Elaine: Hello and welcome to this webinar, the truth about electronic cigarettes also known as vape products. My name is Elaine Lyon, I’m a public health consultant with the Tobacco Section at the Michigan Department of Health and Human Services. And along with me is my colleague Carolyn Choudhry, also a public health consultant for the Tobacco Section at the Department of Health and Human Services. Today, we’re going to be talking about electronic cigarettes, otherwise known as vape products, For consistency throughout the presentation, we’ll mostly be referring to these products collectively as e-cigarettes or electronic cigarettes. Today, you should be able at the end of this presentation, to describe how electronic cigarettes operate and be able to visually identify them. You should be able to list three to four public health consequences, safety and health concerns of e-cigarettes; You should be able to explain why youth are using these products, describe the e-cigarette climate in Michigan, and list two to three e-cigarette-related resources. Let’s first talk a little bit about the various generations of e-cigarettes. They are otherwise known as vapes, vaporizers, vape pens, hookah pens, electronic cigarettes or e-cigs, cigalikes, mini cigs, vape pen, ego, hookah pen, mod, tank, e-pipes. These are just some of the many terms that are used to describe electronic cigarettes. This slide depicts some of the various generation of devices except for the far, far right slide, you will see that many of these products are the more traditional first generation products. So for instance, the tanks and the mods, the disposable e-cigarette, those are more the first generation which were originally designed. The center slide, which is showing the rechargeable e-cigarettes, and then the far right slide that you see, there are more of the new generation products. These products use e-liquid or pods that contain nicotine. They also contain varying compositions of flavorings, propylene glycol, which is a liquid alcohol used as a solvent in anti-freeze and in the food plastics and perfume industries, vegetable glycerin, which is a colorless, sweet-tasting liquid used for flavoring in the e-cigarette, and various other ingredients. What happens is the liquid is heated into an aerosol that the user then inhales. Many newer e-cigarettes on the market have nicotine salts in the e-liquid, which allows very high levels of nicotine to be inhaled more easily, and with less irritation than freebase nicotine, which is actually in traditional cigarettes. So, this is a pretty big problem for the adolescent brain, because we know that the more nicotine the adolescent brain gets, the more nicotine receptors actually develop in their brains, and that increases the likelihood for addiction and more trouble quitting later on in life. E-cigarettes, as I mentioned, are manufactured to look like conventional cigarettes as far as the old generation goes. And some, as you can see, resemble pens, flash drives, or other everyday items. The larger devices, such as the tank systems or the mods, don’t really bear any resemblance to cigarettes. But, they can be easily customizable. And what you should know is that school administrators and local law enforcement have had to confiscate a lot of these products. And so, if you’re doing training on these various products, you may have the chance to get some of them from those administrators or the local law enforcement officials. So, let’s take a look at how the e-cigarette is actually manufactured. E-cigarettes, as I mentioned, are products that allow the user to inhale aerosol containing nicotine and other substances. They’re typically composed of a rechargeable, battery-operated heating element, a cartridge that contains nicotine or other chemicals, and an atomizer that, when heated, converts the contents of the cartridge into an aerosol. Now, pod systems, such as the JUUL, work the same way. But, we’ll talk about JUUL a little bit later. The term vaping is not accurate. E-cigarettes actually deliver a cocktail of toxics chemicals, including carcinogens, into the lungs, as well as other nano particles, which are very difficult on lungs. And from that, many people can develop diseases, and the lungs can become more resistant to antibiotics, for example. Vaping really should be called “aerosolizing,” since the products’ aerosol contains nano particles, such as metals like nickel, cadmium and copper. And e-cigarettes can actually be used for more than e-juice. We know that about one-third of U.S. middle and high school students have reported using e-cigarettes with non-nicotine substances, such as THC. And you can see below that one in three youth have actually used marijuana with the JUUL device. Hash oils can reach about 95% pure THC. So, when kids are using the vape pens for this particular thing, they actually could get seizures and other things like temporary psychosis that can occur with that very high rate of pure THC. So, teens basically use hash oil cartridges that can be substituted for the nicotine solution. Kids are also learning to make their own by dissolving hash oil or THC and glycerin or vegetable oil. Or they can even steep the leaves in a liquid (kind of like making tea with tea leaves) and then they vaporize that liquid. There are a lot of social media outlets that have extensive discussions about how to do this. So, it’s very easy for kids to get their hands on social media that they can learn how to do this process. We mentioned a minute ago that “aerosol” is really a more proper term, not “vapor.” This particular slide shows a tea kettle, which is harmless water vapor, and then on the left, you can see what looks like a can, and that’s how we kind of like to describe e-cigarettes. What comes out of that e-cigarette is an aerosol that contains all these various particles that we have talked about. It’s not harmless water vapor by any means. This actually is a great infographic from the Centers for Disease Control, and it again reinforces the point that the e-cigarette aerosol contains a lot of the dangerous things that you see here, such as the volatile organic compounds, nicotine of course, ultra-fine particles, and cancer causing chemicals. We talked a minute ago about the heavy metals, such as nicotine and lead. One thing that we might want to talk a little bit more about is diacetyl, which is a chemical linked to a serious lung disease similar to chronic obstructive pulmonary disease. It’s actually called bronchiolitis obliterans, and it is called popcorn lung. You can see the infographic shows popcorn there on the bottom. And what happened is a lot of factory workers who worked in factories that produced microwave popcorn and used diacetyl as a butter flavoring developed this disease called bronchiolitis obliterans. And so, this same flavoring is actually used in e-cigarette products and it causes what is known as popcorn lung. This is an irreversible and very serious lung disease. And diacetyl is one of the flavorings that is used most frequently in these e-cigarette products. These are just some of the things that you’ll find in an e-cigarette. At the very top you can see fennel, which is similar to a weed killer, in the lower right cadmium, that is oil-based paint. So, we find all these various things in the vapor found in e-cigarettes. So, simply put, these products produce an aerosol that contains propylene