HJBR Mar-Apr 2019

Healthcare Journal of BATON ROUGE  I  MAR / APR 2019 51 Mindy Calandro, MD Pediatrician contain nicotine. Each of the ever pop- ular JUUL brand pods contain the same amount of nicotine as 20 cigarettes. Nic- otine, which is of course highly addictive, can have detrimental effects on the still growing brain of adolescents, particularly in areas of impulse control, focus, andmost alarmingly, increased susceptibility to ad- diction. These liquids also contain flavor- ing such as pina colada, bubble gum, java chip, popcorn, and caramel. A recent study found that the chemicals used to create the popcorn and caramel flavors, diacetyl and 2,3-pentanedione, respectively, while safe for eating, can actually destroy the cilia of the lungs. Other ingredients include pro- pylene glycol (a component of antifreeze), aldehydes and nitrosamines, among other toxicants and carcinogens. Beyond just the potential negative direct health aspects of e-cigarettes, there is also the issue of harmful youth consumption and addiction. The National Youth Tobacco Survey found a 78 percent increase in the usage of e-cigarettes in middle and high school students from 2017 to 2018, with over 20 percent of high school students reporting the use of a vaping device in the past 30 days. That means over 3.6 million high school students are smoking these devices. Studies have also found that those teens who start a nicotine addiction via e-cigarettes are almost 4 times more like- ly to start smoking traditional cigarettes, a worrisome trend after decades of declining teen smoking rates. Another potential hazard of liquid nic- otine that cannot be overlooked is the potential ingestion of these liquids by un- assuming young children. Many of these liquids are bright red, pink or yellow in color, which can certainly be enticing to children who may mistake them for juices, candy, etc. After the death of a child in 2014 from ingesting liquid nicotine, the Child Nicotine Poisoning Prevention Act was enacted in early 2016, requiring all liquid nicotine packaging to be child-resistant. Even with this law, the number of calls to poison control centers around the United States involving ingesting vaping fluids topped 3,000 in 2018 and 340 in the first 31 days of 2019. Prior to 2016, e-cigarettes were available for purchase to anyone, including chil- dren, through not only brick and mortar stores, but also gas stations, mall kiosks, and online retailers. The aforementioned Child Nicotine Poisoning Prevention Act of 2016 made it illegal to sell these devic- es to anyone under the age of 18, required photo verification of age for those under 27 years old, banned sales of these devices in vending machines, and required warn- ing statements on products regarding the addictive nature of nicotine. While on- line retailers of e-cigarette devices have the same age restrictions, Truth Initiative found that youth were 89 percent success- ful in obtaining these devices when pur- chasing online. The FDAhas also proposed the Deeming Rule, which would require e-cigarette manufacturers to submit their products for FDA review and approval pri- or to going to market. The Deeming Rule was set to go into effect in 2016, however its implementation has now been delayed to 2022, which allows for another 3 years of unregulated e-cigarette products being sold to consumers. There are those that contend e-ciga- rettes are a safer alternative to traditional cigarette smoking because e-cigarettes do not contain tobacco—but at the expense of what other components? Very small and limited numbers of randomized controlled trials show insufficient evidence of e-ciga- rettes as a smoking cessation device when compared to FDA approved smoking-ces- sation treatments. While further investiga- tion is needed, I can certainly see how my adult medicine colleagues will likely see the benefit of a non-combustible smoking alternative. But as a pediatrician, the cur- rent e-cigarette trend for youth is beyond alarming. When I ask my teenage patients about vaping, many of them give me a little shoulder shrug and slight smile as they tell me how ubiquitous these devices are. They appear to be a daily fixture in school bath- rooms these days. I have found that many teens do not even know they are smoking highly addictive nicotine—which Truth Ini- tiative verified when they found that 60 percent of teens thought the primary in- gredient in their e-cigarette was flavoring. More must be done to stem the rising tide of this epidemic for our youth. Our children deserve more than just warning letters and fines from the FDA to e-ciga- rette manufacturers who are marketing to youth. The Deeming Law should be enact- ed now rather than waiting until 2022 so the public will know what they are being exposed to through these vaping liquids. There needs to be a push on the state lev- el to have meaningful laws enacted that would put e-cigarettes on level footing with traditional cigarettes legally. Same regulations, same requirements, same ad- vertising restrictions, same tax levels, etc. Of particular note, e-cigarettes should also be incorporated into current tobacco-free zone restrictions, limiting their presence in places such as schools, restaurants, and public facilities. Hopefully, implementing all of these things, combined with effec- tive social outreach movements much like those of earlier decades by the Surgeon General and Truth Initiative, will help re- verse this rising epidemic of nicotine ad- diction in our youth. n