Adolescents, Vaping, & JUULing: What You Need to Know · 2020-02-21 · TruthInitiative.org, "Juul e -Cigarette Craze HIghlights Why Flavored Products Are So Dangerous" (April 23,

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Adolescents, Vaping, & JUULing: What You Need to Know

Kathryn Reveles PhD, DNP, APRN, CPNP-PC

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Disclosures

• I have nothing to disclose• I will not discuss any off-brand use of medications

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The modern debate about E-Cigarettes

• “Young people have taken a technology that was supposed to help grownups stop smoking and invented a new kind of bad habit, one that they have molded in their own image. The potential public-health benefit of the e-cigarette is being eclipsed by the unsettling prospect of a generation of children who may really love to vape.”

Jia Tolentino, "The Promise of Vaping and the Rise of Juul," The New Yorker (May 14, 2018)

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the different delivery devices (objective 1)

• Vaping is an umbrella term describing the process of inhaling and exhaling the vapor produced by an electronic cigarette or similar device that heats a substance (such as nicotine) without smoke or tar

• E-cigarettes

• Juul

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Juuling: The iPhone of e-cigs

• E-liquid contains nicotine salts extracted from leaf-based tobacco• “The nicotine in a single Juul pod is

roughly equal to a pack of cigarettes.”• Sold online from the company

website and in stores and gas stations• JUUL’s website uses ID match and

age verification technology, and the company has monitoring systems and penalties in place for resellers

American Academy of Pediatrics, "JUULing: What Pediatricians and Families Need to Know?

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JUULING• Two components

• The bottom part• The top part

• Pod is also the mouthpiece• Comes with a USB charger

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Disposable vape pens

• Juul is now old school• Efforts to stop teen vaping are a

step behind the market

(Teens are still vaping flavors thanks to new disposable vape pens, Morning Edition, February 17, 2020 5:04 AM ET)

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FDA Partial Ban on flavored e-cigarettes

ANNOUNCED JANUARY 2020

EFFECTIVE FEBRUARY 2020 AIMED AT STOPPING YOUNG PEOPLE FROM

VAPING

FOCUSED ON ENFORCEMENT OF

FLAVORED CARTRIDGES

(Teens are still vaping flavors thanks to new disposable vape pens, Morning Edition, February 17, 2020 5:04 AM ET)

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Puff Bar

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Adolescents and e-cigarettes

• Youth-friendly flavors are a primary draw of e-cigarettes• Many kids incorrectly think they are only vaping flavor• Majority of youth surveyed in 2016• 99% sold in U.S. in 2015 had nicotine according to CDC

• Nicotine affects the development of brain circuits• Increases the risk of mood disorders and permanent problems with impulse

control

TruthInitiative.org, "Juul e-Cigarette Craze HIghlights Why Flavored Products Are So Dangerous" (April 23, 2018)

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Trends in cigarette use

• Cigarette use is at lowest levels in survey’s history

• Peaked in the mid-1990s, then started a sharp decline

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Nicotine• Highly addictive substance• Large amounts of nicotine are lethal

• The number of poisoning cases linked to e-cigarettes liquid was 2,555 in 2018

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adolescents more Susceptible to addiction

• Teens’ developing brains are uniquely susceptible to the effects of nicotine• Teen years are critical for brain development• Nicotine affects the development of the brain’s reward system

• Increased risk of addiction to cocaine and other drugs• Nicotine greatly enhanced the effect of cocaine in mice• Cocaine dependence is greater in heavy smokers

(>100 cigarettes before using cocaine)• Nicotine acts as a gateway drug with the effects of addiction, especially in

adolescents

National Institute on Drug Abuse, "Electronic Cigarettes (E-cigarettes)" (March 2018)

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Health Concerns

• Evidence is mounting for a link between e-cigarettes and eventual smoking• Teens Vaping E-Cigarettes Up to 7 Times More Likely To Smoke, Later, But Not

Vice Versa NIH-funded study published in Pediatrics, Dec. 2017• Teens who use e-cigarettes are more likely to try smoking, report shows A

consensus report by National Academies of Sciences, Engineering and Medicine, January 2018• E-cig use increases risk of beginning tobacco cigarette use in young adults A

study by University of Pittsburgh Schools of the Health Sciences published in the American Journal of Medicine 2017

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Overview of E-cigarette or vaping product use-associated lung injury (EVALI)

• ED visits continue to decline after a sharp increase in August 2019• Tetrahydrocannabinol (THC)-containing products • Vitamin E acetate is strongly linked• Can not rule out other chemicals

(https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-information)

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evaluation

• Diagnosis of exclusion• Rapid recognition is critical to reduce severe outcomes• Interview• Physical Exam

• Vital signs• Pulse oximetry

• Imaging• CXR

• History of vaping• Respiratory or GI symptoms


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Outpatient management

• Normal oxygen saturation (>95% in RA)• No respiratory distress• Reliable access to care • Able to ensure f/u within 24-48 hours of initial evaluation


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Hospital admission

• Concurrent illness• Respiratory distress• Comorbidities that compromise pulmonary reserve• Oxygen saturation <95% in RA


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Flu season

• Strongly consider influenza testing• Consider treatment with empiric antimicrobials including antivirals

following community-acquired pneumonia guidelines• Antivirals can be considered for confirmed or suspected influenza• Annual flu vaccination (including patients who vape)• Consider pneumococcal vaccine for patients with a history of EVALI


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Treatment of evali

• Cessation of vaping• Consult with pulmonary, ID, psychology, and addiction medicine

specialist should be considered, as indicated• Corticosteroids• In hospitalized patients 65% have rapid improvement• Dosing varies


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Dosing Corticosteroids

• 40 mg daily for 7 days • Dose as for acute eosinophilic pneumonia• No clear guidelines• Initial dose depends on severity of disease• In hospitalized patients with severe hypoxemic respiratory failure requiring

mechanical ventilation, intravenous methylprednisolone with dose ranging from 60 to 125 mg every 6 hours or equivalent is a commonly used regimen• In the absence of respiratory failure at presentation, oral prednisone 40 to 60

mg daily is started and progressively tapered over 2 to 6 weeks• Only 2/3 of patients treated improved suggesting a heterogeneity of

disease

(https://pulmccm.org/review-articles/vaping-associated-lung-injury-part-2/;

https://www.atsjournals.org/doi/full/10.1164/rccm.201710-1967CI

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Similarity to ARDS

• Diverse radiographic, cytological and histopathological characteristics• There may be more inflammatory subtypes relieved by anti-

inflammation and PEEP and wounded by IV fluids• Given its general anti-inflammatory, anti-oxidative properties it is

possible an adjunctive therapy like N-acetyl cysteine [NAC] could be useful

(https://pulmccm.org/review-articles/vaping-associated-lung-injury-part-2/)

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Discharge planning

• Clinically stable for 24-48 hours• Medication reciliation and teaching• Follow up appointment with PCP or Pulmonology within 48 hours• Confirm respiratory status stable• Education• Tapering of corticosteroids if prescribed• Abstinence from vaping

• Long-Term pulmonary f/u within 2-4 weeks• Additional f/u testing 1-2 months • Consider need for PT

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Nonpharmacologic treatment to stop vaping

• http://texasstopsmoking.com/• https://yesquit.org/

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New information

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Questions?

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http://texasstopsmoking.com/

https://yesquit.org/

Documents

Adolescents, Vaping, & JUULing: What You Need to Know · 2020-02-21 · TruthInitiative.org, "Juul e -Cigarette Craze HIghlights Why Flavored Products Are So Dangerous" (April 23,