On Dec. 17, 2018, the National Institute of Health stated that a nationwide survey found that High school seniors who reported vaping “aka, just flavoring” increased to 25.7 percent from 20.6 percent in 2017. Among 10th-graders that percentage rose to 24.7 from 19.3. Also, In 2018 the Centers for Disease Control and Prevention found that Colorado led the nation in vaping product usage with 27 percent of high school students using e-cigarettes — more than twice the national average of 13 percent.
Colorado youth are “vaping” at alarming rates. Electronic cigarettes — or e-cigarettes — are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS). An e-cigarette is a battery-operated device typically containing nicotine, flavorings and other chemicals that, when heated, creates inhalable aerosol vapor. Vaping is odorless, the vapor dissipates very quickly, and the devices can be easily hidden and disguised.
Vaping is very hard to detect and San Luis Valley school officials report confiscating few devices and disciplining few students for vaping. Some Colorado schools have begun to install “vaping smoke detectors” in their restrooms and other school areas in an attempt to curb the vaping epidemic. But these new devices are expensive, over $1,000 each, and are currently cost-prohibitive for smaller school districts with smaller budgets.
In October, David Pino, the Monte Vista School District Resource Officer stated, “Working in the school so far I haven’t seen very much vaping or e-cigs. I can’t follow them around all the time during lunch and the times that I have followed them I actually have had some interactions with children doing marijuana unlawfully.” He added that he has caught students doing regular cigarettes before. But he hasn’t seen any of them vaping or using e-cigs. “Not once this year have I come into contact with a juvenile with an e-cigarette. It’s surprising. I’m not saying they’re not out there. They’re just doing a good job of concealing it or not getting caught with it,” said Officer Pino.
It appears this may be the case, as a 2017 Healthy Kids Colorado survey sampled approximately 56,000 Colorado youth from 190 randomly selected middle and high schools statewide. According to Healthy Kids Colorado Survey Data: When asked, “Have you ever used a vapor product?” Over 40 percent of Colorado high school students stated “yes” while 49.2 percent of San Luis Valley high school students admitted to using a vaping product. According to the same survey data: When asked have you used a vapor product during the past 30 days, 27.0 percent in the state and 20.8 percent of San Luis Valley high school students answered “Yes.”
Rio Grande County Public health nurse Paul Wertz stated, “If this was measles or tuberculosis, even just the flu, we would consider this an epidemic outbreak. What we’re talking about is vaping. Nicotine delivery devices among our youth.”
In the Upper San Luis Valley students have stated that there is a lot of peer pressure to “vape.” Students reported that athletes tend to “vape” less than other students. Being involved in sports seems to provide an excuse not to vape. However, students disclosed that they were able to get vapes and e-cigs everywhere including from fellow students and adults. “Students said that a lot of students are getting away with vaping because they hide it well. Students also stated that they think vaping is a healthier choice than cigarettes.” More concerning, students are reporting that ENDS users are becoming addicted to the nicotine in the vapor.
San Luis Valley superintendents, teachers and health officials are trying their best to curb the usage of e-cigarettes by adolescents. Local schools reported that they are educating students about the health risks associated with vaping. Schools have implemented the Second Chance program which is a web-based interactive, and self-directed alternative to a suspension education program for middle and high school youth who have violated a tobacco policy at school. Some school systems have also partnered with Communities that Care (CTC). The CTC system also consists of web workshops with instructional videos, materials, research, and a Social Development Strategy to promote positive youth development. Some school districts have Health and Wellness Taskforces that implement comprehensive health and wellness classes that use an evidence-based curriculum to address tobacco/drug/alcohol prevention and abuse and other health related topics.
Over 85 percent of e-cigarettes, vaping cartridges contain nicotine
E-cigarettes are devices that heat a liquid into an aerosol that the user inhales. The liquid usually has nicotine and flavoring in it, and other additives. The nicotine in e-cigarettes and regular cigarettes is addictive. E-cigarettes are considered tobacco products because most of them contain nicotine, which comes from tobacco.