glycol, glycerin, flavorings and nicotine, and a lot of other harmful chemicals and toxins, some of which are known to cause cancer. But, remember that nicotine itself is a highly addictive compound, and that it’s a developmental toxicant. So, what are e-cigarettes not? E-cigarettes are not an approved U.S. Food and Drug Administration quit tobacco device and should not be marketed as such. However, as you can see from this slide, there are a lot of ads that have tried to depict e-cigarettes as being safe, even healthy. And so, there has been a lot of marketing that is actually not true, that has convinced people that these products are much safer to use. What we’ve actually found in a lot of the studies is that the use of these products for quitting regular cigarettes actually depresses quitting by about 30%, and it often leads to what we call dual use. So, someone who is trying to quit combustible cigarettes uses these products to try to quit, and they often end up doing both the e-cigarette and the cigarette at the same time. So, we are finding a lot of data that is showing that these products are not very effective in helping people quit regular combustible products. Unfortunately, we’re in a fairly unregulated environment, and so these products have been allowed to be advertised in such a way that it makes it seem much safer to use them. But, people need to be aware that they are not safe, and they are not actually approved to be able to quit combustible products. Carolyn: Okay, at this time I wanted to take a moment and talk about some of these newer e-cigarette products that are on the market right now. On this slide, we have an example of what a JUUL looks like. So, JUUL dominates the U.S. e-cigarette market, with 72% of all the e-cigarettes being JUUL. In the middle of this slide, you can see what the JUUL looks like. It is composed of three different kinds of elements. You have the body that is designed to actually look like a USB. And that’s something that we’re hearing from a lot of schools — that this is the one device that is being used, and it’s being easily concealed as a flash drives. Students are plugging it into their laptops during class, and they’re charging them. As you can see on the lower left-hand corner, that little charging, it looks just like a USB port. And then, up at the top, is actually the mouthpiece and the pod. So, this is where the flavoring comes from. So, here are just a couple examples of what some of the pods will look like. The multi-colored cap will tell you what flavor it is. Here, we have like a cool cucumber, a Virginia Slim, a creme brulee, and a fruit medley. These pods are good for about 200 puffs, which is the equivalent of a pack of cigarettes. So, all of the ,leaded chemicals and the carcinogens that are found in one full pack of cigarettes is found here in just one pod. So, the recognition of JUUL among youth, this was a study that we found from April in 2018 from Tobacco Control Journal, and it was saying that nearly one in five youth have seen JUUL used at their school. They said that it was really easy to obtain JUUL, and most of them were not even aware that JUUL pods always contain nicotine. So that’s something we’re also going to talk about a little bit later with some of the common myths that youth and young adults think are true about these products. And the nearly half of those students who were aware of JUUL believed that it was “a lot” or “a little less” harmful than cigarettes. So, within this study, youth were asked about how they also bought or got these JUUL devices and how they had them over the past 30 days. 74% reported that they got to at an actual physical retail location, 52% reported that they got it from social sources, like friends, siblings or even parents, and then 6% reported that they got it from the internet. And while the internet was not the most common point of access for youth, 89% of youth who did attempt to purchase online were actually successful. So, as Elaine mentioned, there were a lot of first-generation products. So, I just wanted to take a quick moment just to show you what some of those looked like. The slide on the left is one of the first generation as I said e-cigarette, the MarkTen. It looks very similar to a cigarette, and the size is also very comparable to a cigarette, as well. And then the image to the right shows a variety of disposable e-cigarettes. So, the Lava brand comes in a variety of flavors. There’s hundreds of flavors. Here, there’s a cherry, grape, vanilla, and I believe another cherry here. This gives the user about 800 puffs per use, and then the cost of these disposable products range from about $5 to $8. This next product is the tank. Elaine had mentioned that this one is not very popular. It was popular when e-cigarettes first did hit the market. It’s a lot heavier and a little bit harder to conceal. And this one requires actually e-juice to be put into the bottom. There’s a little key here that I show you that actually opens the cartridge and the tank to be able to fill in that e-juice, as well. And speaking of e-juice, I wanted to show a few examples of what the containers looked like back when the e-cigarettes started to hit the market versus what they look like now. As you can see, the image on the right are the ones that are now. These bottles are very bright, and they have flavors that are very attractive, like pineapple, crisp and a strawberry kind of smoothie cocktail here. And then there’s something also called Rainbow Drops. And this slogan for this particular e-juice is called Vape The Rainbow, which sounds very familiar to a popular candy, Taste The Rainbow. So, this is no coincidence, as many other tobacco products have packaging or slogans that are takeoffs from candy industry that really do further attract the youth. These bottles range from about $10 to $15, and now, the bottles hold about 35ml per bottle, versus how they used to only hold about 10ml in the past. This is another device called the Suorin iShare, it looks very similar to the JUUL, and it’s actually a little bit cheaper than the JUUL, as well. So, the JUUL starter pack actually was at $29.99, and now this Suorin iShare is at $17.99. So, this device actually will hold the JUUL pods, as well. But, it can also fit other pods that I’m going to show you in just another slide that are not made by JUUL. So, these are those other pods that are not JUUL, but they are kind of an off brand or what I would say a “counterfeit” pod. These pods will also fit inside of a JUUL, as well. There’s one additional pod, as this pack is a five pack versus the JUUL is a four pack, and there’s actually a higher level of nicotine. And something I want to mention, too, is that these other pods, they have a wider variety of flavors. Here, this shows a blueberry mango and peach, whereas JUUL has a limited amount of flavors now that are available. These pods range at about $14, whereas JUUL ranges upwards to $16 to $17.99. Here are just a few other examples of e-cigarettes that are out here on the market. These are the newer generation. They look nothing like the traditional cigarettes or combustible cigarettes that were used as those first-generation. So, here we have the Suorin Drop, a Suorin Air, a UFO, and a ROLO SMOK Badge. The Suorin Drop looks like a highlighter. It comes in only bright colors, like bright yellow, bright pink, bright green, and bright blue. The Suorin Air has an