RICK WEISS: Hi, everyone. I’m Rick Weiss. Thank you for joining us for this latest SciLine media briefing – this one, on the topic of vaping and health. I want to take just one or two minutes to introduce all of you to SciLine, to your host here for those who haven’t been on one of our media briefings before. We are a totally philanthropically funded free service for reporters with an overall mission of just trying to get more research-based, evidence-based factual information into news stories.
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So we’re really happy that you joined us today for this media briefing on vaping and health. We have three experts with us today to make short presentations. And then we’ll have lots of time for Q&A afterwards. So let me just quickly introduce the three. There are full – fuller bios are on the landing page for this briefing. So I won’t spend time going into all the details.
But we’ll hear first from Dr. Jessica Barrington-Trimis, who is an assistant professor of preventive medicine at Keck School of Medicine at USC who will focus in particular on giving an introduction first to vaping generally. And her focus in particular is on youth and smoking and vaping.
Second, we’ll have Dr. Suchitra Krishnan-Sarin. She’s a professor of psychiatry at the Yale University School of Medicine. She’s also a contributor to the surgeon general’s report on preventing tobacco use among young people and a member of FDA’s Tobacco Product Scientific Advisory Committee who will focus largely on the topic of addiction and toxicity.
And finally, third, Dr. Nancy Rigotti is an associate chief of general medicine at – in the division – sorry – associate chief of the General Medicine Division and director of Tobacco Research and Treatment Center at Massachusetts General Hospital and Harvard Medical School. She is also a member of the National Academy of Sciences’ report on public health consequences of e-cigarettes. And her focus will be in particular on cessation, focusing on adults.
So with the three of these folks, I think we’ll have a pretty good mosaic of information for you on this topic. And, again, I encourage you, then, to submit your questions for discussion afterwards. So we’ll start with Dr. Jessica Barrington-Trimis. The floor is yours.
Youth Smoking and Vaping
JESSICA BARRINGTON-TRIMIS: Thank you. Thanks, everybody, for joining us. I will start with just a brief overview. I’m going to talk a little bit about the evolution of vaping products. I’ll, then, talk a little bit about trends in youth vaping in the United States over the last eight years and finally conclude with a highlight of some of the key findings from population research, specifically regarding vaping and youth.
So let’s start with an evolution. We can go to the next slide here. Perfect. So back in about 2006, 2007 is when e-cigarettes first made their way into the U.S. market. The first products were really structured to look more like cigarettes than like anything else. You can see on the left-hand side there, it looks almost exactly like a regular cigarette. These evolved into products that became a little bit more customizable.
So vape pens were first introduced into the market around 2009 and really differentiated themselves from cig-like products in that they have a rechargeable battery. The product itself can be used over a lengthier period of time – doesn’t need to be thrown away right away. And e-liquid solutions that can be customized to a specific nicotine strength or a specific flavor can be directly added into the vape pen itself and can be purchased separately from the vape pen.
From there, there was an evolution toward products that were more customizable. So we then saw the mods or box mods make their way onto the market. And these are called mods because they’re modifiable products. So here, you know, people can – users can customize their own product. They can use whatever battery they want and combine it with an add – a specific atomizer, combine it with a specific coil and basically mix and match parts to come up with their own unique, custom product. These products also have – you add e-liquid solution separately. And, again, same idea. You can customize your e-liquid solution to whatever nicotine strength and whatever flavor.
From there and most recently – of course there’s a lot of modifications, a lot of different types of products that, you know, have been in between all of these sort of major product categories. But of course Juul has been making a lot of, you know – has gotten a lot of media attention recently when they gained – they began gaining a lot of popularity. And, I think, most recently, Juul, according to Nielsen data, covers about 70 percent of the e-cigarette market.
Juul really was a real deviation away from products prior to Juul for a couple of different reasons. One – Juul products are, you know – with mods and mac mods, there was kind of this movement toward giant vapor clouds. And Juul was, you know, directly opposite of that. It was meant to be concealed, to be hidden. There’s not that much vapor that comes off of a Juul when it is being used. In addition, instead of using freebase nicotine, which is what was used prior to Juul, Juul uses protonated nicotine salt solutions.
The big difference here is that these nicotine solutions can really have a lot higher level of nicotine and a lot more efficient nicotine delivery. So with freebase solutions, the higher levels of nicotine are really aversive to the user, whereas with Juul and salt-based nicotine formulations, very high levels of nicotine are not aversive to the user.
After Juul, there have been a lot of other lookalike products – Juul – products that resemble Juul in size and shape, a lot of other companies that have created these nicotine-salt solutions. Suorin is the one that’s pictured here under other pod mods. These products are referred to, at least in the research community, as pod products because they use a pod rather than sort of freely putting e-liquid into the product.
And then most recently, there’s sort of a new product beginning around 2017 called a Squonk mod or Squonk box mod. The idea behind this class of products was to really, again, increase the efficiency of nicotine delivery and uses sort of like a squeeze – you squeeze the side of the box. And it puts just a little bit of liquid onto the wick, which then can be inhaled and is sort of akin to dripping.
