Vaping And Other Smoking Products And Children

CON T EMPORARYP ED I AT R I C S . C O M | A U G U S T 2 01724

PEER-REVIEWED FEATURE Teen Vaping

Dr Douglass is DNP program

director and assistant

clinical professor, DNP

Program and Nurse

Practitioner Programs,

Drexel University College

of Nursing and Health

Professions, Division of

Nursing, Graduate Nursing

Programs, Philadelphia,

Pennsylvania.

Dr Solecki is assistant

clinical professor of nursing,

DNP Program and Nurse

Practitioner Programs, Drexel

University College of Nursing

and Health Professions,

Division of Nursing,

Graduate Nursing Programs,

Philadelphia. The authors

have nothing to disclose in

regard to affiliations with

or financial interests in any

organizations that may have

an interest in any part of this

article.

The vaping culture of using non–cigarette

tobacco and electronic nicotine delivery

systems (ENDS) is the latest risky trend

among adolescents and young adults. Vap-

ing is the use of high-tech, advanced elec-

tronic devices such as electronic cigarettes

(e-cigarettes), refillable atomizers, and

other tobacco products as an alternative

or in addition to regular cigarettes.1 A con-

cerning 10-fold to 11-fold rapid rise noted

in middle and high school students poses

dangers of nicotine exposure to the pediat-

ric population.2

This article will explore the risk-taking

behavior of adolescents engaging in vaping;

the effects of vaping and the indiscriminate

use of nicotine products on the young; and

strategies that healthcare providers can use

to collaborate with patients and families to

reduce their risk of harm from this emerging

public health epidemic.

Background The first e-cigarette was conceptualized

and patented in 1965 by Herbert Gilbert as

a safe and harmless modality to smoking

cigarettes.3,4 In 2003, an electronic atomiz-

er version was patented by Ruyan Technol-

ogy in China, marketed to the United States

in 2007, and touted as a healthier alternative

to smoking conventional cigarettes.3 Since

the emergence of Ruyan’s first-generation

e-cigarette, novel models have emerged in

design, engineering, and nicotine delivery

methods resulting in second-, third-, and

fourth-generation ENDS delivery devices.4

Modern generation devices have included

mid-sized e-cigarettes known as personal va-

porizers (PVs), which are similar to a pen or

laser pointer.4 The advanced personal vapor-

izers (APVs) contain a mechanical firing de-

vice called a “mod” (short for “modification”)

that may be used in conjunction with differ-

ent atomizers (tank systems), and they vary in

size, shape, and delivery methods. The most

innovative and advanced devices, however,

are regulated “vape mods,” which contain

an internal circuitry. Lingo used among the

diversity of delivery devices includes vapes,

vape pens, e-cigs, e-hookahs, mods, and tank

systems.3,4

Regardless of the novel delivery devices,

use of nicotine-containing products in any

Teen vaping Time to clear the air

BRENDA L DOUGLASS, DNP, APRN,

FNP-C, CDE, CTTS; SUSAN SOLECKI,

DRPH, FNP-BC, PPCNP-BC

Vaping has escalated at alarming rates among adolescents

and young adults. It’s time to educate teens about the hidden

health risks of these innocuous nicotine delivery systems.

CONTINUED ON PAGE 28http://contemporarypediatrics.modernmedicine.com/

CON T EMPORARYP ED I AT R I C S . C O M | A U G U S T 2 01728

peer-reviewed

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form presents dangers and is unsafe.4

Escalation of misuse Vaping is a significant public health

concern and has escalated at alarm-

ing rates among adolescents and

young adults. During 2011-2012, data

from the National Youth Tobacco

Survey revealed a modest increase in

e-cigarette use (used 1 or more times

within the past 30 days) among stu-

dents in grades 6 to 12, from 1.1% to

2.1%.4 From 2011 to 2014, the use of

e-cigarettes grew rapidly to 13.4%

of high school students and 3.9%

of middle school students. By 2014,

e-cigarettes had become the most fre-

quently used tobacco product among

young persons, exceeding conven-

tional cigarette use. In 2015, over

3 million middle school and high

school students reported e-cigarette

use, equating to 1 in every 6 school

students, and over 25% reported try-

ing e-cigarettes.