invisible mouthpiece, so I have an arrow pointing to where the mouthpiece is. The UFO actually has two cartridges, so there’s two mouthpieces for this one. This allows the user to mix and match their flavors. As Elaine mentioned, many youth and young adults are using e-cigarettes for other substances. So, this one may be able to hold THC, the liquid form of marijuana, and the liquid nicotine, as well. And then the ROLO Badge is very brightly colored and is also very attractive to our youth. These prices range from about $20 to $30, and they can be found at retail shops and online, as well. This next one is a Nordik Kit, that’s the name of this one. It kind of has a nice green, almost alligator skin-like, shine to this one. This one differs, because it actually has a button and this button, when it’s held for more than eight seconds, the battery will actually shut off. So, this is something that this brand of e-cigarettes is trying to show — that they actually have a “protection.” I put that in quotes there. And it also shows the battery life and allows the user to be able to start and stop the usage of this device. The Suorin Edge is just another example of an e-cigarette that is on the market now. This one actually comes with two battery packs, as a lot of people want to continue using e-cigarettes throughout the day. But, if their battery drains, this product guarantees that you can just continue to vape or should I say “aerosolize” throughout the day and not have to recharge. This one also says that they have a childproof lock that after you click the key five times, it will unlock. However, I’m not sure how successful this would actually be, because if the mouthpiece was already in the device and the battery was already in, as well, the user could then just inhale. And this one ranges to about $30, so a little bit more pricier than the other ones. But, those cartridges that are on the top of his mouthpiece, those are actually sold separately. Here’s another example of another popular e-cigarette that we’re seeing right now. This one can actually fit in the palm of your hand, it’s very sleek, it’s multicolored, they have these nice fluid lines that look like abstract oil paintings, and it actually comes with a lanyard that is marketed as being decorative and portable. And that actually just goes right on the end, and you can wear it on your wrist or around your neck. So again, another device that is very easily hidden, does not look like that traditional e-cigarette, does not look like the JUUL. So, something that could be very discrete, and people would not know that this is actually an e-cigarette as you are walking around. A few more examples of some more popular and newer generation disposable e-cigarettes on the left-hand side. These are one-time use. These are ones that we had purchased, and there is a mango, a watermelon, and in the middle is a orange/mango/guava. These are about $6.99, and they’re good for about 300 puffs. And the one on my right is actually called the SLM (“Slim”), and it’s shaped like a pen, so it’s marketed to actually look and feel and be the same weight as a pen. So, another device that we may see in schools this next upcoming year, since a lot of attention has been towards the JUUL. We’re kind of anticipating that a lot of students and young adults have probably moved to other devices that we’re now not more familiarized with. This one also has a battery that will automatically shut off after eight seconds, and this one is priced at $14.99. So, on this slide right here is something that I want to bring up to everyone today called “dripping.” So, one in four high school students who have used e-cigarettes have also tried this method called dripping. What it is that the e-cigarette liquid is directly on the hot coils of the device. So, it will actually produce a thicker and more flavorful “smoke” or “cloud.” And this actually differs, because the liquid is much hotter, so it’s actually going to expose the user to higher levels of nicotine or any other substance that’s being used. So, it’s actually going to be a much more harmful, and 64% of surveyed teens say that they actually dripped for that thicker smoke. There’s competitions now that young adults and youth are competing to see who can create the biggest smoke cloud. So again, we have users inhaling at a longer, more forceful, rate to then be able to produce this cloud to be able to win these “competitions.” I wanted to take a moment, as well, to highlight just a few of the devices that are more commonly used with marijuana. This one on the left is called the Puffit. It looks just like an inhaler, and this one is priced at about $120, so we may not be seeing it as frequently. But, this Puffit, you know, you can use it and smoke just about anywhere, anytime, with no one ever noticing, someone may just think that you’re taking your inhaler at the moment. And then the one on the right hand is called a Zig-Zag, and this one actually is also used for marijuana, but more specifically with the wax. Now, this device is another product that, unfortunately, might be a little bit more popular now here in the United States. This is called the IQOS or the I Quit Ordinary Smoking. It’s a heat-not-burn cigarette and actually, what this is, is that there are mini-cigarettes that you just insert into the electronic device. When you press the button, it’s actually going to heat up a little kind of knife-like piece of metal on the bottom, and that’s going to heat, and not burn, that cigarette. So, unfortunately, this device would actually be able to be used indoors, because it does move around our Smoke-Free Air Law. Our Smoke-Free Air Law mentions burning and igniting cigarettes. So, this is a way that the big tobacco company — specifically, Philip Morris — is getting around that Smoke-Free Air Law. And so, kind of just keep your eye out. This could be another device that’s going to be very popular here in the U.S., as it just became authorized to be sold in the U.S. So, I wanted to bring your attention here to another image that we had gotten from the CDC. This is a great infographic. It’s a good one for back to school. It says, “Teachers and Parents: That USB Stick Might be an E-cigarette.” So, this has great little points about, what it looks like, it could be used in schools, remembering that tobacco in any form, including these e-cigarettes, are unsafe for youth, reminding us that the high dosage of nicotine that our youth and young adults are getting are very high levels and can be addictive for that developing brain. I want to draw your attention now to 2017 e-cigarette data that we have for adults here in Michigan versus what is being reported in the United States. Current e-cigarette users, we are here in Michigan, a little bit higher at 4.9% versus the U.S. average. A former e-cigarette user, again, in Michigan, we’re at 17.4%, which is higher than the United States average. And then people who have never used an e-cigarette, we are at 77.7%, which is a little bit lower than the U.S. data, and we did get this data from the U.S. Behavioral Risk Factor Surveillance Survey, which is the U.S. BRFSS. And again, as you can see, we’re a little bit higher rate of current e-cigarette use among adults than the national average. I wanted to show everyone, as well, a 2018 National Youth Tobacco Survey. This is just showing that there is an increasingly alarming use between the time