[Thorpe] Welcome to Beyond the Data.
I'm Dr. Phoebe Thorpe, and here with me today is Dr. Brian King
from CDC's Office on Smoking and Health.
Thank you for joining us Brian.
[King] Thanks so much for having me.
It's a pleasure to be here.
[Thorpe] Our topic today is E-cigarettes.
Can you tell us why they are considered a tobacco product?
[King] Yes, so in the United States we regulate tobacco
products through the US Food and Drug Administration,
and the way they describe a tobacco product is any product
that's made or derived from tobacco.
And we know that the vast majority of nicotine that's used
in tobacco products, including e-cigarettes,
is indeed derived from tobacco.
So since these products contain nicotine,
we consider them a tobacco product in the United States.
[Thorpe] And E-cigarettes are little bit different
than regular cigarettes.
Can you describe how they work?
[King] Yeah, so E-cigarettes is short for electronic cigarettes,
but we know them by a lot of different names.
And they can be called things like vapor products,
hookah pens, vape pens, but the bottom line is they're all
really the same product.
And they work by containing a liquid that's heated
which the user then inhales into their lungs, and it's important
to note that this isn't technically a vapor
which is how people frequently refer to.
It's actually an aerosol that contains small particles as well
as various other ingredients that the user inhales,
and so there's no combustion.
You're not burning anything, but there is a heating of the liquid
which turns into an aerosol which the user inhales.
And they can also exhale into the air
as other bystanders are around them.
[Thorpe] And the aerosol is not just water vapor.
I mean, that's an important part to understand
because I get asked as a physician about E-cigarettes,
and the thing from the session
that I found very interesting was the idea
that were not really certain about the risks
that flavorings add to E-cigarettes.
The one that was mentioned was the butter flavoring Diacetyl
that has been associated with bronchiolitis obliterans
or what's called popcorn lung, which is a deadly disease.
What more do we know about the risks of E-cigarettes?
[King] So our knowledge about what's contained
in both the E-cigarette liquid as well
as the aerosol has continued to evolve over time
that these products entered the United States marketplace
in around 2007.
They didn't really start to uptick in use until 2010, 2011.
But, since that time, we really increased the amount of research
into what these products contain.
And what we can say is that the aerosol admitted
by these products is not harmless.
We do know that the ingredients
and the levels are significantly less dangerous
than conventional cigarettes, but that doesn't mean
that they're completely risk-free.
And so, some of the ingredients we found
in the E-cigarette aerosol are things
like ultrafine particulate that can be inhaled very deep
into the lungs, and also heavy metals that are found
in the filaments of the device and are omitted in the aerosol,
as well as, things like volatile organic compounds.
But one of the most common ingredients is nicotine,
and we know that nicotine is highly addictive.
But there's also evidence indicating
that it can harm the developing adolescent brain
which really makes it important for youth
to avoid these devices.
In addition to some of these other harmful ingredients,
we also know the flavorings.
And so, Diacetyl is just one, but there are a variety
of different flavorings that are used that,
although they may be safe to ingest in things like food,
we don't know what the risks are
for inhaling these devices into the lungs.
You know, your gut can handle a lot more than your lungs,
and that's really important when we look
at the ingredients in these products.
And finally, it's also important to remember
that people are using a lot of things in E-cigarettes,
and that includes other psychoactive substances
like marijuana and THC and others.
And so, when we are talking about youth in particular,
the use of both the nicotine containing varieties as well
as other varieties for other types
of drugs are really a public health concern.
[Thorpe] Okay.
But we have had some recent good news
about the youth meaning middle school
and high school use of E-cigarettes.
Can you tell me about that?
[King] Yes.
It's really a commendable public health accomplishment.
We started assessing E-cigarette use among youth in this country
in 2011, and through 2015, we saw exponential increases
in the use of this product.
And 2016 was the first time
that we actually saw decline among youth in this country,
and that was really a result of the coordinated efforts
to not only educate the public about the harms
of youth E-cigarette use
but also implementing common sense strategies
to not only prevent youth access but also to protect people
from the aerosol and public environments
and various other campaigns
to educate people about these products.
But, on balance, the bad news is that we still have
over 2 million youth that are using E-cigarettes,
and they're now the most commonly used tobacco products
used among US youth.
So we made great progress, but we really need to continue
that momentum to reduce all forms
of tobacco product use among youth.
[Thorpe] So it's going down, but not as lot much as we'd like.