In young adults aged 18 to 24 years,

e-cigarette use (used 1 or more times

within the past 30 days) more than

doubled from 2013 to 2014 to 13.6%,

and as of 2014, more than one-third

had tried e-cigarettes.4 E-cigarette

use data among teenagers and young

adults represent the various product

types of ENDS.3,4

What the vaping culture entails Vaping refers to the vaporization of

substances (nicotine, flavorings, can-

nabis, or other substances in popu-

larity) wherein oil, liquid, or plant

material is heated to a temperature

resulting in the release of aerosol-

ized water vapor and active ingredi-

ents (nicotine, cannabis) delivered

via inhaled aerosol.3-5 Tremendous

controversy has arisen surrounding

potential harm reduction or risks as-

sociated with e-cigarettes/vaping in

young persons.3

Nicotine, a highly addictive sub-

stance in any form, is commonly

vaped.3,4 Health effects of nicotine in-

clude hemodynamic effects second-

ary to catecholamines (eg, increase

in heart rate and blood pressure; va-

soconstriction of arteries and vessels;

endothelial dysfunction; atheroscle-

rosis acceleration).3 During adoles-

cence while the brain is developing,

nicotine can result in addiction and

harmful consequences such as be-

havioral and cognitive impairments,

memory issues, inattention, and ex-

ecutive function impairments.4,6

Harmful effects have been found

from e-cigarette aerosol and addi-

tives.4 Brief exposure to propylene

glycol aerosol has been reported to

PEDIATRIC-FOCUSED LINKS ON E-CIGARETTES AND VAPING

AMERICAN ACADEMY OF PEDIATRICS:

E-Cigarettes and Electronic Nicotine Delivery Systems bit.ly/AAP-ENDS

CALIFORNIA STATE UNIVERSITY FULLERTON:

Electronic Cigarettes: Information for Parents bit.ly/CSUF-ecig-parent-info

CAMPAIGN FOR TOBACCO-FREE KIDS:

Electronic Cigarettes: An Overview of Key Issues bit.ly/tobaccofreekids- ecig-overview

CENTERS FOR DISEASE CONTROL AND

PREVENTION:

E-Cigarettes and Young People: A Public Health Concern bit.ly/CDC-ecigs

MYHEALTH.ORG:

The Truth: Is Your Teen Vaping? bit.ly/myhealthoc-teen-vaping

NATIONAL INSTITUTE ON DRUG ABUSE:

Teens and E-Cigarettes bit.ly/NIDA-teens-and-ecigs

TV Spotlight on Electronic Cigarettes: YouTube bit.ly/NIDA-youtube-ecigs

NEMOURS FOUNDATION, DUPONT PEDIATRICS:

KidsHealth: About E-Cigarettes bit.ly/KidsHealth-ecigs

TeensHealth: E-Cigarettes bit.ly/TeensHealth-ecigs

US DEPARTMENT OF HEALTH AND HUMAN

SERVICES:

E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General bit.ly/HHS-ecigs- SurgeonGeneral-report

Know the Risks: E-Cigarettes and Young People bit.ly/HHS-ecigs-know-the- risks

Know the Risks: E-Cigarettes and Young People. Talk with your Teens About E-Cigarettes: A Tip Sheet for Parents bit.ly/HHS-ecigs-parent-tip-sheet

US FOOD AND DRUG ADMINISTRATION:

Vaporizers, E-Cigarettes, and Other Electronic Nicotine Delivery Systems bit.ly/FDA-tobacco-products

FROM 2013 TO 2014

E-cigarette use among middle and high school students tripled, rising from approximately

660,000 to 2 million students19

CONTINUED FROM PAGE 24http://bit.ly/AAP-ENDShttp://bit.ly/CSUF-ecig-parent-infohttp://bit.ly/tobaccofreekidsecig-overviewhttp://bit.ly/CDC-ecigshttp://bit.ly/myhealthoc-teen-vapinghttp://bit.ly/NIDA-teens-and-ecigshttp://bit.ly/NIDA-youtube-ecigshttp://bit.ly/KidsHealth-ecigshttp://bit.ly/TeensHealth-ecigshttp://bit.ly/HHS-ecigs-SurgeonGeneral-reporthttp://bit.ly/HHS-ecigs-know-theriskshttp://bit.ly/HHS-ecigs-parent-tip-sheethttp://bit.ly/FDA-tobacco-productshttp://MYHEALTH.ORG

