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The Vaping Crisis Continues Unabated

The numbers are not good. Vaping rates among youth are continuing their year-to-year surge. Data from the National Youth Tobacco Survey (NYTS) of the Centers for Disease Control and Prevention, published in the Journal of American Medical Association (JAMA) on November 5, 2019 shows an increase in current (past 30-day) nicotine vaping among high school students from 20% in 2018 to 28% in 2019. Among middle schoolers, that number more than doubled, increasing from 5% to 11% in one year. A total of 3.8 million kids were current users in 2018.

Vaping rates in Marin are even higher than national averages and rates in the Tamalpais Union High School District (TUHSD), which consists of Redwood, Drake and Tamalpais High Schools, are even higher than Marin numbers. The most recent numbers from the California Healthy Kids Survey results are not as current as NYTS data and are from 2017-18. Yet they show, for TUHSD students, that 33% of 11th graders and 24% of 9th graders are currently vaping nicotine. Lifetime use is 52% for 11th graders and 39% for 9th graders. One-third of vaping among 9th graders occurs on campus.

JUUL. In spite of the competition from other brands and knockoffs, JUUL is reportedly still the most commonly used brand. NYTS survey data shows an increase in menthol or mint flavored nicotine JUUL pods to levels near that of fruit-flavored nicotine pods, the latter which were pulled from retail shelves (but continued to be sold through the internet) in November, 2018.

In September, 2019, as hospitalizations and deaths from the then mysterious lung illness were being reported, the Trump Administration threatened to ban all flavored vaping products, including mint and menthol pods. But that ban hasn't materialized. More recently, Trump has promised an announcement "soon" that will "balance youth health and jobs". No such announcement as been made as of yet.

In an attempt to preempt federal action, on October 17, 2019, JUUL announced that it would stop selling flavored (creme, fruit, berry and mange) pods entirely but still sell mint flavored pods. Then on November 7, 2019, JUUL further announced it would stop selling mint flavored pods but continue its menthol. JUUL's Founder and CEO was replaced by an executive from Altria (which used to be Philip Morris and has seen its $35 million investment in JUUL take a hit). Last week, JUUL laid off over 600 workers. The first wrongful death lawsuit was filed last month by the mother of an 18-year old Florida boy who used a JUUL for three years and died in his sleep due to "breathing complications" after being hospitalized for lung problems.

EVALI hospitalizations and deaths. EVALI (which stands for e-cigarette or vaping product use associated lung injury) cases continue to mount. As of November 14, 2019 (CDC numbers are released each Thursday), the count was 2,172 confirmed or probable EVALI hospitalizations and 42 deaths. Not included in that number was the first EVALI death in Marin County (the fourth such death in California) the day before. The 45-year old woman was a Vacaville resident living in Novato with her family and had reportedly begun vaping six months ago. There have been 15 EVALI hospitalizations in the Bay Area.

Is Vitamin E Acetate the only culprit? On November 8, 2019, the CDC announced that Vitamin E Acetate, an oil derived from Vitamin E, was a "very strong culprit" in EVALI cases. Vitamin E Acetate is a sticky honey-like substance that is used in skin creams but clings to lung tissue. It is used to dilute THC oil (cannabis) to boost profits or as a thickening agent.

The conclusion was based on samples of lung fluid taken from a very small group of 29 patients, two of whom died, in 10 states which is a small overall sampling. Thus, while it appears that Vitamin E acetate is associated with EVALI, the evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI. Many different substances and product sources are still under investigation, and it may be that there is more than one cause of this outbreak.

Cannabis vapes tied to 85% of the EVALI cases. While JUUL has received the most blame for the vaping crisis, with respect to the EVALI cases, only 15% has been attributed to nicotine vaping. The vast majority of the vapes have contained THC, the active ingredient in cannabis, with most obtained through the black market, i.e., on the street, online or from friends. One counterfeit THC brand called Dank Vapes was responsible for most of the early cases in Illinois and Wisconsin but plenty of other brands such as Diamond OG and Chronic Carts have been implicated as well.

Oregon cannabis dispensary product death. It is worth noting that the second death on August 23, 2019 was from a store-bought vape product containing cannabis oil. It was purchased at a legal cannabis dispensary in Oregon, which is considered to be well regulated, compared with other states where marijuana has been legalized.

Post hospital continuing lung capacity problems. Many of those hospitalized have continuing issues once they are home. Once healthy and active patients have diminished lung capacity and it is unknown whether they will fully recover with time. Some have reported short-term memory struggles. Many relapse and resume vaping once home and then are re-hospitalized. Over 70% of the EVALI cases have been male, with the majority of hospitalizations being teens and young adults at a median age of 23 years old (for deaths, the median age is much higher).

Beyond the headlines. While the EVALI hospitalizations and deaths are attention grabbing headlines, the numbers are still relatively small given the millions of people in our country vaping. It is easy for your child to think that it won't happen to them and teens generally feel invincible.

Of course, the only number which really matters is ONE - your child — but scare

tactics alone will not work with kids. Thus it is important to discuss with your child not just the scary headlines and death count but facts about vaping, e.g., nicotine is one of the most potent and addictive poisons out there and its toxic to every organ in the body, including the brain, altering neurocognition. Or that one of the biggest misconceptions is that vaping produces a water vapor. In fact it produces an aerosol and aerosol is more akin to hairspray, not water. The aerosol hits the back of the throat and goes into the respiratory system.

Know the lingo. Teens love to do tricks and use certain techniques to make the aerosol go into other body systems. For example, "Ghosting" is when you breathe in at such a high intensity and quantity of vapor that the nicotine toxicity gets into your blood system. "Getting Domed" is when you inhale and hold the vapor/aerosol in the mouth until you swallow so it goes into your digestive system.

Know the other E-Cigarette brands. While JUUL grabs the attention, there are other knock off brands that have gained in popularity and have the same sleek design and fruity flavors as JUUL. Lookalikes to JUUL are the Phix, Vuse Alto (owned by RJ Reynolds Tobacco Co), myBlu, Mark Ten Elite, Suorin iShare and dozens others.

The Suorin Drop or Air also has a more unique design (pictured here) but packs even more nicotine than a JUUL pod. While one JUUL pod has nicotine that is equivalent to 41 cigarettes (20 come in a pack of traditional cigarettes), one small Suorin pod is the equivalent of 90 cigarettes!

The new disposable Puff Bars. Gaining in popularity recently are cheaper, disposable puff bars which come in colorful packaging and flavors (pictured to the right). Youth report that many of their peers think that because Puff Bars are cheaper and disposable, they have less nicotine than JUULs. Not true!

Keep abreast of new research There is new evidence that the aerosol produced by vaping is a probable carcinogen. Laboratory animals who are exposed to the aerosol, which has droplets and nanoparticles that pass through cell walls, have developed cancer.

The bottom line? Just Say K-N-O-W! Know what is out there and what these products look like. Know the signs of use. Know the facts about the health effects and risks to adolescents. And know how to effectively talk with your child. To help you do all that, please visit these blogs from the past year:

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