Learn about nicotine and cannabis vapor products, devices, and trends. This thorough presentation is done by content experts Liz Wilhelm and Arti Shah.
Hi, hello everyone and welcome. This is Mandy
Paradise with the Office of System and
School Improvement.
I'm the Prevention Intervention Services
Program Supervisor here at OSPI and
it's our pleasure today to host a
webinar on Vapes, Juuls, Buds and Shots:
Prevention and Interventions with Youth.
We're just going to take one moment here
to advance our slides. Today's webinar
offers a brief exploration into the most
common substances used and abused by
today's youth. Content focuses on
understanding what vaping is, the appeal
for youth, and what research says about
both the risks and the unknowns of using.
Our webinar will last for one hour and
30 minutes, and we are recording it. The
archived, recorded version will be made
available on the OSPI website. For those
who have registered, a link will also be
sent to you once the recording is posted.
Additionally, after today's webinar, you
will receive an email with a survey.
Please tell us about your webinar
experience, and we're also going to send
a separate email with some documents
from today including the slides, Healthy Youth Survey data, and an infographic
issued by the CDC or the Center for
Disease Control.
So today's webinar topic was chosen due
to high demand from folks in the field
of education. This topic has been
requested by teachers, student assistance
professionals, school counselors, and
other educators. We're so thankful to
offer this resource. We also suggest
watching a recorded GATE webinar titled
"Students who Smoke or Vape: a Red Flag
for Supports." That information will be
made available to you in our follow-up
email.
Not only is vaping a topic of interest
among our professional colleagues, it's
also a topic of concern for Adolescent
Health in Washington State. Our 2018
Healthy Youth Survey data tells us that
the vaping epidemic has reversed decades
of progress reducing youth nicotine use,
and we have failed to prevent a new
generation of nicotine use. The good news
is that the percentage of teens
reporting cigarette smoking in 2018 is
less than half of what it was a decade
ago in 2008. The bad news is that E-cigarettes and vapor products use
increased significantly between 2016 and
2018. We also know from our Healthy Youth
Survey data that they do not perceive vapor products as risky for their health, and
they find that vapor products are really
accessible. We know that 68% of 10th
graders reported borrowing their vapor
products, asking someone to purchase them,
or getting them from a family member.
Today's webinar has three objectives. We
want to be able to, follow us through the
following, which are differentiating
among various nicotine and cannabis
vapor paraphernalia, analyzing health
issues unique to vaping devices based on
published research, and discussing trends
in vapor product use in Washington State.
We are pleased to have two Washington
state content experts as our webinar
presenters today; we have Liz Wilhelm and
Arti Shah. Liz Wilhelm
coordinates the prevention works in
Seattle's WINS Coalition, a drug free
communities federal grant through
Seattle Children's Adolescent Medicine.
Liz has been working in the substance
abuse prevention and community health
field for over 25 years in a variety of
settings, including nonprofits, state
government, colleges, hospitals, and local
health jurisdictions. Over the years, Liz
has managed five different federal
community based prevention grants.
Liz taught and trained prevention science
courses and seminars for over 13 years,
including for the UW, Seattle Central
College, Bellevue College, Western
Washington University, and Tacoma
Community College. Liz has lived in
Seattle for 23 years, grew up in the
Chicago suburbs, and graduated from
Northwestern University in Evanston,
Illinois. Arti Shah is the Public Health
and Education Director at the Washington
Poison Control, Poison Center.
Arti provides Public Health direction
and leadership for the public health
education program. Arti received her
master's in public health from Emory
University, and is certified as a
community health education specialist.
Prior to her master's, Arti served as a
community health and economic
development adviser in Peace Corps, and received her BS in Exercise
Science Hill field work geared towards public health. So big welcome and big thank you
to our presenters today. This is where
I'm going to be passing the mic over to
our presenters, so let's do a sound check.
Arti and Liz, are you live with us right
now? This is Liz, I'm live. Thank You. Liz, tell me when to advance the slides.
Wonderful, and can we hear
Arti? Not quite, I'll work on getting
Arti live. Try now. Arti, there we are, okay,
thanks so much.
Oh, wonderful okay, was wondering what was happening. It was us. Alright, should I
advance the first slide? Yes, let's do
that.