from 2017 to 2018 amongst middle school and high school students. On the bottom left, you can see that there was a 78% increase among high school students. And then also in middle schoolers, we have a 48% increase among middle school students. Right before the 2017 holiday season, our surgeon general actually came out and declared that e-cigarettes was an epidemic among the United States. So, what we did over at the Tobacco Section at MDHHS was that we pulled together data from MiPHY, which is the Michigan Profile for Healthy Youth. And we collected county-level data from the 2015-2016 school year to the 2017-2018 school year. As listed here, you can see that there was a rate of increase in every single county that we have highlighted. We have now increased our county data to about 36 to 40 counties. But, I wanted to just highlight some of these original ones that we looked at. We can see here that there were actually a few that had more than 100% rate of increase. Our “smallest” — I want to say that in quotes, because any rate of increase is very important and very large for us — we saw that was at 29%. So, still a very, very large increase that we’re seeing here in Michigan, as well. Elaine: As Carolyn mentioned just a few moments ago, the youth e-cigarette use is rising really at epidemic levels and, as she mentioned, our own U.S. Surgeon General, Jerome Adams, actually did make a declaration last December declaring that this is a public health epidemic among youth. So, this infographic is depicting a couple different things. On the left, we’ve talked a little bit about how this can cause the developing brain of an adolescent to develop more nicotine receptors. And we know that nicotine addiction can actually strengthen as these receptors increase in the brain, and it can prime the adolescent brain for future addictions to other things. So, it’s very, very important to note that these products are absolutely not safe for youth. And again, just a little bit of a reiteration in the middle there about how the surge of e-cigarette use is epidemic in nature. And then a couple of things on the right that we can do to try to help prevent youth from using e-cigarettes. It’s important to know what the risks are and to be able to talk to youth about the dangers. And similarly, as adults, we really need to be tobacco-free to demonstrate that good role model example. So, bottom line, nicotine is very dangerous for young people whose brains are still developing. We know that it changes the way that the brain synapses are formed, and it actually harms parts of the brains that control attention, impulse control, and learning, as well. So very, very important to understand the risks. And again, this slide just shows a couple more things as it relates to the adolescent brain. We actually know that the human brain matures around age 25 or 26. And that nicotine addiction again is more likely the earlier that one initiates. We mentioned a moment ago that there are some negative aspects of being addicted to nicotine, including such things as mood disorders, learning problems, and so on. We also know that when youth initiate earlier, it’s much more likely a problem for them when they want to quit later on in life. The earlier one initiates, the harder it is to quit later in life. So, again, the earlier that someone initiates any type of tobacco use, the more likely they are to become addicted. That’s why we see a lot of states in the United States right now passing laws that raise the age of purchase for nicotine products to 21, which really is still a bit low, considering that we know the human brain matures at 25 or 26. But again, pushing the age higher in terms of being able to purchase these products hopefully will lower the youth initiation percentage. And therefore, hopefully, we’ll have few users, young users, addicted to nicotine in the U.S. It’s important to note, too, that the tobacco industry knows this. They’re very aware that youth are one of their primary markets. They have known this for years and years. And if you look at a lot of the tobacco industry documents that are out there, it’s very clear that one of their key target markets is youth and young adults. So, this is just another slide showing that most e-cigarettes contain nicotine. And when I say most, I’m talking very close to 100% of these products contain nicotine. They cause addiction, they can harm brain development, and they could lead to continued tobacco product use among youth. A couple other things to be aware of is that a lot of youth perceive e-cigarettes to be less harmful, as Carolyn mentioned earlier. And really, there’s a lot of social source aspect related to e-cigarettes. So, right now, in the state of Michigan, of course, it’s 18 to be able to purchase. A lot of kids in high school are 18 years of age and can legally buy these products. So, they are oftentimes the supplier of some of these products for the younger students in their school. Again, that’s why laws, such as Tobacco 21, where you raise that age, actually would take the social source aspect out of a high school situation. So, again, trying to stop youth from initiating these products is very, very important, knowing that the brain is still maturing, and they’re more likely to become addicted. These are just some of the common myths that exist with regard to the use of e-cigarettes. So, things like, “Well, it’s just flavoring,” not being cognizant of the fact that there are lot of flavorings as we mentioned earlier — diacetyl, which can very much harm the lungs — and other types of things that are in these products that are not just flavorings. A lot of people think, “E-cigarettes are nicotine-free, and there is no way I’m going to become addicted.” But actually, as we’ve said, most of these products do contain nicotine. A lot of kids think, “Nicotine isn’t that bad for me.” And as we’ve said numerous times, nicotine can harm the adolescent brain. “It’s just water vapor.” We’ve already talked about that and have said that there are many toxic metals in these products, there are a lot of cancer-causing chemicals, volatile chemicals. It is not just water vapor. Another common myth is, “I don’t have an addictive personality. I won’t get hooked.” Again, we know that the younger a person is, when they use these products, the more likely they are to become addicted. So, it’s very important that youth do not get exposed to these products and hopefully, don’t initiate use of these products. “Just because I vape doesn’t mean I’m going to smoke cigarettes.” But, as we mentioned earlier, research actually shows that teens who use these products are more likely to try smoking cigarettes. We actually had a study done that was recently published back in February of 2019, and it showed that even tobacco-naive youths who initiate e-cigarettes may be at greater risk of subsequently initiating cigarette smoking. So, these are kids who never would think to initiate combustible cigarette use, who when they use e-cigarettes are being found to be more likely to then initiate combustible cigarettes later on. So, that is a huge concern — that a lot of these kids are trying these thinking that they’re pretty harmless and that it will never lead to a future addiction of any kind. So, why do we have this rise in e-cigarette use? There are a number of reasons. I mentioned earlier that the tobacco industry is very aware of the youth market