So what's driving the use of the E-cigarettes in teens?
[King] So there's a variety of factors
that we believe are contributing to these increased rates
of use among youth that we saw through 2015.
One of the most notable is the advertising for these products.
We know that many of the themes and tactics that have been used
to advertise conventional cigarettes are frequently used
for E-cigarettes.
And we also know that there's some media of for
which conventional cigarette advertising is banned
that is allowed for E-cigarettes.
Things like television.
And so, there's really a prominent advertising
of these products, and we know
that it's reaching kids in particular.
About 18 million US youth reported being exposed
to E-cigarette ads in 2014.
Another factor is flavorings, and we know,
from the existing science,
that flavorings can be particularly appealing in terms
of enticing youth and young adults to use tobacco products.
And a variety of E-cigarettes are flavored, and we know,
from the existing data, that about two thirds of youth
who use these cigarettes report using flavored varieties,
and flavors are the most commonly cited reason
for why youth started using these products.
And so, in the end, we really have a situation
where you know the advertising is bringing the horse to water.
The flavorings are getting them to drink,
and then the nicotine is keeping them coming back for more.
And so, it's kind of a perfect storm in terms
of the youth rates of this use.
But the good news is, we know what works to prevent that.
And if we implement those common sense public health strategies,
we can continue to see the declines that we saw
within the past year among our nation's youth.
[Thorpe] And the real concern is about nicotine
and the teenage brain.
Can you just briefly tell me a little bit more about that?
[King] Yeah.
So nicotine is found in the vast majority of E-cigarettes
that are sold on the U.S. market and, you know, nicotine we use
in things like nicotine replacement therapy
among adults.
And it can be, you know, an effective drug
to help people quit conventional cigarette smoking.
But it's important to note that those are in very measured doses
and weans the individual off
of conventional cigarettes over time.
But nicotine is not necessarily risk-free.
Particularly for vulnerable populations.
We know that nicotine is highly addictive,
but there's also a growing body of scientific evidence
that was outlined in a recent Surgeon General's Report noting
that nicotine exposure can harm the developing adolescent brain.
And we know that the brain continues to develop
into young adulthood up through 25 or 26, and so,
there's really implications for not only youth use
of these products but also young adult use
of any nicotine containing product.
And another thing to remember
with nicotine is it's also been shown to result
in adverse health outcomes among pregnant women
in particularly fetal toxicity.
So there's also implications
about pregnant women using any form
of nicotine containing product, and so, it's really important
for them to talk with their physician before they use any
type of nicotine containing product including E-cigarettes.
[Thorpe] So is there a place that physicians could go
to learn a little bit more about these parts
with the E-cigarettes and the nicotine?
[King] So there's many resources that have been developed
over the past few years, particularly
as the sciences begun to grow.
And we have, you know, more concrete evidence
about what works effectively to help warn people
about these products and also provide them scientific-based
information to make informed decisions.
And in 2016, the U.S. Surgeon General released a landmark
report on E-cigarette use among youth and young adults.
And as part of the release of that report,
there were several materials including resources
and provider cards to help health professionals really
communicate to both children and adults about these products.
And so, in the context of youth,
it really enforces the importance of warning them
about the dangers of these products.
Particularly with regard to the nicotine content.
And among adults, it's a more nuanced conversation
about knowing that we do have FDA approved medications
to help people quit, and those should really be the first line
of defense to help you quit.
And if that doesn't work, you can consider E-cigarettes,
but in consultation with your healthcare provider.
And right now, based on the evidence we have,
there is no conclusive evidence that E-cigarettes are effective
for long-term cessation, and so, it's really important
to use those resources that we know are most effective
to help you quit and in coordination
with your healthcare provider.
[Thorpe] And then for youth, where if parents
or other adults wanted to know more about how they could talk
to teens and young adults about the risks of E-cigarettes,
where would they find some information about that?
[King] So as part of the release of the Surgeon General's Report,
there's an excellent interactive website that was coordinated
with the release of that report,
and it is E-cigarettes.surgeongeneral.gov.
And it has a variety of information
on both the report itself as well
as a public service announcement as well as informational cards
for both parents and clinicians to educate our youth
and young adults in particular about the dangers and risks
of using these products.
[Thorpe] That sounds like an excellent place for our viewers
to go and see what they can find out.
Thank you very much for joining us.
[King] Thank you very much for having me.
[Thorpe] And thank you for joining us.
See you next month on Beyond the Data.