29A U G U S T 2 017 | CON T EMPORARYP ED I AT R I C S . C O M

peer-reviewed

be a respiratory and eye irritant in

patients without asthma.6 Contem-

porary generations of high-powered

e-cigarettes comprising tank sys-

tems have the capacity to heat nico-

tine liquids to high temperatures that

produce cancer-causing carcinogens

such as formaldehyde and acetalde-

hyde in the vapor.4,6 Metals detected

in some e-cigarette aerosol, includ-

ing lead, silver, tin, nickel, iron, cop-

per, and cadmium, may be products

of the heating element (coil).4

Secondhand e-cigarette aerosol

exposure to nicotine, particles, and

potentially toxic chemicals have been

found in emissions studies.3 The ef-

fects of potentially harmful doses of

heated and aerosolized ingredients of

e-cigarette liquids including solvents,

flavorings, and toxicants are not fully

understood.4

Dual use of vaping nicotine and

smoking cigarettes presents added

health concerns.3,4 An association has

been identified in young persons be-

tween e-cigarette use and the propen-

sity to use other tobacco products, in

particular the use of combustible prod-

ucts (ie, cigarettes).4 To illustrate, 58.8%

of high school students in 2015 report-

ed using e-cigarettes and additionally

combustible tobacco products.

The evolving landscape of rec-

reational and medicinal marijuana

(cannabis) use has given rise to an in-

crease in vaping cannabis.5,7 In 2017,

a study conducted among 3847 high

school students in Connecticut was

consistent with high rates of using

e-cigarettes to vape cannabis (life-

time cannabis user, 18%; lifetime dual

users, 26.5%).7 Besides the potential

for nicotine addiction, addiction risk

exists for cannabis and other illicit

drug use.4 Little is known about the

long-term health effects of vaping and

even less has been established about

the potential harm of vaping other

substances such as cannabis.5

Targeted advertising Robust marketing and colorful adver-

tising campaigns directed toward the

youth population through social me-

dia outlets, television, and on the In-

ternet proliferated between 2011 and

2013.3,6 One study found television ad-

vertisements soared 256%, reaching

over 24 million young persons.3 Ap-

pealing, child-friendly flavorings are

a marketing endeavor to attract ado-

lescents, disguise harsh tobacco, and

facilitate nicotine addiction.4,6

In 2014, 466 brands and 7764 dis-

tinctive flavors of e-cigarette products

were available.3,4 Emerging evidence

suggests that flavorings when vapor-

ized at high temperatures result in

chemical reactions of toxic levels of

carbonyl compounds such as form-

aldehyde, although the health effects

are not completely appreciated.4,8

Flavorings/taste were among the

3 most commonly reported reasons for

e-cigarette use among teenagers and

young adults along with perceived low

harm as compared with conventional

tobacco products and curiosity.3

Emerging evidence of use patterns

has revealed that e-cigarettes are

being utilized by young persons for

various alterative behaviors such as

smoke tricks, vape competitions, and

vaping other substances including

cannabis and cocaine.8

“Dripping” is one of the newest

trends wherein e-liquid at high tem-

peratures is manually applied direct-

ly on the atomizer coil and the vapor

produced is inhaled.8 In the first study

to evaluate prevalence rates for drip-

ping conducted by Yale University on

high school students (n=7045) from

8 different Connecticut schools,

anonymous surveys evaluated to-

bacco use behaviors and perceptions.

Results of the anonymous surveys re-

vealed that 26.1% of e-cigarette ever

users (n=1080) reported using the

device for dripping, equating to 1 in

4 adolescents. Reasons for dripping

included: thicker vapor clouds (63%);

better-tasting flavors (38.7%); and a

stronger hit produced in the throat

(27.7%) by dripping. Safety studies are

not available on the practice of drip-

ping, although some research sug-

gests e-liquid exposure may have a

considerable increase in toxic vapors

(eg, acetaldehyde, formaldehyde, ac-

etone) and may increase exposure to

high levels of nicotine.