OK, so this is sort of what e-cigarettes have looked like over the last 10 years. And in particular, you know, when we think about e-cigarettes, one of the things that’s quite important is thinking about how youth are using these products and the impact that these products are having on youth. So let’s go ahead and go to the next slide.
So this is data here from the National Youth Tobacco Survey. It’s an annual survey of high school students in the United States, nationally representative. And they first began asking about e-cigarette use back in 2011. You can see here on the left-hand side, this group of bars is regarding the prevalence of past 30-day use of e-cigarettes. And I have the prevalence of cigarette use in the past 30 days on the right-hand side of the graph just for comparison.
So back in 2011, about 1.5 percent of youth reported that they had used e-cigarettes. This increased rapidly, particularly in 2014. And then in 2018, 20.8 percent of youth had reported that they had used – of high school students had used e-cigarettes in the past 30 days. At the same time, you see a decline in cigarette smoking. Although, the prevalence of past-30-day cigarette smoking has really sort of leveled off beginning in about 2014, 2015 and hasn’t really declined quite as much in recent years.
OK. Let’s go to the next slide. So I’ll conclude with a few key findings regarding youth vaping. These are sort of the main things, I think, that that we know about youth vaping so far. There of course are a lot of questions that still remain. But these are some of the things that have been – that have come out in the literature that are fairly well-established at this point.
First, e-cigarettes are drawing in new low-risk youth to tobacco product use and to nicotine use. There are a couple of studies that have shown that the prevalence of e-cigarettes or cigarette use is far higher than would be expected if e-cigarettes had not entered the market. So e-cigarettes are bringing in new youth who were unlikely to have otherwise used combustible cigarettes.
We know that youth who begin using e-cigarettes are more likely to subsequently initiate use of combustible cigarettes. This is a finding that has been observed in, maybe, 10 to 15 studies in the United States and probably another five to 10 studies outside of the United States very consistently. There’s generally a three- to four-fold increase in the risk of combustible cigarette smoking for youth who use e-cigarettes relative to those who do not use e-cigarettes.
This association also generally tends to be much stronger for low-risk youth. There have been a couple of studies that have found that among the group of low-risk youth who say I would never ever use a combustible cigarette, those who vape are substantially more likely to then begin smoking combustible cigarettes. And these are kids who said they would never ever do it.
A greater frequency of vaping has been associated with progression to a greater frequency of smoking. This has been found in a number of different studies so far. There have also been a few studies that have begun to really try and understand what it is about vaping in particular that leads to that initiation of cigarette smoking or that progression to higher rates of cigarette smoking. So far, there have been a couple of studies that have looked at vaping nicotine. We have a new study that is looking at the type of e-cigarette device. And these have really been associated with frequency of cigarette smoking prospectively. So it’s the transition from vaping with different characteristics, either nicotine or the type of device, with frequency of cigarette smoking later.
Finally, I just want to comment, you know – there have been a lot of different policies that have been enacted across the United States. There – you know, in California and in many other states, there are tobacco 21 laws that are in place that raise the age of sale of products to 21. There are increasingly different policies that are being considered that restrict the sale of flavored tobacco products all in an attempt to really try and prevent youth initiation of vaping there.
There – in particular, we had a study that came out that really found that enforcement of these policies is really important and more important than just sort of having a policy without enforcement. Those living in areas where there was strong enforcement and there were sufficient fees to really enforce these policies, there were lower rates of youth initiation. So with that, I will turn it over to Suchitra.
Vaping Addiction and Toxicity
SUCHITRA KRISHNAN-SARIN: OK. Thank you, Jessica and Josh. So I’m going to just keep moving ahead and tell you a little bit more about the actual e-cigarette products and what they contain because one of the big concerns that we have is not just progression of e-cigarette use to cigarette use, but also what are people who use e-cigarettes being exposed to when they actually try these products? If I could have the first slide – thank you. OK. So this is a very brief overview of what these e-cigarettes contain. Again, as Jessica mentioned, this is a field that is growing rapidly. We learn every day about the different combinations of constituents that are put into these products. But suffice it to say that the aerosol that is produced when you vape an e-liquid, it usually is a pretty good mirror of what is actually contained in the e-liquid.
So an e-liquid can contain solvents like propylene glycol, glycerin, alcohol. It can contain nicotine. It can also contain marijuana. And there are a variety of flavor chemicals which are there in e-liquids along with sweeteners. And there can also be metals in the aerosol which are actually produced when the heating coil in the e-cigarettes is heated – the metals appear in the aerosol. And there could be a variety of other constituents that we do not know about as yet.
If I could have the next slide. So one of the big concerns that we have is nicotine. As, you know, Jessica mentioned briefly, these products were originally created to help smokers quit smoking. And we’re going to hear more about that in a second. But there are also a lot of new users who are being exposed to nicotine through these products. And one important point to remember about nicotine is that it binds to a very basic receptor in the human body called the nicotinic acetylcholine receptor. It’s present all over the body. And binding of nicotine to these receptors can produce many changes, some of which are highlighted on this slide that you see here.
