Transcription:

Tiffany Kaczorowski (Host): Welcome to Inside Pediatrics, a podcast brought to you by Children’s Hospital of Alabama in Birmingham. I’m Tiffany Kaczorowski, and today our guest is Dr. Susan Walley, who's a certified tobacco treatment specialist. She is also an Associate Professor of Pediatrics at UAB - the University of Alabama at Birmingham - and a Pediatric Hospitalist at Children's of Alabama. So today we're talking specifically about E-cigarettes and vaping. Welcome, Dr. Walley.

Dr. Susan Walley, MD (Guest): Thank you, Tiffany.

Tiffany: One of the big myths that first comes to mind is that because vaping doesn't smell as bad, or doesn't seem to bother people, that it's not as harmful.

Dr. Walley: That's a great point, Tiffany, and I think in order to understand why E-cigarettes do have harms, it's important to understand a little bit about what an E-cigarette is.

So E-cigarettes have a lot of different names. They can be called vape pens, mods, tank systems, cigalikes; but all of them have the basic same characteristics, that there is generally a reservoir that contains a liquid, often known as E-liquid, and this liquid contains nicotine but also other chemicals that have been shown to have harmful toxicants, and some of these are cancer-causing and very similar to what's in regular combustible cigarettes.

So when we evaluate what that E-liquid and the vapor that comes of E-cigarettes, we know that they do contain harmful chemicals, and probably one of the most important things when we think about youth is that they oftentimes, most of the time, contain nicotine. And we know that nicotine is the ingredient in regular tobacco products like cigarettes, cigars, that cause addiction, and anything that can promote or increase the number of youth that become addicted to nicotine makes us extremely concerned as a medical community, and also just in terms of us as parents.

I'm a parent of three boys, and I know that adolescents, their brains are not mature, and we have ample evidence to know that adolescents and young adults are more likely to be addicted to nicotine, even just with intermittent use.

So in the past, we might have said, "Well, this teenager has tried cigarettes. That's not a big deal." But what we know now is that 90% of adults who are regular daily smokers, they started before the age of nineteen. So we really need to make sure that our youth are protected from starting a habit like nicotine addiction that can cause problems - health problems - throughout their life.

Tiffany: And you mentioned combustible cigarettes, or combustible products, and that just simply means that it's one that burns, right?

Dr. Walley: That's right. Combustible products are what you think of as traditional tobacco products like cigarettes and cigars where the tobacco is actually burned. And we know that the tobacco leaf contains nicotine, but it also contains thousands of chemicals, and many of those are what causes much of the ultimate health harms that might be from things like lung cancer, and other cancers, to heart disease, stroke, heart attacks. So there are over thirteen cancers that we know are caused directly by tobacco use.

Tiffany: We know that the E-cigarettes and that vaping is marketed to teens; they have flavors, they have colors. What is the risk to teenagers, would you say short-term and then long-term? You talked a little bit about their risk of then moving onto those other cigarette products, but in the short-term immediately, I mean this is nicotine still getting into their lungs, right?

Dr. Walley: That's right, and in addition to nicotine, we have enough scientific evidence to know that the other components of that vapor like ultra-fine particles, and some of those toxicants, can cause health harms. And so E-cigarettes are a new product, and the science hasn't caught up with the popularity unfortunately. So in 2016, we know that 11% of high school students and 4% of middle school students were current users of E-cigarettes. But in the short-term, adolescents who use E-cigarettes have more coughing and wheezing. No surprise, they're inhaling something that's dangerous into their lungs, and that it can also increase asthma attacks.

Unfortunately, long-term we really don't know exactly what kind of health effects it has to the lungs, to the heart, and to the rest of the body. But it took over fifty years to really gather evidence about traditional combustible cigarettes, and to know that it's the most deadly product that's legally sold, and we don't want another fifty years to go by with us letting our kids use E-cigarettes and then finding out, "Oh, this is a harmful product."

Tiffany: Right.

Dr. Walley: So we want to use a precautionary-

Tiffany: Preventative approach.

Dr. Walley: Preventative approach, exactly.