Wonderful, okay. Well this is Liz, and
I'll go ahead and start. Arti and I are
going to bounce back and forth in presenting this information so that
there's a change of voice and hopefully
people will stay interested; but I think
there's a lot of interest in this topic
anyways, so Mandy, thank you for that
wonderful introduction; and we just
thought we'd just add a little bit more
detail of what we're going to cover
today in our webinar. So, we're going to
give you a little bit of background
about the prevention works in Seattle
Coalition in the Washington Poison
Center, and then we really want to spend
a considerable amount of time talking
about nicotine and the different forms
that it comes in. Cannabis, and a
little bit on alcohol. We want to back
that up with some of the research and
the trends with the data that we
currently have, and thank you Mandy for
sharing the current Healthy Youth Survey
data about e-cigarettes, and a little
touch on some prevention programs and
strategies in Washington and some tools
and resources. So we will be using the
terms e-cigarettes, and e-cigs and JUULs,
and vapes and vapor products
interchangeably, so I wanted to make sure
that that information was out there
first. Consistently through our slides, we
tend to use the word e-cigarettes just
to just to keep that consistency, but know that in the conversation, we're
covering several things. So quickly, about
Prevention WINS and the reason that
we share this information, is because of
the question of why is Prevention WINS
Coalition and the Washington Poison
Center
presenting this webinar? Why has this
been a strategy and a high-level
activity for both of our organizations?
Well, Prevention WINS is a coalition that
is currently funded by a drug-free
communities grant, and it's housed at
Seattle Children's Hospital and
Adolescent Medicine, and has been around
for about 14 years, and really serves
Northeast Seattle based on our zip code
requirements from the drug-free
communities grant. We've always been
focused on underage drinking, on nicotine,
marijuana, and prescription and
over-the-counter drug use and abuse with
kids; and so as a coalition of course,
we've got a variety of partners, and
there are four specific- you have the
public schools in our community, the
Washington Poison Center, UW, law
enforcement, a variety of parents, and a
variety of other media and health care
providers. But I'm going to circle right
back to the Washington Poison Center.
So, the Washington Poison Center is
physically located in Northeast Seattle,
though serves the whole state of
Washington. And so when I came on
board as the Coalition Coordinator for
Prevention WINS, and had discovered
that Seattle Children's and the Poison
Center have always had a partnership, we
made sure to really dig in there to be
sure that the Poison Center was a
specific part of our coalition. And when
in doing that,
four years ago, the Poison Center
specifically called out some data
numbers to the, to Prevention WINS of
concern, and one of them being about
e-cigarette use, and particularly about
accidental ingestion and overdoses of
very young children, toddlers, of the
e-juice of the liquid nicotine. And the
Poison Center, being as fantastic as they
are, said, "How do we get out in front of
this to try to prevent this?" And that is
what launched the great partnership of
developing the e-cigs training of trainers, "Finding the Truth
Among the Vapors." So today's webinar is
based on that three and a half hour
training that Arti and I and many other
people now provide across the state, and
so we've taken a chunk of
that information to be able to share
today, and so I feel very fortunate to be
able to work with a poison center to be
able to share this information. So go
ahead and advance to the next slide, and
Arti, over to you.
Wonderful. Well my name is Arti and I work
at the Washington Poison Center, and the
Poison Center has been alive and going
for about 63 years. Our call center staff,
whenever someone calls in to the
National toll-free number, it's staffed
by nurses and pharmacists of a specific
specialty in poison information, and we
like to call them 'spies,' Specialists in
Poison Information. So they get to go
digging under understanding what
individuals are exposed to, and how to
give the proper medical management and
care. On average we receive about
63,000 calls a year, about 200 a day,
so we're very, very busy in our call
center; and we get calls about
emergencies as well as for information
calls as well, for questions. There's a
public health educator on the eastern
side as well, who's housed at the Spokane
Regional Health District, who is my
counterpart; and we get to tackle the
whole state and go out and do outreach
and presentations and training all
around the state. Last year we reached
about 56,000 individuals, and there's
many different trainings and
presentations all around the state. And
if you look at the right hand side,
you'll see a Mr. Yuk mascot is there, and
people may wonder or may say out live,
say out loud, "Oh, there's Mr. Yuk." He's
still alive, and he never went away. We
just lost funding for a little bit
and he's back in action and ready to,
ready to go all around the state.