and is constantly trying to come up with new ways to sell these products to youth, as well as other segments of our society, including racial and ethnic populations and the LGBTQ community. But, youth are a prime target for the tobacco industry. The flavors, as Carolyn has talked about, in e-cigarettes are very numerous. If you actually open a bottle of e-juice, you can smell the lovely flavor, and I’ve often said that just smelling that flavor makes me want to drink the liquid. So Carolyn will talk in a little bit about some of the safety concerns around these products. But, certainly, one of the major reasons that youth have started using e-cigarettes is because of the multiple and wonderful smelling and tasting flavors. And then the lack of regulation. So, because these products are largely unregulated, although I will say the FDA — the Food and Drug Administration — is moving in the direction of being able to do some regulation around these products. But, it has been rather slow at times. So, a lot of these products have been able to come on to the market — and really flood the market — in the last couple of years without any sort of regulation. So, this unfortunately has allowed the industry to grow really at exponential rates over the last couple of years, and a lot of it has targeted our youth through various forms of advertising and social media and the like. Let’s just talk for a moment about some of the flavors that we are seeing. There are thousands and thousands of e-juice flavors and pod options that are available for e-cigarettes. During the one-year period between 2017 and 2018, among high school students who used e-cigarettes, the use of any flavored e-cigarette, including menthol, increased. So, we know that flavors in tobacco products are problematic, because they’re appealing, and they’re actually listed as one of the top three reasons that youth use e-cigarettes. The other thing you should be aware of is that kids whose first tobacco product is flavored are more likely to become current tobacco users than those whose first product was tobacco flavored. So, I mentioned just a few minutes ago that the FDA — the Food and Drug Administration — is starting to step in and do a little bit more regulation. They’ve actually proposed a step to curb youth use of flavored electronic cigarettes. So, back in 2018, the FDA proposed to restrict the sale of some of these flavored electronic cigarettes in stores. However, they did not ban mint and menthol, as well as tobacco flavors. This is a big problem, because we know that many youth — around 81%, as a matter of fact — start with flavored products, and many are using menthol to get started in this addiction. Over half of high schoolers are using menthol-flavored products. So, there’s been a lot of pressure put on the FDA by these companies, and the mint and menthol flavors have been taken out of that prohibition. We know also that the tobacco industry markets very heavily, as I mentioned, to a number of communities who use these products, and that includes youth. So, right now, we have this ban that is in effect for these various flavors, with the exception of mint, menthol and tobacco. But, really, what we want to make mention of is that the best solution, the best strategy, would be to ban all of these flavored products. And these products are also very trendy in nature. As you can see from some of the pictures here, these depict a lot of the older generation devices. What was really effective in getting youth started with these products is the sequence, the way that you could customize the tanks, and the mods, and the pens, in various ways, whether it be color, or wraps, or sequence, things dangling off of these items. So, young people are clearly the target for these products in the market. And we also know that there’s a lot of social media marketing that’s going on. E-cigarettes make frequent appearances on social media newsfeeds and timelines. Most recently, JUUL has relied heavily on social media to market and promote their products. We actually know that back in 2015, JUUL spent more than a million dollars to market its product on the internet, according to one study that we read. So, the social media growth and the availability of these products on social media, as you can see here, there are a lot of young people who are depicted in the pictures and they often are at JUUL launch parties. As you can see on the right there, a bunch of young women who look like they’re having an absolute blast at a JUUL launch party. And then they put that on social media, and their friends see it and wonder what they’re all about. And of course, we know that that breeds further use of these products. So, if you look at the advertising that goes into social media by the various e-cigarette companies, you will see that these products are heavily, heavily advertised on the various social media websites. There are tweets happening all the time. I know that Carolyn had mentioned last week that she was on social media and had seen that there were about eight million tweets in one day with regard to the social media campaigns that were going on. So, we’re well aware these companies are using social media to market to our youth. And in fact, here are some more images from the social media that actually is happening around these products. The companies, as you can see here, use a lot of celebrities, including DiCaprio here on the lower left. The woman on the right is a very top-level model, Bella Hadid, who did an actual live video feed using an e-cigarette. And then the gentleman in the top left is a person from Iran who is very well-dressed and using one of the products. So, these are very attractive to our youth, and we know that the companies focus on these people, getting them to be influencers within the young adult market. So, it’s very important to realize that our kids are seeing this type of marketing all the time. One item of note, I did hear that Bella Hadid was asked to remove this particular post after there was some flack over it. But, again, the damage was done, and it’s really important to note that these people are actively engaged in using and promoting these products. And when young people see them, it is very attractive to them, and of course, what do they want to do but model themselves after some of these folks and begin using themselves. Targeted marketing is also another thing that is happening quite regularly with these products. As you can see here, we have a lot of young people in the lower right who are carrying signs, advertising various products. These companies have been known to sponsor races, and many, many other music festivals, and all kinds of things. So, these products are definitely in places where traditional combustible products have not been for a very long time, because they’ve been prohibited from being in these places. So, really, what we’re seeing is a complete remake and redo, kind of a déjà vu of combustible cigarettes now featuring e-cigarette products. And again, here you can see some of the images for the various products that are out there. There are a lot of colorful images, and you can see the use of young models. The gentleman in the top right, “Mondays Don’t Need to be So Hard.” So, you can go out and take a break with the JUUL. This was very frequently used. A lot of young models as we can see, the colorful images — those are the kinds of things that JUUL