Priming Young Adults with Vaping

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The National Institute of Health announced that recent national survey research discovered that almost 1 in 3 (27.8%) 12th graders reported some kind of use of a vaping device in the past year, while the use of hookahs and regular cigarettes is declining. When asked what they thought was in the mist they inhaled, 51.8% said it was just flavoring, 32.8% said the mist contained nicotine, and 11.1% said they were smoking marijuana or hash oil. Nora Volkow, the director of NIDA, said: “We are especially concerned because the survey shows that some of the teens using these devices are first-time nicotine users.” Recent research suggests some of them could move on to regular cigarette smoking … or other drugs. And some additional research suggests many teens don’t actually know what is in the device they are using.

Monitoring the Future (MTF) is a yearly survey of 8th, 10th and 12th graders in school nationwide. The MTF survey is done by the Institute for Social Research at the University of Michigan for NIDA, the National Institute on Drug Abuse. When the survey asked about vaping over the past month, 11% of 12th graders reported vaping nicotine and 4.9% reported vaping marijuana. See the following chart from the NIH news release.

According to the CDC, e-cigarettes are now the most commonly used form of tobacco by youth in the U.S. Dual use, using both regular cigarettes and e-cigarettes, is also common among young adults 18-25. The reasons reported by young people for trying e-cigarettes include curiosity, taste and the belief they are less harmful than other tobacco products. Over 80% of teens and young adults who use e-cigarettes said they use flavored e-cigarettes.

Back in June of 2016 the FDA finalized a rule that extended its regulatory authority to all tobacco products, including e-cigarettes, cigars, hookahs and pipe tobacco. The rule requires health warnings and bans free samples. It also restricts youth access to newly regulated tobacco products by not allowing their sale to those younger than 18 and requiring a photo ID. Manufacturers will have up to two years to continue selling their products while they submit a new tobacco product application (and an additional year while the FDA reviews the application).

The rule will help prevent young people from starting to use these products, help consumers better understand the risks of using these products, prohibit false and misleading product claims, and prevent new tobacco products from being marketed unless a manufacturer demonstrates that the products meet the relevant public health standard.

If the new technology in e-cigarettes helps reduce toxicity compared to conventional cigarettes, encourages current smokers to switch completely and/or are not widely used by youth, they potentially could reduce disease and death. “But if any product prompts young people to become addicted to nicotine, reduces a person’s interest in quitting cigarettes, and/or leads to long-term usage with other tobacco products, the public health impact could be negative.” The FDA encouraged manufacturers to explore product innovations that would maximize potential benefits and minimize risks. The revised rule allows the FDA to further evaluate the impact of these products on the health of both users and non-users.

Psychiatric Times reported e-cigarettes were first developed and commercialized in China in 2003. They entered the US market in 2006. During their first ten years on the market, before the FDA ruling discussed above, advertising and sales of e-cigarettes increased exponentially every year. “While tobacco advertising has been banned from television and radio since 1970, e-cigarettes are promoted widely on these media channels, on the web, and in social media, with many ads reaching youth.” Mislabeling has been a problem with some products labeled as nicotine-free containing nicotine and others having higher concentrations of nicotine than labeled.

The evidence for e-cigarettes as a cessation aid to quit regular cigarette smoking is limited. Dual use of regular cigarettes and e-cigarettes is common. One study reported half of current smokers report regular use of e-cigarettes. A meta-analysis of twenty controlled studies found the odds of quitting cigarettes was 28% lower in individuals who used e-cigarettes. However only 2 randomized controlled trials have been done, and: “The quality of evidence was judged to be low grade, and in both trials, e-cigarettes with nicotine were no different in efficacy for quitting smoking than placebo (nicotine-free) e-cigarettes.”

So at this point in time, the evidence does not support the use of e-cigarettes as an aid to stop smoking regular cigarettes. It should be noted that the American Heart Association’s policy statement of e-cigarettes does not recommend their use. However, if a patient has tried and failed other cessation methods or is unwilling to try them, the AHA does recommend trying e-cigarettes for smoking cessation.