So we're going to delve into vapor products, or e-cigarettes. The federal
level agency terms e-cigarettes as ENDS, E-N-D-S. This stands for electronic nicotine
delivery system, and it's defined as the
battery operated device that vaporizes a
substance for inhalation. And for us
today, we're not going to use the term
ENDS. You don't really hear individuals
saying "I'm going to go outside and use
my ENDS'" or "We're going to go over there
and use my ENDS," they usually say vape
product or e-cig, or mod or JUUL, and so
those are the terminologies that we're
going to be using interchangeably. We're
going to be talking about both nicotine
as well as cannabis vapor products. Now
there are three main parts to a vapor
product-there is your battery, and then your atomizer, where is also your heating
element is, and there's a liquid
reservoir for your e-liquid nicotine,
where the liquid nicotine atomizes and goes out of the mouthpiece. And the
e-liquid come in various different types
of bottles. The one on the right lower
hand side, you'll see it says 'seedless
watermelon' or 'ejuice,' those are some
examples of what e, liquid nicotine
comes in. There's also larger bottles
that it will come in as well. Now we're
going to go through various different
types of vapor products. It's a very fast
market and it evolves very, very quickly.
The most basic type of vapor product
that we have seen on the market, the
first one was your minis or your cig
lights, and that
specific vapor product is on your top
left-hand corner. It looks very much like
a combustible cigarette. Another example is on the bottom left-hand corner. There's a
top one is N-joy and the bottom last one
is called your "Blue,' so these are your
disposable vapor products, where you use
it, use it until all the e-liquid is
completely done, and then you toss it
away. And they come in various different
strains, various different flavors, like
your cherry fresh, or your vivid vanilla,
your tobacco, or mint glacier, comes in
various products. And these are
disposable-you don't recharge them, you
don't refill them, you're done after you
use them. Your second type is your mid-
size rechargeable vape pen. And that
specific one looks like, it's the top, it is
on the top row and in the second, there
you go, thank you Mandy. It's a specific
vape pen right there, and this one had
one heating element. It, you can pour, put
liquid nicotine inside of the vape pen,
and the nicotine could be various
different strengths and various different
flavors as well; and this is rechargeable. So once you fill it up once, you can
recharge it, you can refill it, and you
can vape any time of day and continue doing so.
You don't have to toss it away after. You may even see one of these vape
pens kind of hung as a lanyard around
someone's neck as well, kind of like a
necklace. And this is very, this is
different from the vape pen to the right of
that. The one that I just spoke of had one heating element, and that one
right there that's being circled, has
three different heating elements. That is
something called your mod or your
advanced personal vaporizer. This one in
particular has three heating elements;
and if you've ever seen anybody use a
vapor product, and you see these big clouds that are producing from their
mouths, or you see them in the car, on the
street, they're using one of these. Now
this will have three heating elements
which help create these large clouds in the
air, and it can also, similar to the
mid-size rechargeable vape pen, fill it up
with any sorts of vape liquid, various
different flavors, various different
strengths, etc. Now the ones that I just
talked about all still are filled with
straight-based nicotine, and this is one of
your most basic types of nicotine. Now
what we're going to be transitioning
into, is nicotine salt based formula,
which is a much stronger concentration
of nicotine, and these products that I'm
about to talk about also stays in your
bloodstream. The nicotine stays in your
bloodstream for a longer period of time
because of that nicotine salt-based
formulation. So the first one that I'm
going to be talking about is your JUUL,
and you may have seen this before. I've
heard of it before on the news. It looks
very much similar to a USB Drive, and
it's the one that's on the bottom, middle
side, middle, see where the arrow is being
circled around? Now the JUUL comes with
various different pods, and the pods have,
all of them have nicotine; and there's
various different flavors as well that
you can also get with the specific
nicotine vapor product. And this one has
the salt-based formulation. It's very
sleek, easy to use, and it's very much,
it's more familiar to our middle
schoolers, high schoolers, and youth
population. And this specific vapor
product, you don't necessarily refill it.