has used, especially in the very beginning to broadcast and market their products. And we know that this took JUUL to a very high level of industry, capturing that industry. So, right now, they’re at about 72% of the e-cigarette industry, perhaps a little higher. But, they were able to do this through a lot of their social media marketing, as well as these types of ads. And then this, we decided to put in because we are hearing from a lot of schools about the JUUL epidemic in the schools. And so on the left you see there is a line for the regular use of the bathroom, and then on the right, there is a line for all the JUULers who are going into the bathrooms during breaks to use this product. So, this is happening all the time in our schools. In fact, we’ve been at a number of presentations where high school principals have said to us that they spend a majority of their day talking with students and really working with them on their possession of e-cigarettes in the schools. Finding ways to deal with this has been very difficult. They’ve currently had issues with so many suspensions in some cases that they’ve looked to us for some alternatives to suspension. And so, we’ve been trying to help a lot of the schools with ways that they can help their students really deal with the addiction that is e-cigarettes. On the right, this is somebody holding up a JUUL, and basically, they’re saying, “I can’t stand it when people pee in the JUUL room.” And again, just another indication that these bathrooms have become rooms for kids to use between classes and that kind of thing for them to actually go in and use these e-cigarette products. Combustible cigarettes haven’t been able to be advertised on TV, radio or billboards in quite some time. But, you can see the image to the right there, that’s not the case with e-cigarettes. This is a display of the NJOY e-cigarette, and next to it, you can see candy. So, just think about the kids who are walking into this retail environment who are seeing e-cigarettes while they reach for their favorite candy bar or a pack of gum. This is deliberate, and the tobacco industry pays for placement in various retail locations. It is no accident that signage is placed at eye level when kids walk into retail environments. So, it is something that is just out there and really is becoming more of a social norm, similar to the way cigarettes used to be sold out in front of the counter, if you may recall, not behind the counter as they are required to be today. E-cigarettes, because of the lack of regulation, many of them are on the counter out in the store and easy for youth to see, touch and smell and become attracted to. So, we know that advertising and flavors and a lot of things, but particularly those two things, have really given rise to the youth e-cigarette use. So, the lack of regulation, the point-of-sale opportunities in the retail environment — all of these things have influenced youth in ways that bring them to think that these products are very attractive and that they want to try them. Carolyn: All right. So now, we’re going to talk a little bit about the health concerns. Here, on this side, I want to just mention that dual use, as Elaine had mentioned before, that we see a lot of youth and young adults using both e-cigarettes and combustible tobacco. And now, we also know that people are using e-cigarettes for other substances, as well, such as marijuana. So, really, dual use can go up to tri use or you know, even more than that, depending on what the user wants to use in this device at the moment. Again, I wanted to mention flavorings. Elaine had spoken about diacetyl in the beginning of this presentation. So, just remembering that flavorings are meant to be ingested and not inhaled. So, that is a very big health concern that at the moment, we only have the short-term health effects that are being reported. So, we don’t really know about all the long-term effects regarding all of these flavors. We do know that cinnamon was just reported as being one of the more dangerous and harmful flavors that are currently in these products. And we do know that cinnamon is in most of these mixtures of e-juice and pods, because it kind of helps boost up that flavor. Again, with the flavoring, we want to remember about that popcorn lung that Elaine had mentioned earlier on in this presentation. So, just keeping in mind that the flavors is what’s attracting our youth and our young adults to use these products, and it’s also one of the more dangerous health concerns to them, as well. The next bullet point that I wanted to mention was about primary, secondary and third-hand aerosol exposure. Primary exposure is when the user is using, so they’re getting those health effects right away themselves. Secondhand, most of us are familiar with the term of secondhand smoke, so that will work just the same way here for secondhand aerosol exposure. That would be if I was using one of the e-cigarettes right now, and if I was to blow out the aerosol cloud, Elaine sitting here next to me would get those secondhand effects from everything that was in that smoke cloud that Elaine had mentioned earlier on in the presentation. Remembering that those things are chemicals and carcinogens, that would be affecting someone who would be next to me if I was using. Thirdhand is something that not many people are very familiar with. So, I’m going to give a little scenario and kind of take it back to tobacco, as well, with cigarettes. So, let’s say if I was to go outside and use a cigarette or an e-cigarette and then come back inside, and I was to ride an elevator up with somebody. We’re all kind of a little familiar with kind of smelling that smell after someone has smoked, even if they’re not currently smoking in front of you. So, thirdhand is kind of that residue that lingers after someone has used a cigarette or an e-cigarette. So, that thirdhand aerosol exposure is, it’s kind of like that smell that you would get from being next to someone in the elevator, but you would still also get those chemicals and carcinogens. Just for an example, if I was to also use the product inside this room and then, after this webinar today was finished, leave the room. But, then there’s another group of people who come in and want to use this room. So, everything that was in that cloud has to settle, so all the chemicals and carcinogens will actually leach onto the table, the microphone I’m using here, the seat, the carpet, the walls. So, that thirdhand exposure is going to continue to kind of release those toxins and chemicals for years to come afterwards. So, here are just a few of the health concerns that were reported to the FDA. We have heard reports of pneumonia, asthma, cardiovascular disease, skin disorders, like contact dermatitis, oral health concerns, like mucosal lesions, disorientation, seizure, hypotension, and there’s many others. But, these were just some that we wanted to bring to your attention here today. I’m going to move now to the safety concerns regarding and surrounding e-cigarettes. This image here shows a picture of someone who was actually charging their e-cigarette in their vehicle and that the console, that middle console, there actually exploded. So, the charger and the device had a misconnection, and it actually exploded. So, that is an image of an actual device that exploded in a vehicle. We’re also hearing about fires, poisonings, and even