Most e-cigarettes, vaping juices, and other vaping derivatives marketed and sold in the United States today contain nicotine derived from tobacco. Estimates are over 85 percent of vaping products contain nicotine, but this number is difficult to determine as many products that are being sold as being nicotine free have tested positive for nicotine. This calls for stricter regulations by the FDA, so consumers know what they are inhaling.
The health effects of passive exposure to e-cigarettes with no nicotine, as well as their actual use and the extent of exposure to these products, have just begun to be studied. In November 2018, the FDA announced that it would limit the available e-cigarette flavors to tobacco, menthol and mint. Companies including Juul had previously sold flavors like mango and cotton candy, which suggested that children were a target for the growing industry. As in the past, it is clearly evident that the “flavors” in e-cigarettes are targeting teens, young adults and nonsmokers. The concern is that over 85 percent of e-cigarettes with “sweet flavors” contain nicotine and users will unwillingly become addicted to nicotine.
A study estimated that there are 7,700 unique flavors exist and most are fruit or candy flavors. Popular flavors are mint, coffee, fruit flavors, bubble gum, Belgian waffle, straw-berry daiquiri. Flavors have been used for decades by “big tobacco” companies to attract youth to tobacco products and to mask the flavor and harshness of tobacco.
The teen years are critical for brain development, which continues into young adulthood. Young people who use nicotine products in any form, including e-cigarettes, are uniquely at risk for long-lasting effects. Because nicotine affects the development of the brain’s reward system, continued e-cigarette use cannot only lead to nicotine addiction, but it also can make other drugs such as cocaine and methamphetamine more pleasurable to a teen’s developing brain.
Vaping related symptoms, possible causes of deaths and illnesses
The long-term health effects of vaping are unknown because research on the vaping caused illnesses has only begun to be studied.
But here is what we do know. When someone vapes, they are not just inhaling harmless water vapor as many believe. Besides nicotine, e-cigarettes can contain harmful and potentially harmful ingredients, including:
• Ultrafine particles that can be inhaled deep into the lungs.
• Flavor additives such as diacetyl, a chemical linked to serious lung disease.
• Volatile organic compounds.
• Heavy metals, such as nickel, tin and lead
• For THC-containing vaping products, vitamin E acetate has been identified as being a highly probable vaping cartridge additive that is causing lung injury and death. On Nov. 8, 2019, the Center for Disease control announced that they identified vitamin E acetate in the lung fluids of 29 people sickened in the outbreak of dangerous vaping-related lung injuries. Inhaling vitamin E has been described as “inhaling grease” that coats the lungs cells. In October, the CDC expected a correlation between THC-containing vaping liquids, but the Nov. 8 findings show a direct correlation with vitamin E acetate at the primary site of injury within the lungs.
Many of the THC-containing products used by those sickened, or who died, were obtained on the illicit market. Vitamin E acetate has been used in recent months as a cutting agent or additive on the cannabis black market to stretch the amount of THC in vape cartridges. Vitamin E acetate is a popular additive because it is colorless and odorless, has similar viscosity to THC oil and is much cheaper.
Vitamin E acetate is also used as a thickening ingredient in e-liquids which may not contain THC. The CDC is maintaining its recommendation that consumers consider refraining from using all vaping and e-cigarette products, including those containing nicotine. That is because a small proportion of patients stricken with EVALI continue to report exclusive use of nicotine-containing products.
On Oct. 29, 2019, the Center for Disease (CDC) reported 1,888 cases of e-cigarette vaping product use associated lung injury (EVALI) and 37 deaths. One week later, Nov. 5, the CDC reported 2,051 cases of EVALI and 39 deaths with more suspected EVALI deaths under investigation. Each week more and more ENDS related illnesses and deaths are being reported.
Nov. 5, 2019, CDC EVALI patient data found:
14 percent of the EVALI patients are under 18 years old;
40 percent of patients are 18 to 24 years old;
25 percent of patients are 25 to 34 years old; and
21 percent of patients are 35 years or older.
About 86 percent of EVALI patients reported using THC-containing products; 34 percent reported exclusive use of THC-containing products.
About 64 percent reported using nicotine-containing products; 11 percent reported exclusive use of nicotine-containing products.