There is evidence that smoking e-cigarettes increases the risk of cardio vascular problems. Swedish researchers, in Antoniewicz et al., demonstrated that in healthy volunteers, ten puffs from an e-cigarette caused an increase in endotheial progenitor cells (EPSs) of the same magnitude as smoking one traditional cigarette. The average e-cigarette user takes 230 puffs per day, raising the prospect that prolonged use could result in serious health consequences. “These findings suggest that a very short exposure to ECV [e-cigarette vapor] caused a rapid EPC mobilization in blood, which may indicate an impact on vascular integrity leading to future atherosclerosis [hardening of the arteries].” A heart specialist for the European Society of Cardiology was quoted in the Daily Mail as saying: “It really surprises me that so little vapour from an e-cigarette is needed to start the heart disease ball rolling. It’s worrying that one e-cigarette can trigger such a response.”

Researchers at the University of Connecticut found evidence that e-cigarettes containing a nicotine-based liquid are potentially as harmful as unfiltered cigarettes in causing DNA damage. The study’s lead author said the results surprised him. “I never expected the DNA damage from e-cigarettes to be equal to tobacco cigarettes.” He was shocked the first time he saw the result, so he diluted the samples and ran the controls again. “But the trend was still there – something in the e-cigarettes was definitely causing damage to the DNA.”

Researchers at the University of North Carolina found that not only do e-cigarettes trigger the same immune responses as regular cigarettes, they also trigger some unique reactions. E-cigarette users uniquely showed significant increases with neutrophil-extracellular-trap (NET)-related proteins in their airways. “Left unchecked neutrophils can contribute to inflammatory lung diseases, such as COPD and cystic fibrosis.” The study also found that e-cigarettes produced negative consequences known to occur in regular cigarettes such as an increase of biomarkers of oxidative stress and activation of defense mechanisms associated with lung disease. They also found an over secretion of mucus secretions that have been associated with diseases like chronic bronchitis, bronchiectasis and asthma.

Another study by Eric and Denise Kandel, “A Molecular Basis for Nicotine as a Gateway Drug” has raised concerns with e-cigarettes as “pure nicotine-delivery devices.” Their study demonstrated that nicotine acted like a gateway drug for cocaine on the brain of mice, “and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke, or e-cigarettes.”

These results provide a biologic basis and a molecular mechanism for the sequence of drug use observed in people. One drug affects the circuitry of the brain in a manner that potentiates the effects of a subsequent drug.Although the typical e-cigarette user has been described as a long-term smoker who is unable to stop smoking, the use of e-cigarettes is increasing exponentially among adolescents and young adults. Our society needs to be concerned about the effect of e-cigarettes on the brain, especially in young people, and the potential for creating a new generation of persons addicted to nicotine. The effects we found in adult mice are likely to be even stronger in adolescent animals. Priming with nicotine has been shown to lead to enhanced cocaine-induced locomotor activity and increased initial self-administration of cocaine among adolescent, but not adult, rats. Whether e-cigarettes will prove to be a gateway to the use of combustible cigarettes and illicit drugs is uncertain, but it is clearly a possibility.

Don’t be too quick to dismiss the Kandels’ nicotine-gateway theory. They were doing basic research on the effects of nicotine on specific areas of the brain. Priming with nicotine enhanced the effects of cocaine in the nucleus accumbens. “Priming with nicotine appeared to increase the rewarding properties of cocaine by further disinhibiting dopaminergic neurons in the ventral tegmental area.” They only observed the priming effect of nicotine when mice were given cocaine at the same time as nicotine. For more on Denise Kandel’s gateway hypothesis see: “Rebirth of the Gateway Hypothesis.”


E-Cigarettes Are Just Unhealthy

© diego_cervo | stockfresh.com

© diego_cervo | stockfresh.com

The pros and cons of e-cigarettes have been trading studies and expert opinions back-and-forth for a number of years. In “Nicotine without smoke: tobacco harm reduction,” The Royal College of Physicians sees e-cigarettes as “an ideal tobacco harm reduction product.” While acknowledging that e-cigarettes are not currently made to medical standards and are probably more hazardous than nicotine replacement therapy (NRT), the report said it was unlikely that the health risks from long-term vapor inhalation would exceed 5% of the harm from smoking tobacco. The report also downplayed concerns that e-cigarettes will increase tobacco smoking and act as a gateway to smoking in younger people. But this strong endorsement is not the last word on the saga of e-cigarettes.