You can re-use another pod, but you
don't open up the pod and refill it. Not
to say though, that there, there are
videos online on how to open up the pod
and refill it using various different
tools, and filling it up with nicotine
salt-based formulation;
however it's not designed to do so. Your
next iteration of salt-based vapor
products is your juices your Soar and Drop or your Smock Badge, and those are
the two on the right hand side. The one on the top is a Soar and Drop, and the one on
the bottom a Smock Badge. Now this one is, also has a nicotine salt-based
formulation, and it is refillable. It's
designed to be refillable. It's
rechargeable as well, and if you, if you
hold it in your hand, it actually fits in
the palm of your hand. It's very sleek
and small and easy to conceal as well.
Now one of the first kind of concerns
that we have is the mods in particular,
hold a lithium ion battery. And what we
know about lithium ion batteries is that
the batteries, when they get to a certain
boiling point, there's a flammable
electrolyte in when it heats up this certain area, it bursts, and it causes the battery
to explode and catch fire. And so there
are many different stories of
individuals having their e-cigarette
explode in their mouths, their pockets,
their purses; and this is one of the
concerns that we have, is the burns that
are caused by these different products.
We've already, yeah, this is Mandy, I just
wanted to draw our viewer's attention to
this image down here. Can you tell us
what's happening? Yeah, the individual
went into the convenience store and he
was paying for his products that he was buying, and his e-cigarette was in his
pocket, and it all of a sudden blew up,and it was in his pocket. He like ran
outside right after, but he had
third-degree burns. And, on the top it
says, "An Exploding Vape Pen Caused Florida Man's Death," and so that we
actually saw one reported death of a
vapor product exploding and catching
fire. Now there are four main types, main
ingredients in vapor, and vapor product
liquid. And this is one of our biggest
concerns. We felt it not, it wasn't adequate
if we just talked about the vape liquid, and we needed to also talk about the
explosiveness of batteries as well. But
this is one of our biggest concerns, is
the actual liquid. The four main ingredients
are your nicotine, which acts as a
stimulant in certain doses, and acts as
depressant in other doses, in higher
doses. Nicotine, at the poison center
we categorize it, if someone calls in and
there's mild or moderate symptoms, that
means they're having a upset stomach, nausea,
vomiting, headaches, heart rate increase,
high blood pressure; but when we consider
a severe case, severe symptoms,
those are categorized as seizures and
confusion, having weak, low blood pressure, and more muscle paralysis. Now, the other
two ingredients are more for shelf,
shelf life in the propylene glycol and
vegetable glycerin, and then flavoring is
another ingredient. And flavoring doesn't
just, isn't just one specific ingredient.
Multiple different chemicals that are
made up of flavoring. Now this is a graph
that we created to help you understand
the different sorts of doses that you
can get for various different liquids,
and how much it costs. So if you look at
cigarettes,
it's about 47 cents per dose, and so you
get twenty doses in a
cigarette, so 47 cents each. For a low-dose
ejuice, it's about 15 cents.
Higher dosage, it gets to be cheaper and
cheaper. So if you look on your
right-hand side, you'll see your salt-
based ejuice, is about a cent, and you get
that many doses. It's much more cost
effective to have a nicotine salt-based
formula that's a high concentration and
it's much, much cheaper. And it's
interesting because vapor products don't,
aren't necessarily priced based off of
the nicotine content and strength. Hey Arti, this is Mandy again. Something
that I have heard in the field and you
can pause me and say we'll talk about later,
but I know that there's really high
nicotine content, so I'm seeing lower
prices for more doses, and that may be the
toxicity is higher. Is that, am I reading
that right? That's, great question.
If you flip to the next slide, I'll definitely
meant to talk about that more. Awesome,
thank you. Now, talking about the strength
of the doses and what the toxicity looks
like. So for incombustible cigarettes,
there are twenty cigarettes in a pack, and each cigarette has about 12
milligrams of nicotine. But once you
actually use the nicotine use, it says
it's about one to two milligrams that
you actually intake. At a low dose
e-cigarette, let's say it's about six milligrams of strength, and if it's in a 15
milliliter bottle, and that's your
average bottle size, the whole bottle
will have about 90 milligrams of
nicotine. Now let's talk about a high
dose e-cigarette liquid. 36 was a higher
dose that we were finding in our stores,
and in, if you look at how much of
nicotine would be in the whole bottle,
its 540 milligrams; and what we found at
the Poison Center, I asked our specialist, is what
what is a lethal dose? And their response
was, one teaspoon of a thirty-six
milligram strength bottle is a lethal
dose for a 20 pound baby. A couple of
teasp…, one teaspoon in a thirty six
milligrams strength bottle. Now I want to
kind of help you understand what JUUL looks like as well, because you see that
a lot more often, and you hear on the
news as well and you won't understand
what's the difference.