People who vape should be aware that this illness is occurring and be on the lookout for symptoms that include: shortness of breath or trouble breathing, chest pain, cough, fatigue & possible fever. People who think they may have been sickened by any vaping product should contact their doctor, local public health agency or poison control at 1-800-222-1222.
Some localities have taken e-cigarette regulations into their own hands. San Francisco, where Juul has its headquarters, voted in June 2019 to ban the sale of e-cigarettes that have not been approved by the FDA — which, for now, is all of them. Many countries have banned the import and sale of ENDS products. In the U.S., states are beginning to ban the sale of flavored ENDS and restricting their usage in public areas. In July 2019, the state of Colorado put e-cigarette use in the same category as tobacco cigarettes under the Colorado Clean Indoor Air Act. Retailers are also recognizing the health risks and liability in selling ENDS products. In June 2019, Walmart raised the age consumers can buy tobacco and ENDS products from 18 to 21 while also stopping its sale of fruit and dessert flavored nicotine products.
What’s past is prologue
Today, once again, health officials are alarmed by the marked increase in ENDS use among youth and young adults and are concerned that these products may undo the years of tobacco control efforts that have successfully reduced cigarette smoking among both youth and adults in recent years.
On Nov. 23, 1998, attorney generals from 46 states, the District of Columbia, and the U.S. territories signed a contractual agreement the Master Settlement Agreement (MSA) with the major cigarette companies to settle state lawsuits to recover the costs, borne by Medicaid and other public programs, of treating smoking-related illnesses. Under the terms of the MSA, the companies agreed to make annual payments in perpetuity, totaling approximately $125 billion over the first 25 years, and to accept certain restrictions on tobacco product advertising, marketing and promotion. Specifically, the MSA prohibited cigarette companies from targeting youth in the advertising, promotion or marketing of their products; banned the use of cartoons in advertising; limited each company to brand-name sponsorship of one sporting or cultural event a year, excluding concerts, team sports, events with a significant youth audience, or events with underage contestants, banned non-cigarette apparel with brand-name logos except at brand-name sponsored events; restricted the use of nationally recognized non-tobacco brand names for cigarettes; and limited free samples of cigarettes to adult-only facilities.
Many of the same “big tobacco” companies that contractually agreed to the 1998 Master Settlement Agreement are now owners of e-cigarette companies. The most popular e-cigarette brand is Juul which has three-quarters of the U.S. e-cigarette market. In December 2018 Philip Morris USA purchased 35 percent of Juul. The brand Vuse, which came in second in the e-cigarette industry with 10 percent of the market share at the end of 2018, is owned by R.J. Reynolds Vapor Company, a subsidiary of Reynolds American Inc., which was acquired by British American Tobacco in 2017.
These same big tobacco companies are once again touting their products as a healthier alternative to cigarettes. And once again, these companies are peddling addictive products that contain nicotine and other chemicals that cause lung disease. Public health groups like the American Cancer Society, American Heart Association, American Lung Association and the Campaign for Tobacco Free Kids are once again fighting for greater regulation and taxation.
The advertising and marketing of e-cigarette products has created scrutiny from public health professionals and legislators who have noted many similarities to the advertising claims and promotional tactics used for decades by the tobacco industry to sell conventional tobacco products. Several of the e-cigarette marketing themes have been rehashed from past cigarette advertising including messages focused on freedom, rebellion and glamor. E-cigarette products are marketed with a variety of unsubstantiated health and cessation messages, with some websites featuring videos of endorsements by physicians. Unlike conventional cigarettes, for which advertising has been prohibited from radio and television since 1971, e-cigarette products are advertised on both radio and television, with many ads featuring celebrities. E-cigarettes also are promoted through sports and music festival sponsorships, in contrast to conventional cigarettes and smokeless tobacco products, which have been prohibited from such sponsorships since the Master Settlement Agreement (MSA). E-cigarettes also appear as product placements in television shows and movies.
A greater concern is the usage of social media by e-cigarette corporations to target youth. As was true in the tobacco industry, the e-cigarette industry organizes users through advocacy groups. The extensive marketing and advocacy through various channels broadens exposure to e-cigarette marketing messages and products; such activity may encourage nonsmokers, particularly youth and young adults, to perceive e-cigarette use as socially normative.