So essentially, if you think about it, when you’re exposed to nicotine from these products, you can experience any of these different both short-term and long-term symptoms, of course depending on how much nicotine you’re exposed to. The nicotine levels in the newer Juul products are much higher than the nicotine levels in some of the older products. So it is very possible that with the Juul products, you are exposed to much higher levels of nicotine, where you could experience more of these side – many of these events that are listed on the slide.
If I could have the next slide. So we are particularly concerned about nicotine exposure in adolescents and the reason being, it’s not just related to the earlier slide I showed you with all the different effects that nicotine can have on the body but also very specific literature that exists that has very clearly shown that in adolescent animals, nicotine is a neurotoxin. It alters normal maturing of the brain during the adolescent period, which can produce changes in learning, memory, attention, increases in hyperactivity.
Adolescent animals – so a lot of this work has actually been done in animal models because of course it would not really be ethical to bring a human adolescent into a lab and expose them to nicotine and see what happens. So a lot of this work and important science has been generated using preclinical animal models. And these animal models show that the adolescent animals are very sensitive to even low levels of nicotine, which means that they get addicted very easily. And nicotine addiction in these animals also makes it easier to get addicted to other substances like marijuana, alcohol, cocaine, opiates.
In parallel, there is a small literature that has examined similar phenomenon in human adolescents who use tobacco products. Remember, until e-cigarettes came on the market and, you know, these only-nicotine devices were not available earlier, most people used tobacco products which – like cigarettes and cigars which contain nicotine with a variety of other chemicals. Now in adolescent humans who use these tobacco products, the long-term studies show that they experience memory and attention deficits. They are more likely to go on to using other substances. And they’re also more likely to develop anxiety and depression symptoms. Now I have to emphasize that while a lot of these effects in humans could be because of nicotine, it’s very hard to parse this out based on the earlier data, which was obtained primarily with, you know, all tobacco products.
If I could have the next slide. The other big concern we have with e-cigarettes are the flavors. I don’t know if you all know this, but at last count, there are supposedly over 15,000 different flavor combinations. And many of the youths, as we expect, do love this aspect of e-cigarettes. They love to mix and match and create their own flavors.
This is just some pictures that I got off the Internet of the variety of flavors that are available. You can get just about anything you want. And unfortunately, the problem is that most of these flavors are made up of chemicals. So flavors are not just benign, you know, agents. They are made up of very specific chemicals, some of which are listed on this slide on the left-hand side. This is just a small listing of some of the flavor chemicals. And many of these flavor chemicals have known toxicity profiles. So they can actually produce inflammation, oxidative stress. A variety of other inflammatory processes can be activated. And we are just learning about all of this.
But – and of course this is all really dependent on how much of the flavor chemicals you are exposed to. And if you tend to use the devices which heat the e-liquid at high temperatures, you could be exposed to more flavor chemicals and have more toxicity.
If I could have the next slide. So on my last slide, I just have a few points that I would like to focus on in relation to, what can we do? So I think one of the first things we need are policies to reduce appeal of e-cigarettes for youth. E-cigarettes are highly appealing to youth because of how innovative they are, how you can use them to use or create all these new flavors. You can hide them very easily because they are so small and easy to hide. There are a variety of things that e-cigarettes’ – characteristics e-cigarettes have that appeal to youth. And we need policies to reduce appeal to youth.
We really need public education campaigns. My group does a lot of work with the students and schools in Connecticut. And we find that even today, despite all the articles and news information on this, most youth parents and teachers know very little about e-cigarettes and that they contain nicotine. Many of them think that they are just being exposed to water vapor, which is not correct at all.
We desperately need youth-directed prevention and cessation programs for youth who are actually addicted to these products. How do we help them quit? And we all need to help youth who have not started – you know, we need to make sure that they don’t start. And as a segue to Nancy’s talk, I think we really need policies that promote the use of e-cigarettes in a structured way for smoking reduction and cessation, which is what they were really developed for. Thank you.
RICK WEISS: Thanks very much. We’ll move to Dr. Nancy Rigotti.
Vaping for Smoking Cessation
NANCY RIGOTTI: Thank you, Suchitra. It’s a pleasure to be here with you. Could I have the first slide? OK. So, so far, we’ve been talking about electronic cigarettes in terms of potential risks or harms that they might have. And the point I’d like to make is that the net public health impact of electronic cigarettes depends on the balance of three factors. Two of them are potential risks, and one is a potential benefit.
So we’ve heard already about how there is the potential for them to attract never-smokers or nonsmokers to start using e-cigarettes, become dependent on nicotine and then perhaps switch to using cigarettes. A second concern is that there may be health risks to vaping itself, maybe from the nicotine, maybe from the other constituents of – if you could go back, please – of the other constituents of e-cigarettes. And there, I think it’s important to make the distinction between the risks – health risks when we’re talking about never-smokers, nonsmokers versus health risks when we’re talking about adults who already smoke.