So JUUL is a very smart in its ways,
and their cartridge is actually smaller.
It's about 0.7 milliliters per pod, and
the actual strength of the JUUL is 59
milligrams. So the pod is very small and
I want you to imagine taking a 15
milliliter bottle and filling up that
bottle with the JUUL salt-based
nicotine liquid. I want you to imagine
filling it up to 15 milliliters. If you
filled it up, the whole bottle would have
about 885 milligrams of nicotine in that bottle
of JUUL liquid. That's about 59
milligrams per milliliter.
Now salt-based e-liquid, as there's a 70
milligram as well, as the strength as you
can see, they're getting higher and
higher as vapor product industry evolved.
A 70 milligram bottle would have about
1050 milligrams of nicotine. Now what
we're seeing in terms of the marketing
and advertising side, nearly seven out of
ten U.S. middle and high schoolers report
exposure to a vapor product from might be
the television, a magazine, YouTube, from a retail store. This is a 2014 number.
I would suggest that it would be much
higher now. I would even suggest it was
eight or nine.
All right, this is my turn to transition
over to Liz. Great, thanks Arti.
What do we know for research about e-cigs and vapes at this point? Next slide.
So one of the issues that we hear, and I
bet that everybody who's on this
particular webinar has probably heard
this in some way, that e-cigs are less
harmful and safer than combustible
cigarettes, or even a comment from
somebody who would say, "Well at least I'm, I'm using a vape, and I'm not using a
traditional cigarette, so it must be
safer." So what we know with a little bit
of research that we have and there's a
lot of research that is evolving right
now, that that typically yes, cigarettes
have a whole lot more chemicals than
than vapes do, so at least 7,000
chemicals have been identified in
cigarette smoke, so right. So vaping
probably is less harmful than smoking
combustible cigarettes, but we need to
keep in mind that the information in the
research then says that safer doesn't
equal safe. So that particular
discussion is still in the works for
a lot of the research that's going on, to
be able to show just what all types of
damage and exposure that we have in
using vapes. So less harmful and safer, so why can't
we say safe? Because we know that there
are metals, heavy metals that leak from
the heating coils, and that they are
added into the vapor as a person uses
the device. And so you can see that we've
identified lead and chromium,
nickel and manganese as part of the
vapor that is coming out of the device;
so it's not just, it's not just water
vapor. We also know then that, that over
time, the inhalation of these metals
really does cause damage, and we have
seen that lead to cancer. When we talk
about all the research that we have over
the decades about combustible cigarettes,
so we can make that linkage to, to these
metals being inhaled and contributing to
lung, liver, damage and cancer, to various
types of damages to the immune system,
the cardiovascular system, and to brain,
and to inhibiting brain development. So
that's harmful and safer, but again why
can't we say safe? Well we've got some more information, again, looking at what we
have known about combustible cigarettes.
So we know from looking at the aerosols
from vape products that they contain some
of the same things that we see from
combustible cigarettes,
of course nicotine. We see that there is
a formaldehyde that is released in the
process. When we're talking about a
higher voltage, and Arti is going to
tell us a little bit more about the
different heating methods with e-cigarettes and JUULs and other
devices, so those chemicals have been
connected to cancer. Free radicals we
know that free radicals cause various
damage to cell structures, and cell
structure damage is a leading
contributor to various cancers. And then
we've also identified the diacetyl, and that is
known as the term 'popcorn lung,' so
coating the lungs and causing damage to
lungs and the inhalation of air and
oxygen exchange. So we're waiting for
more research to come out, it's going to
take some time; but in the meantime, you
know, we're developing the various
damages in the use of vapor products.
So we use that little graph here to say
that we know about specific chemicals
that are related to e-cigs, and specific
injuries that occur because of those
chemicals, so at some point there'll be
that direct linkage of research that
says that. Next slide.