hazardous waste. So, e-cigarettes are actually being treated by users as they would a cigarette. So, like I’m talking about like those disposable e-cigarettes or even the pods and the cartridges. Once someone has completed using them, they’re throwing them out the car window, they’re throwing them onto the sidewalk. But, unlike cigarette butts, they don’t squish underneath the tires and so, instead, they’re actually going to puncture them. So, this has been reported, that many flat tires — and some accidents — have actually been caused by the waste and litter of these products, as well. So, something that is very important, this slide is an infographic from the Children’s Safety Network. Listed here are symptoms that can occur from nicotine exposure or poisoning. So, we want to be aware that the onset of these symptoms occur very quickly. For example, one of the symptoms is seizures, and that can actually occur within the first 20 to 30 minutes and be deadly, unfortunately. So, due to the smell of the flavorings and this liquid nicotine, as Elaine had mentioned, many youth — and even just small children and infants — are actually ingesting this liquid nicotine, and there have been deaths as a result. It’s very important to note that less than a fourth of a teaspoon of 1.8% concentrated liquid nicotine can be found fatal in a 50-pound child. This will alter the amount of the teaspoon measurements depending on the concentration of the liquid nicotine that’s being used and also the weight of the child or adult, for that matter, who may be using. So, this is why we like to put the poison control help number up, because if you see any of these symptoms or if there is a spill, we would want to call poison control right away. Again, that number right there, 1-800-222-1222. I highly recommend if you work with youth or young adults, or anyone for that matter, to input this number into your phone at this time. This is also an image coming from American Association of Poison Control. There’s been a lot of data collected throughout the years about electronic cigarette and liquid nicotine cases. Here, it shows from 2013 all the way to present. I want to make note that you can see the spike that has been called in to poison control at 2014. Also make note that JUUL did kind of hit the market around 2015, so that’s why we were seeing also a little bit more spiked from 2013. And then, for your attention for 2019, there are 635 cases that have been reported, only for the months of January and February. So, in two months starting this year, we’ve already seen a very large number of calls being reported to poison control. This image is one that we always like to show, this is an image of a New Mexico man’s C1 vertebrae. What happened was that he was using this e-cigarette, and the cartridge actually lodged in his vertebrae after it exploded while in use. Right in the middle, you can see the cartridge in that bright white format right there. Luckily, this individual lived. However, not everyone is as lucky. In February of this year, a young Texas man at the age of 24 was using a device when it exploded. It actually nicked his carotid artery. So, he was not as fortunate, and he actually died on the scene. This other image was just from actually about couple of weeks ago. This is image of a teenager who actually was using this device, and as he was using it, it exploded. His mother actually had purchased this e-cigarette for him, because she thought that this would be a great way for him to kind of stop using combustible cigarettes. He suffered extensive wounds to his mouth, missing teeth, and a broken lower jaw. His doctors actually compared this explosion to a close-range gunshot wound. This case actually appeared in the New England Journal of Medicine, as well. So, Elaine had mentioned a lot of the social concerns, so I won’t go too much further into this. Just pointing out that they’re playing out of Big Tobacco’s playbook. They’re back on TV. It’s in the workplace, in our schools. They’re showing us false health claims, and it’s really aimed towards the youth. As you can see here, Santa Claus is actually promoting that he doesn’t always vape, but when he does, he chooses the Vapor Shark. Another thing that is really important to remember that Elaine will also mention is that all of these products currently in Michigan do not fall under our Smoke-Free Air Laws, so they’re able to be used indoors, which is why this woman here is saying, “Hey Smoking Ban, I can use these products inside.” So, basically, bottom line for the public health consequences and health and safety concerns, is that e-cigarettes are not safe for youth and young adults, pregnant women, or really anybody. So, if you’ve never smoked or used any other tobacco products or even used e-cigarettes, do not start. Scientists still have a lot to learn about these e-cigarettes. They’re very young in their studies here in the U.S. Elaine: Okay. Let’s talk a little bit about the federal regulation of these products, as well as what is going on in the state of Michigan. The Food and Drug Administration previously had not been regulating the manufacture of e-cigarette components and parts until August 8, 2016, when the FDA began regulating all tobacco products. What’s important to note here is that at the federal level, these products have never been able to be sold to anyone under the age of 18, and they are also defined as tobacco products. This is very different than the way we see it in Michigan. So again, under the FDA Deeming Rule, I mentioned no sales to persons under the age of 18. They heightened their age verification situation by requesting photo ID. There were no sale of tobacco products in vending machines or free samples. So, there were some restrictions put on e-cigarettes at the federal level at that time in 2016. In Michigan, because of the federal law — or the FDA Deeming Rule — which prohibits retailers from selling e-cigarettes, components and parts since 2016, that became law back then and this rule has also applied in Michigan. So, since that time, there have been no sales legally, there should be no sales of electronic cigarettes, their components, and parts. And that goes along with the federal Deeming Rule, which was established in 2016. However, electronic cigarettes in Michigan are treated differently. As recently as June 4, 2019, we had the passage of Senate Bill 106 and Senate Bill 155. Basically, what these bills do — well, what SB 106 does — is to define e-cigarettes in a different way than the way that the Food and Drug Administration classifies them. They’re defined separately from tobacco products. Remember, I said that the FDA Deeming Rule defines e-cigarettes as tobacco products. Not in Michigan. They are classified as alternative nicotine products, vapor products, and the like. So, as Carolyn mentioned, they do not fall under the guidance of the Smoke-Free Air Law. We’ll talk more about that in a minute. Senate Bill 155 simply is requiring containers to meet a minimum safety standard and requiring that retailers put these products in a case behind the counter. So, because we have this differentiation at the federal level versus the state level, there are a lot of problems that arise. So, remember at the FDA level — the federal level — e-cigarettes are defined as tobacco products. In Michigan, they are not. So, we have further appeal to youth. In Michigan, because we don’t define