Writing for AfterParty Magazine, Tracy Chabala pointed to a study published in the New England Medical Journal raising the danger of inhaling formaldehyde at concentration levels higher than that of nicotine. If that doesn’t good healthy, you’re correct. Formaldehyde is a known cancer-causing agent, and “How formaldehyde-releasing agents behave in the respiratory tract is unknown.” The study authors calculated the risk from e-cigarettes to be 5 to 15 times as high as the risk of long-term smoking. What’s more, “formaldehyde-releasing agents may deposit more efficiently in the respiratory tract than gaseous formaldehyde, and so they could carry a higher slope factor for cancer.”

In her article,“Can Your E-Cigarette Give You Cancer?,” Tracy Chabala noted there were several strong opinions on the study. A lawyer for the American Vaping Association said the study used the vaping device “in a manner that no one does.” He likened it to leaving a steak on the grill all day—“many cancer-causing substances might be formed but no one would eat such charred works.”  I’m not sure I buy his analogy, that vaping with an e-cigarette is like having a good steak on the grill. But his point seems to be that one limit of the study was that the researchers based their findings on a method of using their devise that no one actually does when vaping.

What the study actually reported was that they used an e-cigarette with a “tank system” and a variable-voltage battery. The aerosolized liquid was collected in an NMR spectroscopy tube over five minutes with each puff of their device taking 3 to 4 seconds. They did not find any formaldehyde-releasing agents at the low voltage setting. However, they did detect agents at the high voltage setting. The lawyer for the American Vaping Association seems to have overplayed his analogy. A biologist from the American Cancer Society said he was reasonably convinced that all the formaldehyde released during the test tube studies would likely break down into formaldehyde in the e-smoker’s lungs. I think I’m going with the opinion of the biologist on this one.

The President of The Cancer Action Network, an advocacy group of the American Cancer Society, urged the federal government to consider the new findings and finalize its proposal to regulate all tobacco products, including e-cigarettes. The findings were just another example of how little is known about these products or the varying levels of exposure to toxic chemicals that can result from using any of the hundreds of different types of e-cigarette devices. He said federal regulation was imperative to help address the health risks of e-cigarettes and others who are exposed to e-cigarette vapor. “Furthermore, until the FDA finalizes its proposal to regulate e-cigarettes and other tobacco products, the industry’s unfettered ability to market these products to kids remains a threat to public health.”

In May of 2016, David Nather reported for STAT News that the FDA issued a set of rules regulating e-cigarettes for the first time, despite strong resistance from the industry. All states would now be required to ban the sale of e-cigarettes to anyone under the age of 18. All devices that went on sale after February 15, 2007 would be subject to FDA review unless the manufacturers can prove their products are ”substantially equivalent” to products being sold or that there is another reason they should be exempt. Dr. Robert Cardiff, the FDA commissioner said: “Today’s rule is a milestone in consumer protection. It marks a new chapter in our efforts to do everything we can under the law to protect Americans from the dangers of tobacco products.”

Manufacturers would have between a year and two years to prepare their applications, depending on whether they are submitting to the reviews or arguing they should be exempt. Then they would have another year to win approval from the FDA. The rule would not ban flavored tobacco products, including e-cigarettes. But the FDA is working on a rule that would restrict cigar companies from using flavors in their marketing just as cigarette makers can’t include flavors in their sales pitches.

The president of the American Vaping Association said it was a big win for American cigarette companies and a giant loss for small businesses.  He predicted that in two or three years, “nearly every vape shop in the country will be closed.” I’m not sure that would be such a bad thing. It seems that the rhetoric pitting Big Tobacco against little vape shops has ignored the real concern over the potential health hazards of vaping instead of smoking tobacco products.

While acknowledging there are anecdotal reports that some people have used e-cigarettes to stop smoking, Mitch Zeller of the FDA said the agency needed more data on how e-cigarettes are being used, including how many people who use e-cigarettes never used tobacco products before. “I hope everyone can agree that kids should not initiate on e-cigarettes simply because of the harm that can come from nicotine.”

Lobbyists for the cigar and e-cigarette industries pushed Congress to create bills that would either exempt them from the new rules or grandfather in products already on the market. Representative Tom Cole of Oklahoma, the chairman of the House subcommittee funding health programs, added a measure to the FDA’s funding bill for next year that would get rid of the February 2007 effective date. Cole said his legislation “provides the same framework for new tobacco products without needlessly subjecting small businesses to unnecessary regulations and without treating law abiding adults like naïve children.”