Tiffany: Right. You are the lead author of the AAP, the American Academy of Pediatrics' policy statement on electronic cigarettes. So tell us about that, about that policy statement, and people trust their pediatricians, families trust their pediatricians.

Dr. Walley: Well that's great to hear. The American Academy of Pediatrics is the largest organization of pediatricians, and one of our missions is to educate both our pediatricians and parents on different issues and topics that are important. And so this policy statement, which I was very honored and fortunate to be a part of, it's multi-faceted in the things that it covers. But from a pediatrician standpoint that is seeing an individual patient, we want to make sure that they know that this is not a safe product.

So in addition to recommending to never try any tobacco products, E-cigarettes are included in that, because beginning in 2014, E-cigarettes are the most common tobacco product that youth are using. So if a pediatrician is talking to their patient who is eleven, twelve, thirteen, they need to be saying not only, "Don't use cigarettes," but also, "Don't use electronic cigarettes."

Tiffany: And do you think one of those reasons could be that it's not as detectable because it doesn't smell as bad? Maybe these kids are trying it and they think, "My parents won't smell it on me because it's a pleasant smell, or it doesn't have much of a smell, it won't leave a smell on my clothing."

Dr. Walley: Absolutely, and we all know that teenagers, that is the time of rebellion, and they're testing limits, and so thinking about being able to use this new product that they're told with TV advertisements and advertisements on social media are healthy, and fun, and cool, and also with the added effect of thinking that they can get away with it.

So certainly we want to make sure that teenagers know that these are things that have their own risks, and not only do we know that teenagers are using them to vape E-liquid, which contains nicotine and some of those other products we know are harmful, that teenagers are also using them for sometimes illicit drug use including things like hash oil. And again, it is more difficult to smell the product, and thus a lot of teenagers kind of feel like they can get away with using them in places that they might not have been traditionally.

Tiffany: One brand in particular called JUUL is really very popular among middle schoolers, high schoolers. It's really made its way into the market now, right?

Dr. Walley: That's right. JUUL is an E-cigarette product that as of 2018 is greater than 50% of the market share. One of the major concerns is that JUUL uses a system that has something called pods, and the pods contain a very concentrated E-cigarette solution that is fifty-nine milligrams per milliliter. So each pod is over forty milligrams of nicotine, and we know of adolescents using one or two pods a day, and the amount of nicotine that that youth is exposed to is very concerning. And with this huge explosion of JUUL, kids will talk about JUUL'ing as a verb.

Tiffany: JUUL'ing.

Dr. Walley: JUUL'ing, yeah. This is something that we're hearing from teachers and educators that students are using this in the bathroom, even in the classroom, because while it's not true that it has no odor, it doesn't have the same odor as if you were to smoke a conventional cigarette.

Tiffany: And I'm picking this up and looking at it, it looks like a junk drive. I mean it's so small, it looks like a little bit longer than a traditional junk drive or thumb drive, but the pod is teeny tiny. And I mean, they could easily slip it into a pocket or something like that, the pod that has the liquid in it. So this is supposed to be supposedly equivalent to a pack of cigarettes.

Dr. Walley: That's right.

Tiffany: Just this one little pod.

Dr. Walley: That's right.

Tiffany: And if those teenagers are smoking two pods a day, that's two packs a day. That's incredible.

Dr. Walley: That's right.

Tiffany: Wow.

Dr. Walley: And we've heard of schools that have actually had to ban the USB drives because, like you said, it looks very similar to a USB drive, and it's very difficult for teachers to really detect it. Kids are smart, and clever, and they'll hide it in their clothing, they'll hide it- they'll palm it and use it on the sly.

So this is a very big concern to public health advocates, to pediatricians, obviously to parents, because it has such a slick design, and it's become what we call a term 'social norming.' So if there are a lot of people in a school system, or your friends are JUUL'ing and using the JUUL, it might not seem as bad for you. It might not seem as a health risk, and so this is something that we with the American Academy of Pediatrics, Children’s of Alabama, we are really trying to tackle and get the word out there.

Tiffany: One of the things that a parent could talk to their child about when they're bringing up this subject is that it's illegal for them to have this.

Dr. Walley: Just like you might with alcohol.

Tiffany: Absolutely, and just let people know how highly addictive it is.