Promoting public awareness Adolescents encompass over 20% of

the population in the United States.9

Harm reduction prevention and ear-

ly interventions of risky behavioral

patterns established during the de-

velopmental periods of youth are

not only significant for influencing

adolescents’ current health status,

but also their future health status

In 2014, the products most commonly used by high school students were:19

e-cigarettes 13.4% || hookah 9.4% || cigarettes 9.2%

cigars 8.2% || smokeless tobacco 5.5% || snus 1.9% || pipes 1.5%http://contemporarypediatrics.modernmedicine.com/

CON T EMPORARYP ED I AT R I C S . C O M | A U G U S T 2 01730

peer-reviewed

into adulthood. In 1 study in which

teenagers were asked why they used

e-cigarettes, more than half the stu-

dents stated the main reason was

simple curiosity.10 Of concern was

that when asked what they were in-

haling when vaping, more than

60% reported that they were vapor-

izing “just flavoring,” not realizing

e-cigarettes contain nicotine. Only

10% of the adolescent research par-

ticipants stated they were using

e-cigarettes in an attempt to quit

smoking regular cigarettes.

Another alarming problem is the

increase (161% to 333%) in calls to

poison control centers that involve

children aged younger than 5 years

suffering potentially fatal poisonings

through the ingestion, inhalation,

or absorption through the skin or

eyes attributed to access to the liquid

nicotine cartridges, which are not re-

quired to be childproof.3 Concentra-

tions of e-liquid nicotine for refilling

e-cigarettes are ample enough to re-

sult in a fatal overdose sometimes as

high as 1000 mg/10 mL and are com-

monly sold in colorful bottles or car-

tridges attractive to children.3,4

The use of ENDS has achieved no-

toriety to the adolescent population

in particular via the Internet through

social networking and by the promo-

tion of tobacco products using viral

strategies from tobacco companies

that have been directly and indi-

rectly marketing via social media.11

The traditional dissemination of re-

search findings, health information,

and regulatory actions using journal

publications and government reports

to stakeholders involved in this public

health problem may need to be recon-

sidered.12 Technologic advancements

with communication and advertis-

ing outlets may have implications

for public health advocates who will

need to explore alternative strategies

to engage and inform the community

at large on emerging health concerns,

promotion, and prevention.

Parental support and guidance A national endeavor issued by the

office of the US Surgeon General,

E-Cigarette Use Among Youth and

Young Adults, outlines 6 goals and

strategies to reduce e-cigarette

use among adolescents and young

adults.4 Strategies to accomplish

these goals encompass areas where

stakeholders (eg, individuals, par-

ents/caregivers, families, teachers,

coaches, youth influencers) can be-

come involved. One way parents can

engage is to become educated on the

risk of e-cigarette use, enabling the

parent/caregiver to educate their

own children about the harmful ef-

fects of e-cigarettes, other nicotine

products, and vaping of illicit sub-

stances. Being tobacco-free role

models, opening discussions about

the harms of tobacco and nicotine

products, and protecting young per-

sons from indirect exposure, such

as tobacco smoke or aerosol from

e-cigarettes, are illustrations.

Role of healthcare providers Lack of knowledge can be a result of

healthcare providers’ receiving lit-

tle or no formal training in either

their academic or practice settings

on screening, treating, or provid-

ing referrals to young patients and

their families in regard to vaping.

Healthcare providers may not even

be screening for the use these prod-

ucts. If asked about tobacco use, ado-

lescents and young adults who are us-

ing these products may not consider

them tobacco, and respond that they

are not using them. A recommenda-

tion would be to add vaping to the

electronic medical record’s tobacco

screening tool when screening for to-

bacco use in the pediatric population.

Healthcare providers can play a

key role both in clinical practice and

as faculty in higher education. The

provision of skills necessary to ad-

ICD-10 CODES VAPING

The following are suggested

ICD-10 codes for the diagnosis

and treatment of tobacco/

nicotine use or abuse in

children. Check with your

contracted plan and individual

state Medicaid program for

coverage policy.