Mitch Zeller noted that Cole’s measure would eliminate all reviews of e-cigarette products that came on the market after 2007 (the vast majority of them) and clear the way for future products that are similar in design. The proposal “would have an enormously adverse impact on public health and the ability of FDA to do its job.” Beginning on August 8, 2016, the FDA will start regulating e-cigarettes, all cigars, waterpipes (hookahs), tobacco, pipe tobacco, and nicotine gels.

So this leads us to the newest published study of e-cigarettes in the journal Environmental Science & Technology by Sieiman et al., “Emissions from Electronic Cigarettes.” Their study found that all electronic cigarettes emit harmful chemicals. Levels of those toxic compounds are affected by factors in the use of e-cigarettes such as temperature, and the type and age of the device.

A news release from Berkley Lab said the study found that the thermal decomposition of propylene glycol and glycerin leads to the emissions of toxic chemicals such as acrolien and formaldehyde. Propylene glycol and glycerin are found in most e-liquids, the substance vaporized in e-cigarettes. There were 31 different toxic chemicals found at significant levels in e-cigarette vapor. Hugo Destailats, one of the researchers said that while it may be true emissions are much lower from e-cigarettes than conventional ones, that’s only true for certain users, for example, long time smokers who cannot quit. “Regular cigarettes are super unhealthy. E-cigarettes are just unhealthy.”

One of their findings indicated there was a big difference in emissions between the first and last puffs. They found that vapor temperature rose quickly in the first 5 to 10 minutes until it reached a steady state temperature around the twentieth puff.  Emission levels between the first few puffs and the steady state increased by a factor of ten of more. Factors affecting the levels included the device used, the battery voltage and the emitted compound.

In order to test effects due to the device aging, the researchers used a single device over nine consecutive 5-puff cycles without cleaning it. Emissions for formaldehyde, acetaldehyde, and acrolein, which are all irritants or carcinogens, increased. “In some cases we saw formaldehyde levels increase 60 percent between cycles 1 and 9.”

This effect is consistent with the buildup of polymerization byproducts on or near the coil leading to accumulation of the sort of residues that are often referred to in the blogosphere as ‘coil gunk’ or ‘caramelization.’ Heating these residues would provide a secondary source of volatile aldehydes.

Looking at the effect of voltage on emissions, the researchers found that as the voltage increased, both the amount of e-liquid consumed per puff and the vapor temperature were higher. Destailats pointed out this did not mean e-cigarettes were safer to use at lower temperatures. “We found there are emissions of toxic chemicals at any temperature at which you use the device. . . . And the higher the temperature, the more emissions.”

This won’t be the last word in the e-cigarette saga. The back-and-forth conflict is just getting started. You should also keep in mind there is another aspect to the e-cigarette conflict. E-cigarettes are modified or “hacked” to smoke marijuana—dry herb, hash oil or THC liquids. They’re called, ironically, e-joints. See “E-Cigarettes and E-Joints” or do your own Google search.


E-Cigarettes and E-Joints

E-cigarettes were marketed as safer alternatives to regular cigarettes and even smoking cessation aides. Now they are being modified and marketed as THC delivery systems—an e-joint, if you will. Sound strange? I found several YouTube videos on using or converting e-cigarettes for use with marijuana products like hash oil. Here is a short “how to” video. If you prefer more professional vaporizers, you can try the Wacky Puffer and other commercial products.

It didn’t take too long to get from the first e-cigarette to the e-joint. In was only in 2003 that a Chinese pharmacist developed the first e-cigarette. They were introduced to Europe in 2006 and to the U.S. soon after. In 2008, the WHO said it did not consider the e-cigarette to be a legitimate smoking cessation aid. The first Vapefest was held in March of 2010 in Richmond Virginia. In April of 2011, the FDA announced that e-cigarettes would be regulated like traditional tobacco products under the Food Drug and Cosmetic Act. Any e-cigarette product claiming to help stop smoking or that it provides any other health benefit will be strictly regulated as a drug or medical device.