So for adults who are already smoking, the comparison is combustible tobacco smoking, which is one of the most risky things you can do. And so the standard is not so high in terms of safety. You could tolerate more potential health risk because it’s almost certainly going to be less risky than continuing to smoke cigarettes.
On the other hand, when you’re talking about nonsmokers, never-smokers and especially kids and young adults, the – you’re looking at an absolute risk compared to not being exposed to any of these products at all. And so the concern is much – for health risks is much greater.
So far, we’ve talked about the health risks. But why are we talking about these at all? Because if all we had were consumer products that were bad for you and led to sick nicotine dependence, we probably would get them off the market. The reason that smoking cessation experts have been interested in this is because of a potential benefit that they might help more smokers to quit smoking, especially smokers who have been unable or unwilling to quit with the current treatments that we have.
So the thought is that we have a number of smoking cessation medications and behavioral treatments that are effective. But they’re certainly not 100 percent effective. And there’s room to improve. At the same time, we also know that only about a third of smokers who are trying to quit use any treatment at all. And so that’s a problem.
At the same time, we know that lots of people are going out and buying consumer products, which are these vaping devices. And so it seems possible that you could perhaps increase the reach of smoking cessation treatment if you devised a treatment that a lot more people wanted to use. And it looked to us like more people were interested in using e-cigarettes. So there is this great potential that we could help many people quit smoking. And smoking (inaudible) is a leading preventable cause of death in the United States.
Could I have the next slide? So about a year ago, the National Academy of Science, Engineering, and Medicine put out a document or a report that is shown here on the public-health consequences of electronic cigarettes. And it was an effort to – it was FDA-funded. And it was an effort to summarize the evidence as it stood approximately a year ago. And this was the highlight – the first three bullets here are the major conclusions.
One was that e-cigarettes contain fewer and lower levels of toxic substances than are in conventional cigarettes – so less exposure to bad stuff. A second regarded health risk – while not without health risks, they are likely to be far less harmful than smoking combustible tobacco cigarettes. So, again, that was the relative harm compared to continuing to smoke among adults.
The long-term health effects, however, are not clear, which was the caveat. We also looked at effect on behavior, both cessation and initiation. And Jessica summarized the results from the report on initiation. What we had for cessation was much more limited. There was a – there were only two randomized controlled trials available at that time. And it looked like using e-cigarettes may help adults quit smoking. But it was clear that more research was needed, especially randomized controlled clinical trials that could demonstrate that people using e-cigarettes compared to some comparison product or no product was – were more likely to quit smoking.
So if we could – so that’s where we stood about a year ago. And then the Juul phenomenon became very obvious in the United States. And a lot of the attention went to concern about kids, as appropriately it did. In the meantime, we were still kind of left hanging about, what is the benefit for cessation?
So if we could go to the next slide. Just a couple months ago, the – Peter Hajek and his colleagues published in The New England Journal of Medicine this clinical trial, which was a very helpful trial for us interested in cessation. They enrolled – they did this trial in Britain. They enrolled almost 900 adult cigarette smokers who smoked 15 cigarettes a day. That’s three-quarters of a pack. And they were going to a special stop-smoking program that’s available through the British National Health Service.
And specifically, they had to say that they really didn’t care whether they got nicotine replacement product – that’s NRT or patch or gum – or an e-cigarette to quit. They wanted to quit. But they would be happy with either one. And so they were randomly assigned to either get the nicotine replacement – and they recommended a combination of patch and gum, which is probably – is more effective than a patch alone. And they got this for free for three months. Or they were given a starter pack of e-cigarettes which meant they were given a device, not a Juul – I would point out – but more like a second-generation device that you saw earlier, and one bottle of e-liquid and told to go out and buy some more of whatever flavor they liked. All of them, in both groups, got four weekly counseling visits.
And what the trial found was that one year later, that 18 percent of the individuals who were assigned to get e-cigarettes were not smoking cigarettes. And 10 percent of those who were assigned nicotine replacement products were not smoking cigarettes. This was clearly a much higher rate for e-cigarettes than cigarettes. And so that was a clear demonstration that, at least under these circumstances, electronic cigarettes could help people to quit smoking – looked like they might even be better than nicotine replacement.
My own personal view about this is that it’s one study. I think that – my interpretation is that they are effective for cessation. But I would not necessarily conclude that they are more effective than nicotine replacement. But I think that they – this puts them in the toolkit that we have for cessation products potentially – I would say potentially.
So – however, there were some concerns expressed. And one of those is that if you looked among those who were not smoking cigarettes at one year, 80 percent of those in e-cigarette group were still using e-cigarettes while only 9 percent in the nicotine group were still using nicotine-replacement products. So some people were quite concerned because the – of the large number of people using – who were still using e-cigarettes even though they were not smoking cigarettes, which gets us to, I think, a key question of why there’s a fair amount of dissension in the public health community.
If we could go to the next slide, please. So – that a key question underlining the e-cigarette controversies is, what is the goal of tobacco control? Is it to eliminate deaths due to tobacco smoking, which really means eliminate combustible tobacco use but tolerate, perhaps, electronic cigarette uses for short term or perhaps even long term, depending on their health effects and probably also tolerate long-term nicotine replacement therapy which we already pretty much accept as an adequate response? Or is it to eliminate nicotine addiction?
