primary care doctor, that those are
generally better for you than doing
something recreational that can be very
harmful to your lungs. "What about the
argument that everything's fine in
moderation? Does that apply here?" So I do
agree that everything is fine in
moderation. It really depends on how you
define moderation. In the case of
e-cigarettes, I would define moderation
as almost nothing. The reason for that is
we know that e-cigarettes--most
e-cigarettes contain nicotine, and once
you start using nicotine, it's very, very
difficult to quit, even with a small
amount of use, so I would say
"everything's fine in moderation" probably
doesn't apply to e-cigarettes. The other
argument I would make is that many of
these cases of e-cigarette use-related
lung injury are in patients who had
never even used an e-cigarette before, so
maybe not necessarily heavy users, so one
time can actually be catastrophic in
some cases, especially in these sort of
third-party homebrew applications of
electronic cigarettes. "How does one
combat smoking addiction and now
e-cigarette smoking addiction?" Again,
there are a lot of great resources on
the CDC. There are smoking cessation
programs that have been very helpful;
they've been demonstrated to be very
helpful. Nicotine replacement therapy
that's prescribed by a doctor, as long as
it's used correctly, can be very
effective. There are certain medications,
sort of off-label use medications that
can be very effective in nicotine
addiction and have been shown to be very
beneficial for active smokers and for
people who are addicted to nicotine. And
I think that's it. Were there anything else? Okay,
well, I hope you learned something today.
Please feel free to call the pulmonary
office at UCLA if you have any other
questions.
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