So another issue that comes up
frequently is that, that e-cigs and vapes
don't cause secondhand harm. So next
slide. We don't know that for sure. Again,
research being conducted now and we just
go back to the fact that it is not just
water vapor that's being released from
vape devices. So safe? Again, safer
doesn't equal safe. We have found
measurable levels of these various
toxins in secondhand vapes, vapor,
so we see things like formaldehyde and
acetone, and a variety of other chemicals
that have toxic associations with them.
Let's talk about third hand vapor. So
there is some research and a particular
research that was conducted
looking at the various, the various
pieces of a room where vaping had taken
place, and measuring the amount of
nicotine residue that was found on those
particular elements in the room. So these
researchers looked and checked the
floors, the walls, windows; they looked at
the ceiling and any metal surfaces.
They took some residue from the
window sills, and they found that there
was indeed nicotine residue in the
floors and windows, so we know at, at an
adult level, we have exposure at that
third-hand level, but where we're finding
it, if we're finding it on floors and
windows, and we know that our very young
children, especially toddlers,
there could be exposure there from being
on the floor, or from reaching up to a
window sill as well.
This is Mandy, I just wanted to pull
people's attention to the graphic you're
sharing where it says, 'The residues from
nicotine and its breakdown products can
recombine and form carcinogens called
nitrosamines,' how do I say that?
And that the conversion to nitrosamines
takes place two hours after the burning
of tobacco has ceased.
That's, that's, I didn't know that. And
Arti has more information about
this particular research. And Arti, I don't
know if you, if you know the exact
pronunciation, and if there's anything
else you wanted to add here go, ahead and
take that time.
Alright we're gonna move
ahead. I wanted to share
that this specific image was taken from
a tobacco, kind of finding, and we wanted
to share like, these are some of the
findings that we see from tobacco smoke,
and what the potential it could be for
bigger products as well. Thank you.
So the next issue, so this is, this
relates to what Arti was talking about
earlier, in regards to how much nicotine
is in our ejuice products. And so, we've
heard several times from kids that they
really believe that there isn't any
nicotine in the products that they're
using, and that they specifically feel
that they have chosen various ejuices because of the flavor and the coloring,
and that, that what they understand is
that there isn't any nicotine in there.
Well we have a painful surprise around
that. So there was a study that was
conducted recently, where researchers did
test 35 different eliquid samples, and
all of them have labels that they had
zero milligrams per milliliter
of nicotine, and over 90% of those
samples actually contained nicotine.
Six of those samples from two different
manufacturers, and again they were
labeled as 0 milligrams per milliliter.
They actually also contained nicotine in
amounts ranging from over 5% to 23.9
milligrams per milliliter. So it's true,
when we look at the 2017 Monitoring the
Future Study, so being able to take a
national picture, that our teens and
young people really believe that they
are really just vaporizing flavors, and
and at least we do have this research to
show that that's just not the case. There
really is nicotine in these juices.
And so look at what our tenth graders
nationally are saying-they just, they
really thought it was just flavoring and
that was the reason why they were vaping,
and that was the reason why they felt
that it was safer, and that it wouldn't
be a problem.
Next slide. Liz and what you're saying,
and like also, oh go ahead Arti. I just
would also like to include another piece
of data. The 2017 tobacco control
research study
found that 25% of 15 to 24 year-olds
recognized JUUL in a photo, but majority
of those individuals, about 81%, didn't
know that it always contains nicotine.
That was an interesting point that I
heard earlier in our webinar, was that
nicotine or that the JUUL pods always
contain nicotine. So I'll go ahead and
hand it over to you at this point. Also
this is Mandy, I wanted to note that
we're seeing some questions come in, and
that we are monitoring those questions
in the chat log, and we just got asked, "Is
it true that all JUUL pods contain
nicotine?" Yes, all JUUL pods do contain
nicotine. There are no JUUL pods that do
not contain nicotine. Thank you. So the
fourth issue is we might mean here
e-cigarettes can be used as smoking
cessation method. People may ask like,
"Why are you preventing someone that helps, why are you preventing something that helps
people quit?" Well first off, that's not, FDA
has not actually approved vapor
products as a cessation method. It has
not been approved by the FDA as a
legitimate smoking cessation device. Some adults may use this product to quit
combustible cigarettes and transition
into vapor products, but most likely our
young adults are not actually initiating
vapor product use to quit combustible
cigarettes. What we're actually finding
is youth are using e-cigarettes for
social reasons, and it's actually, even
though it's, even if they haven't tried
combustible cigarettes, when someone uses e-cigarettes it's actually, individuals
are more likely,
whether it's three times more likely,
five times more likely, eight times more
likely, to use future combustible
cigarettes. Youth are more likely to use
feature combustible cigarettes if they
use a vapor product, even if they've
never used a combustible cigarette in
the past before. And what's interesting
also is that the UW right now is
conducting research and has evidence to
show that e-cigarettes, vapes, JUULs, are
all being labeled now as truly gateway
drugs to our young population starting
with combustible cigarettes; so that
research is as just being released right
now in our own backyard. So we'll be able
to incorporate even more sound science
behind that really important piece about
starting with e-cigarettes as a young
person and moving on to combustible
cigarettes. If you look at this graph
in front of us, this is the Healthy Youth
Survey for various different grades, and
it's the most recent one, and it looks at
it over time.