I think everyone would agree that we want to eliminate nicotine addiction in youth. But do we need to eliminate it in all? And then the real question is can we achieve both? And if so, how? And I think that this is where there is a lot of agreement on the edges. And there’s some disagreement sort of in the middle about exactly what we’re trying to accomplish.
If I could have the next slide, please. So the last – what I’d like to do finally is just leave you with some questions because in this field, we have more questions than answers, unfortunately, because of the way these products came on the market without any clear regulation. So the first point is that e-cigarettes, I think, can help smokers to quit. But under what conditions are they most effective? That’s the information we still need to figure out.
Next – just keep clicking on the slide. So what – so, for example, here’s some questions. What types of devices might be most effective? It’s entirely possible that while Juul looks like it has been an important contributor to a disaster among kids, that it may be the best device for cessation because it has the highest nicotine delivery and presumably, smokers are looking for that nicotine delivery.
Next. Then how often and how long do smokers need to use e-cigarettes in order for them to be effective? If it’s a short period of time in the way that we use medications for six months, then we could tolerate a higher level of potential risk if people were only going to use it for six months. However, if they’re going to use it for the rest of their lives, then I think we would be more concerned about long-term risks of e-cigarettes. Next. Then how much or what type of behavioral support is needed? I’d point out that in the study that I pointed out – that I described for you, there were behavioral supports. If people don’t have any sort of behavioral support and they just go out and buy Juul and they – nothing else, is that going to help? I think that’s a question we need to find an answer to.
Next. How important are flavors for encouraging smokers to quit? It’s clear that flavors are important for encouraging young nonsmokers to start smoking, and we should be very worried about that. Some people have expressed concern that maybe flavors are also important for encouraging smokers to quit. And so when we think about banning flavors, are we – might we be harming adults? I’m not going to say that I would take that position, but that’s certainly something we have to worry about.
Next. And then finally, what about dual use? What we have learned is that for people who switch over, that the data in the report that I cited earlier made it clear that if you switch over from cigarettes – from cigarettes to e-cigarettes. You have less exposure to the bad constituents of cigarettes. And therefore, you’re likely to have a health benefit. But we know that the majority of people – of adults who are using e-cigarettes are also continuing to smoke, about 60 percent. And so dual use is not – there’s very little evidence that dual use is an important factor for reducing health risks.
And then finally, we can have the last bullet here. And Suchitra already talked about this. Do we need interventions to help vapers, not smokers, to quit, both adults and kids? While it’s likely that many of the young people who are getting starting today may turn into smokers, not all of them will. But they may stay as vapers. And they may need help with their nicotine dependence. And that’s a completely open field as best I know.
So I’m going to stop there. And thank you for your attention – and turn it back to the – our fearless leader.
What are the links between the explosion of teen vaping and marijuana use among adolescents?
RICK WEISS: Thank you. Thank you very much, Dr. Rigotti. To those of you who are logged in for this briefing, I want to remind you that if you have questions, you can type them into your Q&A box. And let us know if there’s a particular person on the panel you want to direct that to. Although, we’re going to let anyone on the panel answer, additionally, any of the questions that come in. Meanwhile, we do have a few to get us started.
And this first question is from Jennifer Oldham, who is a freelance journalist, asking, what are the links between the explosion of teen vaping and marijuana use among adolescents? Not sure who would like to pick that up first.
SUCHITRA KRISHNAN-SARIN: I’m happy to if Jessica doesn’t want – can’t step in. So I don’t know that I can really say that the explosion in teen vaping is related to marijuana vaping, although, because we don’t have those kinds of studies. You know, we haven’t looked at that particular issue. What I will say is that the devices that are being used for marijuana vaping are very similar to the devices that are being used for nicotine vaping.
So the – just the accessibility of these devices in the market could have led to increase in marijuana vaping. Some of the devices that are – the Juul, for example, has a counter product which looks almost exactly like the Juul, which is meant for marijuana. So there is a good possibility that these associations exist. But I don’t know that we have specific information on one leading to the other. Jessica, would you like to add something?
JESSICA BARRINGTON-TRIMIS: Yeah. So I just will add that there – we have at least one study that has shown that there’s a strong association sort of in both directions between marijuana use and e-cigarette and tobacco use. So kids who or young people who use e-cigarettes are more likely to then subsequently initiate use of cannabis products as well. And that’s not specific to cannabis vaping. You know, we have looked at all different types of cannabis use. And use of any tobacco product is associated with use of any cannabis product.
Is vaping marijuana less harmful than smoking combusted marijuana?
RICK WEISS: You know, I’m wondering – I’ll just throw in an add-on question here. In much the same way as vaping nicotine might be less harmful to one’s health than smoking a combustible cigarette, is there any at least theoretical basis to believe that vaping marijuana might be less harmful in some way than smoking combusted marijuana leaves?