these products as tobacco products, a lot of youth, of course, think, well, they must be safer than tobacco products. Hence, that could be one of the things that’s leading to the rise in use. And probably, also, it has an effect on the way parents view e-cigarettes as not being as harmful as combustible products. The way we define these products does create confusion with the federal rule, as well. And so, we also find that because we have a different definition here in Michigan, these products are not taxed like combustible products would be. We mentioned they’re not covered by the Smoke-Free Air Law, and still, they avoid the advertising restrictions that have been placed on combustible products for years. As we mentioned earlier, they’re still on TV, you hear them advertised on radio, social media, and so on. If you see a retailer who is actually selling to youth under 18, there is a number that can actually be called, and you can see it here on this poster. This is something that the FDA put out a couple of years ago, but it still applies today. And this is a very great poster to have handy. The number, as well, is something that you can have handy to report any violations. Even though electronic cigarettes don’t share the same definition in Michigan as they do at the federal level, there are a lot of things that local entities are doing to curtail the use of electronic cigarettes. So, we are working with numerous locations who are trying to pass — and have passed — tobacco-free parks policies, beach policies, other outdoor locations, such as bus stops and the like. So, locals can do things that put higher restrictions in place with regard to e-cigarette use. A lot of bars and restaurants prohibit their use indoors. And then of course, schools have tobacco-free policies. Many of the schools in Michigan include e-cigarettes in their tobacco-free campus school policies. There are a number of other things that can be done by you, our listeners, and that includes support for increasing taxes on these products and using money to prevent tobacco use, as well as dedicate some of that money to quit programs. You can look at including e-cigarette products in indoor smoke-free air laws, as well as outdoor clean air policies, and work with your schools to make sure that they have these comprehensive tobacco-free policies which include e-cigarettes. You can educate your communities and circles of influence about these products. Use youth to spread the message. They are a great group of people to take your message to decision makers and stakeholders in the community. Have retailers put these products behind their counters. Make sure if you’re a health professional that you’re asking youth, as well as all your patients, about e-cigarette use during their visits with you. And keep us informed of what your actions are doing. We are here to help, and we can provide a lot of technical assistance to assist in all these different capacities. Last, I’m going to turn it over to Carolyn for a few quick resources that we’d like to mention to you. Carolyn: So, the first one here is a very new program that we have here in Michigan. It’s called My Life, My Quit. It’s a quit tobacco and vaping program for youth and teens. It’s the first comprehensive program designed, it was actually designed by youth for youth. So, it’s great that all the messaging and the promotional ads and all that, we know that they will be something that would catch our youth’s eyes. There are five real-time coaching sessions that you can get via live text messaging, online, chats, or calling in. They are trained specialists, specifically for youth. And upon completion, you would get a certificate that would be watermarked. So, this is also going to be a good program to use for alternatives to suspensions for anyone out there who works in schools. So, it’s a toll-free number, and then there’s also a website that you can go on to. And as soon as you do click on the website, and as soon as the user would use it, they’d be able to chat right away. Little fields pop up saying, “Hey, do you want to talk? Do you want to quit?” And so, there’s a lot of different ways that our youth and young adults could use this program. So, this program, though, is specifically for users that are under the age of 18. So, that’s something really important to remember. So, now for the rest of these slides, I am not going to go through them. I will leave them up just for a few seconds, so that you can see some of these great youth tobacco quit resources. So, please feel free to pause at any time. And then to really take a look and see which resources would best fit you for what more you want to know or what more you want to do in your community. Again, this is also something from The Truth Initiative. They’ve had a campaign going on, Safer Does Not Mean Safe. So please, I urge you to take a look at truth.com for any further information you might need there. And then Truth Initiative also has a “This Is Quitting” program, another texting program, as well. So, this is another resource that can be used. And then The Real Cost is a great resource, as well. They have great ads and campaigns and visuals that are out there at this time. It’s designed to educate at-risk youth from ages 12 to 17 about all the harms of tobacco use, including e-cigarettes. They’re more than 10 million at-risk users in the U.S., which is probably even more at this time, given this epidemic that we’ve just entered into. And then here is just a few more Real Cost resources. There’s a great YouTube video for some of these campaigns. And then at the bottom here, they actually have great prevention curriculum. So, going from grades nine through 12. So, I highly recommend everyone to check that out. Now, I just wanted to mention the Stanford Toolkit. This is another great toolkit of use for educators, administrators, parents, guardians, and anyone who works with youth. They have a great variety of resources for curriculum. Again, they have great quizzes and online activities. So, I highly recommend you also take a look at this toolkit. Again, more resources on this page — the Guinea Pig Generation fact sheet, because unfortunately, that is what our youth and young adults are right now. They’re guinea pigs with the health and social and safety concerns surrounding these products. And then there’s also some great “how to talk with your teen” tip sheets. So, I highly recommend everyone to go on to Know the Risks. That’s another great resource. And then, of course, we have our tobacco quit resources here at MDHHS, our Tobacco Section, we have our Quitline or 1-800-QUIT-NOW. So, if you are 18 and older, you can also call in. The My Life, My Quit is kind of geared more towards this e-cigarette epidemic that we have. However, we urge everyone — no matter what age you are — if you need help to quit, we recommend to go ahead and look at the website or at this phone number. And if there are any questions concerning this webinar today, again, here are our names. My name is Carolyn, and my colleague Elaine here today. And here are our email addresses. We hope that you enjoyed this webinar, and that you have your takeaways and your highlights, and that you’ve learned something new today that you didn’t know before starting this webinar. So, we want to thank you all for taking the time today to sit down with us and learn a little bit more about e-cigarettes. Thank you.