F17.290 Nicotine dependence, other tobacco product, uncomplicated

F17.298 Nicotine dependence, other tobacco product, with other nicotine- induced disorders

F12.90 Cannabis use, unspecified, uncomplicated

F12.10 Cannabis abuse, uncomplicated

F12.21 Cannabis dependence, in remission

T65.291A Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter (For children who accidentally ingest a liquid nicotine refill)

Z71.6 Tobacco abuse counseling

Z72.0 Tobacco use

Z87.891 Personal history of nicotine dependencehttp://contemporarypediatrics.modernmedicine.com/

CON T EMPORARYP ED I AT R I C S . C O M | A U G U S T 2 01732

peer-reviewed

dress the health and safety implica-

tions of pediatric nicotine use and

exposure needs to be incorporated

into clinical practicum course objec-

tives. Education initiatives in medical

and nursing practice can enhance the

ability to assess and synthesize data,

make clinical judgments, and initiate

diagnostics decisions. The develop-

ment of appropriate plans of care and

anticipatory guidance may be a sus-

tainable, long-term solution related to

this evolving public health epidemic.

Recommendations for policy and practice Regulatory policy lagged behind the

rapid revolution of e-cigarettes and

vaping resulting in risk to children, ad-

olescents, and young adults.13 In 2014,

the US Food and Drug Administration

(FDA) expanded regulatory authori-

ty under the Family Smoking Preven-

tion and Tobacco Control Act of 2009

to include all tobacco products includ-

ing e-cigarettes and hookahs.4,11 Con-

cerns by public health advocates exist

because the proposed regulations do

not include regulations of marketing

practices or flavored nicotine products

targeting young persons.13 E-cigarettes

presented a paradigm shift in the to-

bacco landscape. Vaping has gained

huge popularity among the younger

population and is an area wherein ex-

panded tobacco control policies and

enhanced surveillance of current and

emerging patterns of use are needed.4

Although recent regulations are

now restricting the sale of these

products to minors nationwide, the

marketing of these products in col-

ored refill packages and in a variety

of candy flavors is aimed at attract-

ing the younger generation with the

misperception of being a harmless

habit.9 Added hazards include a rise

in vaping other substances such as

the concoction of chemicals, canna-

bis, or synthetic drugs. Legalization of

medical marijuana and recreational

marijuana use in some states are rea-

sons rooted in escalating use of va-

porized cannabis use among youth.

Emerging patterns of alternative use,

such as dripping in 1 in 4 high school

students, support the need for regu-

lations and restrictions on e-cigarette

devices to avoid easy manipulation

for novel experimentation.8

Globally, taxation has been used

as an effective means to reduce ciga-

rette consumption. with approxi-

mately a 10% increase in price re-

sulting in a 1% decrease in smoking

prevalence.12 There is wide variabil-

ity in the taxation of non–cigarette

tobacco products in some markets

where ENDS have not been subject to

tobacco taxes. Consumers, particu-

larly adolescents, may seek more cost-

effective products, thus switching to

other tobacco products or substitut-

ing related ENDS. The FDA could

evaluate risk/exposure claims pro-

viding opportunities for tax advan-

tages to products as a way to draw

users away from more hazardous

products. Such regulations could also

bring about changes in non–cigarette

tobacco products that could impact

public health by reducing attractive-

ness and/or toxicity.

The New Jersey State Assembly and Senate are

reviewing a legislative bill (S298/A3704)14,15 to

ban all flavored electronic cigarette products.16

If the bill passes in both legislative houses and

is approved by Governor Chris Christie, the

opponents of the new law are concerned that

vape stores statewide would be out of business.17

This bill would expand on the 2008 New Jersey

law that already restricts the sale or distribution

of flavored electronic smoking devices,

cartridges, and liquid refills to adults, except

for 3 flavors: clove, menthol, or tobacco.16 The

current law also prohibits the sale or distribution

of electronic smoking devices to individuals aged

younger than 19 years, the same as cigarettes.17

Although many understand the marketing

concerns and potential health risks of vaping

as related to minors, the opponents of the bill

resent the limited sale of flavors to adults and

the potential impact on positive anecdotal

experiences of quitting traditional tobacco

products by vaping instead.17 Proponents of the

bill and public health advocates are concerned

these products are marketed toward young

persons and may increase the incidence of

tobacco use among children.

Despite the protests, the controversial bill

appears to be enduring the debate paralleling

antivaping legislation that is prevailing worldwide.