NANCY RIGOTTI: I can take that…
SUCHITRA KRISHNAN-SARIN: So – sorry, go ahead.
NANCY RIGOTTI: I think that that’s a reasonable hypothesis. We don’t have any data. But I think it’s a reasonable hypothesis because nothing is burned. And much of the harms of smoking cigarettes – tobacco cigarettes – are the fact that people are using – that there’s burning, that there’s carbon monoxide, oxidant gases and other things which are toxic to the body. And if you’re vaping, presumably, you would not be exposed to those. Vaping marijuana, you’re presumably not exposed to them in the same way that you would be if you were smoking a joint.
Is “popcorn lung” still a concern?
RICK WEISS: Great. We have another question here from Nick Gerbis at KJZZ radio asking, is so-called popcorn lung still a going concern or has the progression to new technologies that deliver more nicotine – have they removed the push to overcharge the delivery devices?
NANCY RIGOTTI: That’s – this is Nancy. This is a good question. There were a few case reports or case series of popcorn lung. And they were associated with sort of overcharging and overheating. So we know that Juul has a limit on the temperature, which is one of its nice features as a vaping device. I have not seen any evidence suggesting that there is either an association or less of a risk. I think there’s a lot we don’t know about how much there was an association. It was more that we saw a case series. And I’m not sure that we have a clear association between vaping and popcorn lung. Although, there certainly were a couple of cases that looked concerning.
SUCHITRA KRISHNAN-SARIN: Can I add something to that? So the popcorn lung is not just related to temperatures in the Juul. It’s also related to a chemical, specific chemical, which is present in the flavor. It’s called diacetyl. Popcorn lung was actually discovered in people who were working in popcorn factories. And the butter flavor used in these popcorns uses this chemical, diacetyl. And it’s exposure to this chemical that leads to popcorn lung.
So many flavors were using diacetyl for a long time. There was a huge series – a large number of papers that actually came out from California, highlighting the concern about the inclusion of this chemical. My understanding is that diacetyl was subsequently removed from e-liquids. However, I will say this, since the e-liquids are not regulated, we do not know – nobody is going around testing them to see if diacetyl is included or not. So there could be e-liquids out there that still might contain this particular chemical.
Does vaping cause sudden hearing loss?
RICK WEISS: Interesting. Great. Our next question is from Joy Victory, who is reporting for a healthyhearing.com. What is your perspective on anecdotal reports that vaping causes sudden hearing loss? How might vaping’s impact on hearing be different from the damage of traditional smoking on the years, such as through long-term blood supply damage?
NANCY RIGOTTI: I have not heard about an association between vaping and hearing loss.
RICK WEISS: The anecdotes haven’t reached you. (Laughter).
NANCY RIGOTTI: They have not. That’s…
RICK WEISS: Anyone else on the panel?
JESSICA BARRINGTON-TRIMIS: No…
SUCHITRA KRISHNAN-SARIN: I don’t think I have heard any of those either. The most recent thing that we have heard was the relationship with nicotine vape exposure and seizures that was just put out by the FDA yesterday. But we have not heard of hearing loss.
Is Juul the best device for smoking cessation?
RICK WEISS: We have a question from Erin Brodwin at Business Insider, and this is for Dr. Rigotti. You mentioned that Juul may be the best device for cessation because it has the highest nicotine delivery. Is that based on peer-reviewed research, such as a kind that Juul has recently published? Or is that based simply on the fact that they have more nicotine, and so therefore, the presumption would be, it could be more effective?
NANCY RIGOTTI: It was a theoretical hypothesis not based on research specifically.
RICK WEISS: Great. Have you – this is a follow-up question there that you or others might want to pick up. Have you followed the research that Juul has been putting out on their own in recent months? And what do you think of it? It’s a loaded question.
NANCY RIGOTTI: I have not. I have not seen it, I have to admit. I think I saw something that that was out recently. But others may have more to say.
RICK WEISS: Anyone else on the panel?
SUCHITRA KRISHNAN-SARIN: There were some posters at a recent tobacco conference. You know, I think the jury’s out on these products. We need research conducted by multiple people to really confirm findings. As scientists, we never believe in a single finding. As Nancy pointed out that the – with the e-cigarette, there’s one randomized controlled trial which shows it works. In the same way, we need to be able to replicate what the Juul folks are finding. And I hope the field will do that.
NANCY RIGOTTI: I would agree with Suchitra exactly.
Who is funding the bulk of e-cigarette research? Do we know why vaping seems to make some kids more likely to take up cigarette tobacco smoking?
RICK WEISS: Here’s a question from freelancer Mary Chris Jaklevic who’s – actually has a twofold question here. First – who is funding the bulk of e-cigarette research at this time? And also, do we know why vaping seems to make some kids more likely to take up cigarette tobacco smoking? Why don’t we deal with the funding first? Does anyone have a sense of where the money is coming from for looking at this issue?
SUCHITRA KRISHNAN-SARIN: Most of the research, to date, on e-cigarettes is funded. A lot of it is funded through the NIH and FDA in the U.S. through funding mechanisms that come through the NIH. And, Jessica, do you want to take the second part of the question?