Dr. Walley: That's right.

Tiffany: Now you're a parent, you mentioned that earlier of three boys, and you're also a pediatric hospitalist, so you do see all types of patients, all kinds of illnesses, and conditions coming through the hospital. Is that your motivation or your inspiration for getting behind this cause and educating people about the dangers of E-cigarettes and traditional?

Dr. Walley: I've been a hospitalist here at Children’s for longer than I'd like to admit, and the most common things that we see here in the hospital are things like respiratory illnesses like asthma attacks, like an illness called bronchiolitis, which is something that occurs with infants that get a viral infection like RSV.

And all of those illnesses are worsened or caused by tobacco smoke exposure, and in the process of seeing these patients, and seeing how parents of course want the best for their child, oftentimes I realize they did not know that their habit, this addiction was harming their child. And so part of what really drove me is let's help these parents, let's help these caretakers find a way to break this addiction. We know that nicotine addiction is a disease, and just like any other disease, we want to support and help parents so they can in turn help make sure that their children are more healthy.

Tiffany: Okay, so Susan, you received a grant from the Alabama Department of Public Health to be the Principal Investigator for the youth tobacco prevention program. Tell us about that.

Dr. Walley: I'm working with Children’s of Alabama as well as the Jefferson County Department of Health, and University of Alabama at Birmingham, and we're all coming together to try to educate our youth here in Birmingham about the harms of tobacco, specifically of electronic cigarettes.

So at this point, we've educated more than 1,500 youth in our area, and the excitement I think of youth in getting this education, but also being partners with us to educate their friends, and to really establish a culture where it's not okay to use tobacco, it's not okay to use electronic cigarettes.

Tiffany: So how do you educate those parents in the reverse? How do you get them to talk to their kids about prevention and about not starting?

Dr. Walley: Right.

Tiffany: With any kind of nicotine product.

Dr. Walley: You know, we tell parents that even if your kids don't seem to be listening to you, or watching you, they are. And I have three boys of my own, and I know that sometimes they'll bring up things that I didn't think that they were interested or watching me. So don't use tobacco products, and don't use electronic cigarettes.

Tiffany: Let's talk about some of the other effects, not just the effects of inhaling the nicotine product or the E-cigarette liquid, but the other poisonings that are happening. We're seeing an increase in calls to Poison Control Centers, right?

Dr. Walley: That's right. In the past few years, there's been an astronomical increase in poisonings related to E-cigarettes and E-cigarette liquid. The liquids, as we talked about, come in many different flavors, and a lot of them are very appealing to youth. Like sour gummy, or death by chocolate, and these liquids can have a very concentrated amount of nicotine in them, and they also smell delicious.

And so unfortunately, there are children who have been able to get into their parents' or caretakers' E-liquid and swallow the liquid, which causes toxicities, and there's even been a child death related to swallowing the concentrated nicotine solution from E-cigarettes.

Tiffany: Wow.

Dr. Walley: And then having seizures and dying. So this is a completely preventable death, and these are completely preventable poisonings.

Tiffany: And not just that, but you said sometimes the batteries explode in the device itself.

Dr. Walley: That's right. Because of the limited regulation related to E-cigarettes, not only the liquid but of the device itself, that these batteries have been known to explode and cause very serious burns.

Tiffany: Wow, so some side effects that we wouldn't even think about.

Dr. Walley: That's right.

Tiffany: It's not cheap to vape or to purchase E-cigarettes. I mean, these devices you brought in here you said are $100? Almost $100?

Dr. Walley: There is a very large range and different price points. So it goes down from the disposable E-cigarette, which might be $5 at your local gas station, to something like this product, which is what we would consider like a mod and tank system, that was almost $100.

Tiffany: Okay.

Dr. Walley: So unfortunately, the cheaper the price, the most it's going to attract youth.

Tiffany: Right.

Dr. Walley: And particularly as you can see, this E-liquid looks exactly like everybody's favorite candy.

Tiffany: Wow. Sourpatch Kids. Candy cane batch, it looks exactly the same, the packaging, the marketing behind it.

Dr. Walley: That's right. And that is another tactic that E-cigarette companies are using to attract youth.