NEW JERSEY DEBATES LEGISLATIVE BAN ON SALE OF FLAVORED ELECTRONIC SMOKING DEVICES

CONTINUED ON PAGE 38http://contemporarypediatrics.modernmedicine.com/

CON T EMPORARYP ED I AT R I C S . C O M | A U G U S T 2 01738

clinical brief

ment is believed to be inf lu-

enced by age, frequency of res-

piratory track infections, and social

factors such as daycare exposure. The

American Academy of Otolaryngol-

ogy–Head and Neck Surgery (AAO-

HNS) currently recommends tympa-

nostomy tube placement for children

with bilateral OME if they are aged

3 months and older and have hearing

difficulty, the study notes. Tube place-

ment also may be indicated in chil-

dren with unilateral or bilateral OME

if there are other symptoms present,

such as ear discomfort, vestibular

problems, and reduced quality of life

or school performance. Likewise, the

American Academy of Pediatrics sup-

ports tympanostomy tubes for chil-

dren who have experienced recurrent

AOM, with 3 episodes over 6 months or

4 episodes in a year.

In children with OME, researchers

found that mean hearing thresholds

increased by 9.1 decibels after tympa-

nostomy placement, and that tympa-

nostomy tubes, tympanostomy tubes

with adenoidectomy, and myringoto-

my with adenoidectomy were the most

effective interventions when it came

to hearing improvements. There were

no differences, however, in hearing

thresholds between children treated

with tympanostomy versus watchful

waiting after 1 to 2 years.

For long-term hearing improve-

ments, the research team found that

tympanostomy tube insertion with

adenoidectomy and myringotomy

with adenoidectomy were the 2 most

effective interventions, while tympa-

nostomy tubes alone, antibiotic pro-

phylaxis, and watchful waiting were

the least effective strategies.

For AOM, researchers compared

tympanostomy placement to a placebo

group and found that 3 of 20 children

in the placebo group had no further

episodes of AOM, while 12 in 22 who

received tympanostomy tubes were

without additional episodes after the

intervention. Another study analyzed

by the research team found that 40%

of children in a placebo group had no

further episodes of AOM compared

with 35% in the tympanostomy tube

group. Researchers noted, however,

that children in that study who were

treated with tympanostomy tubes had

a shorter duration of AOM episodes

than the placebo group.

Although evidence does support

short-term positive results, research-

ers note that the lack of long-term

hearing benefits between watchful

waiting and tube placement supports

the hypothesis of the preferred natu-

ral, spontaneous resolution of middle-

ear effusion that most children

experience.

Despite some limited evidence of

improved quality of life after tube

placement, neither of the 2 studies that

evaluated parental stress or health-re-

lated quality of life found a significant

difference between tympanostomy

tube placement and watchful waiting,

according to the researchers. Also,

adverse events were difficult to track

as they were not often reported, and

many cohorts did not follow up post–

tympanostomy tube placement until

the extrusion of the tube.

Researchers note that they were not

able to predict which children would

be most likely to benefit from tympa-

nostomy tube insertion for chronic

middle-ear effusion, although there

was evidence that tubes might be par-

ticularly effective in young children

attending daycare or in older children

with persistent hearing impairments

lasting more than 3 months.

Steele says his report does not offer

recommendations on when or if tubes

should be placed, but says the findings

are in line with recommendations al-

ready established by the AAO-HNS. He

says he hopes the report will encour-

age shared decision making between

parents and pediatricians.

Summary There is the potential risk that public

misperceptions and regulatory prac-

tices do not often coincide with the

actual risk for tobacco products.12 The

pervasive tobacco control movement

based on strong science has been in-

strumental in driving numerous pol-

icy changes. Some of these positive

strategies include indoor smoking

restrictions, advertising bans aimed

at children, taxation (providing an

economic disincentive for smokers

to continue), and education. These

effective methods can inf luence

strategies regarding the use of non–

cigarette tobacco products that may

result in beneficial outcomes in pub-

lic health for the future.

Teen vaping CONTINUED FROM PAGE 32

For reference, go to

ContemporaryPediatrics.com/

tympanostomy-tubes

For references, go to

ContemporaryPediatrics.com/

teen-vapinghttp://contemporarypediatrics.modernmedicine.com/http://ContemporaryPediatrics.com/tympanostomy-tubeshttp://ContemporaryPediatrics.com/teen-vaping

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