JESSICA BARRINGTON-TRIMIS: Yeah. So I’ll just add that in California, we also have the Tobacco-related Disease Research Program, which is – has been funding a lot of local research in California on e-cigarettes and more recently on cannabis products. With respect to reasons why youth are transitioning from e-cigarette use to combustible cigarettes, you know, I think the jury is still somewhat out on that. I think that this is a really interesting and important question.
We, here at USC, have been doing some qualitative interviews with young adults who either started with e-cigarettes and then transitioned or are now dual users or who just remained e-cigarette users to try and get some more information about why they are transitioning. You know, I think – I’m not aware of a great deal of literature that has really found any particular factor. Although, I think there are a lot of different theories out there, one in particular that it’s the exposure to nicotine and potentially a really positive initial experience with nicotine via e-cigarettes that leads youth to explore other options and other forms of nicotine delivery.
What is the balance between publicly and privately or industry-funded research on vaping?
RICK WEISS: And I’m just going to follow up on Mary Chris’s funding question a little bit further. So you’ve all – a couple of you have mentioned publicly funded sources here. But is there anything we can say about the balance between the amount of investment in that kind of research right now versus what we know or don’t know about the extent to which privately funded, industry-funded research is going on? We know the history of this with cigarettes that helped delay, I think, most people would agree, the institution of some more restrictions on cigarette smoking. Is the same thing happening in this field as well?
SUCHITRA KRISHNAN-SARIN: So I would say no. There is industry-funded research. But a bulk of the research actually is funded by federal sources. And the reason we are able to do this now as opposed to when cigarettes came out is because the regulatory field is different now, you know, since President Obama signed, in 2009, the Family Smoking Tobacco Prevention Control Act that actually has allowed the FDA – it’s given the FDA the authority to regulate tobacco products. So there is a lot they can do in terms of generating science around this issue so they can regulate it properly.
The problem with e-cigarettes is that the growth has been just so rapid that I think the science has not been able to keep up with this rapid growth of the products. And that’s why we are all struggling.
Can smoking or vaping buds from industrial hemp plants reduce anxiety?
RICK WEISS: Here’s a question from June Berimun who’s a freelance reporter. Is there any information about teens smoking or vaping buds from industrial hemp plants in order to achieve calm or reduce anxiety?
SUCHITRA KRISHNAN-SARIN: I’m sure if you look on YouTube, you’ll be able to find somebody who is doing that. I cannot give you any numbers, though.
Is there a moral-hazard analogy to be made between promoting naloxone or methadone for heroin use and promoting vaping or e-cigs for tobacco addiction?
RICK WEISS: Is there anything out there that people are not trying in a vaping device? A question from Oliver Morrison at Public Source. Is there an analogy – this is interesting – to be made between the moral hazard of promoting naloxone or methadone for heroin use with the moral hazard of vaping for e-cigs? Why are they perceived so differently publicly?
SUCHITRA KRISHNAN-SARIN: Do you want me to take that, Nancy? Or…
NANCY RIGOTTI: Why don’t you start?
SUCHITRA KRISHNAN-SARIN: (Laughter) OK. All right. So they’re both harm-reduction methods, right? So harm reduction is a very important component of treating any kinds of addictions. And it’s been used in a variety of ways. So, for example, having a safe driver, you know, is an example of harm reduction. Having safe needles is an example of harm reduction. These are all methods to prevent people from being exposed to harms from different substances.
The huge difference between methadone and e-cigarettes is that methadone, even though it is used from a harm-reduction perspective, is very well controlled. There – it’s delivered. You know, it’s given under a prescription. There are people who monitor use of that product, as opposed to e-cigarettes which are – which is just a free for all in the market.
It’s available. There is – and the reason it went this way is because there is a concern that if you impose too many restrictions on these products, that smokers may choose not to use them, that a smoker would not want to go get a prescription for an e-cigarette and, therefore, you know, this is the way to proceed to give them more free choice of these products.
So there is no – they’re not – e-cigarettes are not restricted the same way that methadone products are. I don’t know if that answers a question that was asked. But…
What policies can best regulate vaping?
RICK WEISS: Anyone else want to chime in on that? All right. I’ve got a couple more questions here, one from a freelancer. What sort of policies do you think can possibly serve as a way to regulate vaping? And ancillary to that, what is the role of parents and the community in regulation, especially in schools?
JESSICA BARRINGTON-TRIMIS: So I think one of the things that we really need is more information on factors that really differentiate between the youth population and the adult population. So I think this panel was really nice in separating out sort of – especially with Nancy’s slides – that there’s – you know, there’s – this is a very multifaceted problem, right? There are a lot of moving parts here. And while adult smokers may benefit from e-cigarettes, youth who are using e-cigarettes who never would’ve otherwise used nicotine products are clearly – this is problematic. So I think, you know, what we really need are – is more data and more information on whether there are specific components of e-cigarettes that might strike that middle balance where, you know, we can make regulations that prevent youth or discourage youth from initiating e-cigarette use while not discouraging adult smokers from transitioning to e-cigarettes. And I think right now, you know, there’s not a lot of data out there on what those factors may be.