Tiffany: And this one is called 'Donut Juice,' and it smells really sweet.

Dr. Walley: It's very sweet smelling, very appealing again to youth, and we know most youth are using these flavor products.

Tiffany: Right, because they think that it's not harmful. They think it's like candy, and it's as far away from candy as you can possibly get.

Dr. Walley: That's right.

Tiffany: Because it's very harmful.

Dr. Walley: The last scientific study that looked at different flavors found over 7,000 flavors of E-cigarette liquid, and again, many of them are dessert flavored, candy flavored, things that are very appealing to youth.

Tiffany: And how much does something like this cost?

Dr. Walley: Depending on the size and certainly the brand, you could pay anywhere from $20 to $40.

Tiffany: Okay. So I mean, the kids have to be getting this money from somewhere, so maybe if they have a little job on the side, they work a job, and they might be using it for that.

Dr. Walley: And you know, of course that brings up the point, where are kids purchasing these items? And unfortunately, they can get them really anywhere from gas stations, vape shops, grocery stores. You've probably seen them at the kiosk in the mall. But then one of the other places that is completely unregulated is over the Internet. And so if you go to the Internet and try to purchase these products, there's no regulation at all.

Tiffany: Yeah, you talked about the lack of regulation before, and so this type of liquid is not being evaluated or studied by anyone except for researchers like you trying to figure out what's in it, and the harmful effects of it. And then also, do they have to be a certain age to purchase?

Dr. Walley: In the state of Alabama, the age of purchase and possession of tobacco is nineteen. The federal law is eighteen, so Alabama does have stricter regulations than the federal law, but around the country, there really is a movement in order to protect our children to have the age of purchase and possession of tobacco to twenty-one. So at this point, there are five states, and over 270 counties and cities that have changed that age of purchase, including some of our neighbors in Mississippi and Arkansas have cities and counties that have changed their age of purchase to twenty-one. So it's called Tobacco 21.

Tiffany: We talked about the fact that you're a parent, a mother of three boys, and so what do you say to them about tobacco use? Some practical advice?

Dr. Walley: Well I think children these days are exposed to so much more than I was at this age. They have of course TV, but now social media, and I think they really want the truth, and they want to hear it from trusted people like a parent, like a pediatrician, like our staff here at Children’s of Alabama. And so I think that the main thing is to make sure that you give them those messages and that you're truthful and also that you're firm about what your advice is.

And so I tell my boys I don't want them to use tobacco products as well as other activities like illegal drugs, or alcohol, and these are the reasons why. So letting them know what the health effects are, and what I see in the hospital from the children and the parents that I encounter. I think that's a powerful message, and that's a message that we want all parents to share with their children. Oftentimes I will ask, "Does anybody that you know, any of your friends use electronic cigarettes?" And I think that that helps open the conversation up versus saying, "Are you using one?"

Tiffany: Right.

Dr. Walley: Sometimes that can be a little confrontational.

Tiffany: Right. So if there are parents out there who want to learn the best way to educate their kids, and help prevent their children from using tobacco products like E-cigarettes or traditional cigarettes, what would you suggest?

Dr. Walley: We all know that kids watch us, even when we don't think that they're watching us. So the number one thing that I would say is make sure that you're modeling behavior where you're not using tobacco products, whether it's E-cigarettes, or traditional cigarettes. If you are a tobacco user, there are many resources if you're interested in quitting. And we know that most people who use tobacco products do want to quit. They know that there are harms, and sometimes they just don't know where to go.

So your pediatrician or your own physician are great resources, and then another free resource here in Alabama and across the nation is the 1(800) QUIT-NOW line, which is 1(800) QUIT-NOW. And what that does is it provides free counseling on effective ways that you can quit, as well as in most states, free nicotine replacement therapy. Here in Alabama, it actually provides eight weeks of free nicotine patches, which is quite a great resource. So talk to your kids. Kids listen to you, even if you don't think they do.

Tiffany: Very good. Well thank you so much, Dr. Walley, for joining us. We enjoyed having you.

Dr. Walley: Thank you, Tiffany.

Tiffany: Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at www.ChildrensAL.org/insidepediatrics.