A July 2014 report by the World Health Organization (WHO) suggested a variety of restrictions for e-cigarettes, including a ban on indoor use of e-cigarettes until “exhaled vapor is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined.”  The Fix pointed out how the tobacco industry is entering the e-cigarette industry. Phillip Morris International has purchased the UK company Nicocigs, an e-cigarette maker. The Fix has several articles on e-cigarettes available, including pro and con sounding titles.

In October of 2014, six U.S. senators signed a letter to the FDA urging companies to label e-cigarettes, “listing all of the health threats the products pose.” Then there is Dr. Nathan Cobb, an assistant professor of medicine at Georgetown School of Medicine who thinks e-cigarettes could bring down traditional smoking and save thousands of lives in the process. However, Dr. Stanton Glantz, doesn’t believe that e-cigarettes are as effective in helping people quit smoking as marketing claims they are.

This commentary assumes that e-cigarettes, as currently in the marketplace, will help people quit smoking and ignores the consistent evidence from population-based studies that smokers who use e-cigarettes are about one-third less likely to quit smoking.

There is growing concern that e-cigarettes aren’t really that safe. Ryan Aliapoulios on the AfterPartyChat website noted the obvious problem, “they still deliver the same addictive chemical at the root of so many other health problems: nicotine.”  He mentioned a study, “A Molecular Basis for Nicotine as a Gateway Drug,” that said while e-cigarettes eliminate some of the morbidity from combustible tobacco, they are “pure nicotine-delivery devices.” They have the same effects on the brain as smoking tobacco and they pose the same risk of addiction.

The authors said the use of e-cigarettes is rapidly increasing among adolescents and young adults. “Our society needs to be concerned about the effect of e-cigarettes on the brain, especially in young people, and the potential for creating a new generation of persons addicted to nicotine.”

In “E-Cigarettes Are Not As Harmless As We’ve Been Told,” The Fix reported that Dr. Glantz and his research team found that e-cigarettes produced greater risk than initially thought, “delivering high levels of nano particles which can trigger inflammation and have been linked to asthma, stroke, heart disease, and diabetes.” Glantz was furthered quoted as saying that e-cigarettes are rapidly increasing in popularity with kids. While they are promoted by tobaccos companies that have purchased e-cigarette companies as a way to quit smoking, a safer less polluting alternative to regular cigarettes, “What the evidence to date shows is that while a puff on an e-cigarette isn’t as dangerous as a puff on a regular cigarette, the main effect they seem to be having is to keep people smoking cigarettes.”

So what about e-joints? They actually exist, according to Scientific American. There is a Dutch company, E-Njoint, BV that has released what it says is the first electronic joint—the E-njoint Disposable. It is battery-powered and vaporizes a liquid vegetable-glycerin and polypropylene-glycol with added flavoring. Polypropylene-glycol is the “e-liquid” used in e-cigarettes. Glycerin is colorless and odorless liquid that is widely used in pharmaceutical formulations.

The next version of the E-Njoint will be both rechargeable and capable of being filled with cannabis or a derivative. “Once the cartridges are empty, users are able to fill these cartridges with a liquid. Those liquids may be standard liquids bought at any store around the world or it could be an extract of a cannabis plant.” The company also plans to release an e-joint that can be used with “dry herbs,” like marijuana.

Pamela Ling of the Tobacco Control Policy Fellowship at the University of California, San Francisco’s Center for Tobacco Research and Education said that while the Dutch company is the first to call its product an ‘electronic joint,’ “the idea of using electronic vaporizers for THC or marijuana is not new, and this company is far from the first. ”

An NPR report on “vape pens,” handheld vaporizers for marijuana, noted how they are reshaping the marijuana business and culture. Two years ago, one man was selling vape pens out of the trunk of his car. Now his company, Grenco Science, has a 6,000 square foot headquarters in central Los Angeles.

The concentrates used in vape pens can be very strong. As I noted in a previous, article, “A Little Dab Will Do Ya,” hash oil concentrations can reach 90 percent THC, while the most potent marijuana is usually no more than 20 percent. These high THC levels are even a concern for Allen St. Pierre, the executive director of NORML, the National Organization to Reform Marijuana Laws:

Between the fact that you can potentially pass out with a single inhalation, or you can have such property damage and potential bodily harm just producing it … these [issues of the vape pen] definitely need to be addressed. . . . This is a screaming call for regulation if there ever was one.