Flavors, I think, is a really interesting target. As Nancy mentioned, it may be that flavors are sort of far less important to adult smokers seeking to switch to e-cigarettes but are way more important for youth who are initiating e-cigarettes. And if so, these proposed flavor bans that are beginning to pop up sort of all over the country may be a really good regulatory target. But I don’t think we really know enough yet about what the specific impact of flavors are, particularly among adult smokers who are seeking to switch to e-cigarettes.
NANCY RIGOTTI: So I could add to that that I did see one paper that I read that was also talked about at the recent tobacco meeting where what we – what they did was do a choice experiment, a theoretical experiment where they took adults, and they asked them what would happen – who are using e-cigarettes – what would happen if we banned flavors in e-cigarettes? And many of them – more of them were likely to go into becoming smokers than quitting smoking. On the other hand, when they said, well, what if we take flavors out of everything, including cigarettes so that you wouldn’t have menthol cigarettes? And then in that situation, what they found was that more people went towards cessation. So it gave me at least some evidence that perhaps the way to go, if we’re going to be banning flavors in e-cigarettes, is to be banning flavors in all tobacco products, including cigarettes and little cigars and other products and that sort of getting flavors completely out of the tobacco market would probably be the optimal solution. Whether that is politically feasible is quite another question, but that probably would be the best way to go.
If vaping helps adults stop smoking, but is harmful for youth who haven’t started smoking, does an age cutoff make sense?
RICK WEISS: You know, a follow up to what you were saying, Dr. Barrington-Trimis, if age is the big divider, you know, these things are potentially beneficial to adult smokers but potentially problematic to youth who haven’t started smoking yet, doesn’t that just suggest that an age cutoff for the ability – you know, an enforced age cutoff for access could be the simplest and most important thing to do to get started, or am I oversimplifying?
JESSICA BARRINGTON-TRIMIS: Yeah. I mean, that’s a great point. So there are a couple of – so to begin with, yes, like, a lot of different places across the U.S. are, as I mentioned, raising the age of purchase of all products, including e-cigarettes, to 21 or over.
Kids these days are – kids these days. Kids these days are quite smart, right? You know, it’s very easy to get a fake I.D. these days. It is very easy to purchase products online, you know, in order – even products that have sort of – even websites where you have to enter a credit card. Like, you can just go to the local corner market, hand them a $20 bill and get a $20, like, temporary credit card that can, then, be used to buy whatever you want. You know, one of the strategies here in a lot of different communities in Southern California has been to restrict the sale of all tobacco – of all flavored-tobacco products to places that are only accessible to those who are 21 or older which, I think, might be a good strategy.
You know, the other problem with flavored products, you know, even if people can’t buy them under the age of 21, if they’re going to the local 7-Eleven and, you know, buying gum at checkout and the flavored little cigars are right next to the gum, you know, it’s, like, early-and-often marketing exposure to kids which we know has been strongly associated with subsequent then initiation once you get older. And oftentimes, these advertising – end up sort of right at the eye level of kids, not of adults but lower down. So, you know, I’ll end with that. I don’t know if Suchitra or Nancy have anything else to add.
SUCHITRA KRISHNAN-SARIN: I’d just like to add one thing, which is that I think, you know, all these regulations are wonderful. But what we also need is a lot of public education. There are still people out there who don’t understand why this is bad and will still sell products to the kids even though they are not supposed to. So I think a serious public education like this event today to make people understand why these products are bad for you and why you should not be selling them to kids is important.
NANCY RIGOTTI: So I was just going to add that it – if we look back in history, that efforts to reduce the supply of addictive products like cigarettes 20 years ago have never been all that successful. You know, we’re doing well. But it’s hard to – for supply-reduction alone to be the answer for – and so we do need to reduce demand. And some of the things of public education that Suchitra was suggesting would be among those.
Now the other thought – the other suggested policy that I’ve heard people talk about is, what if you took flavors off the market entirely? But if adults wanted a flavored electronic cigarette to help them quit smoking, you could have them available by prescription. That would – that could be done. A company making electronic cigarettes like Juul could get an FDA approval as a cessation aid through their drug mechanisms. And that’s another possibility.
RICK WEISS: Fantastic. Well it’s 3 o’clock here on the East Coast, which means we’ve been on here for an hour, our promised time. So I’m going to end our Q&A there.
I want to thank all three of you. This has been such an interesting conversation about a really complicated public health puzzle that obviously is going to take a lot of thought and a lot of science and research to help us figure out. It’s really great that you three have helped us understand what the research says so far and to remind us how much more science has to get done to get through this. Thank you all for participating.
Thanks to all the journalists who were logged on today. Please feel free to get in touch with us. Let us know how you’ve enjoyed the media briefing. Please do check out the website, and follow us on @RealSciLine. We thank you all. And we’ll look forward to seeing many of you again on our next media briefing.