If you look at tenth graders in
particular, last year the past thirty day
use was 13%, and this year our data shows
that past thirty day use has increased
to 21%, so one in five tenth graders have used a vapor product
in the past thirty days. If you look at
it from the twelfth grade level, in 2016
it was 20%, and this year's
data shows that about 30% of students in
the 12th grade have used vapor products
in the past thirty days. If you look at
our Washington Poison Center data, majority
of the
blue bars it's all 0 through 5 year-olds,
as pediatric exposures. You can
see that there's an increase in trend in
2014 and 2015, and slightly decreasing.
All of the exposures that we see at the
Poison Center are pediatric exposures
and we don't really know why exactly.
Individuals of 0 – 5 year olds have,
why the trend is increasing or
decreasing. One thing we do know is the
vapor product e-juice or bottle
at one point was not child resistant, and
kids were getting into it, and they were
leaking, it was leaking in their mouths, on
their skin, on babies hand or forehead,
and that could be very toxic to them.
This is, I also want to note that our, all
the exposures in Washington state are
not reported to us, and we are, we don't
receive every single case and every
hospital exposure. This is only the calls
that we get at the poison center through
our national toll-free number.
Now transitioning into cannabis. There's
another way of vaporizing, vaporizing
something and that's cannabis, vaporizing
another substance, and cannabis became
legal just a few years ago. And, if you
would switch forward to the next slide,
I'll go into that why individuals
vaporize cannabis? They can get high faster,
there's limited odor to the actual vapor
products, and there's a perception of how
it's healthier than smoking. There's this
term also used as "stealth vaping" that we
know of, and you know it's easy to hide.
You don't smell it at all, and there's
this perception of healthier. Now if you
look at the Washington retail market,
there are various different types of
products out there. On the right
hand side, you see JuJu Joint, that's a
very similar product to our nicotine
types of products, where you use it
and you toss it away, similar to Blue or
Njoy. This one you also use it and toss
it away after you're done, and it has
cannabis inside of it. And you can only
purchase cannabis products in retail
stores in Washington State, cannabis retail
stores. On the left hand side, you'll see
a midsize rechargeable pen for a
cannabis product. The one on the left
hand side, you'll see that the top is a
mouthpiece, the middle area is where you
can open it up and put various different
products in, you can hash oil or CO2 oil
or plant material inside, and if you
press the button you can take a hit from
the mouthpiece. And this is also, this is
rechargeable, reusable, and what not.
Then if you look at the one next to that,
that is called your Pack 3 and you can
purchase this, and it comes with various
different modifiers, and you can have one,
one vape product, and they provide
multiple different formulations of
cannabis. That could be dried herbs, so
your plant material. It could be a,
contain hash oil or wax, or shatter, and
it can be co2 oil as well. The next image
that you see is a vape pen. Those
cartridges that you can use for co2 oil
and vaporizing co2 oil, and this is
also reusable, rechargeable, comes in
cartridge form. The next one on the right
hand side, you will see a Grunco G pen,
and that is specifically to vaporize dry
herb or plant material. And this image
right here just shows exactly that you
can, on the bottom you'll see the
similar batteries, and you can purchase
different modifiers in the middle, to
vaporize various different products,
various different formulations of
cannabis, whether it's dry herb, waxes,
concentrates, or co2 oils. And you can
switch the mouthpiece as well to
vaporize that specific product.
Hey Arti, this is Mandy, when
I'm listening to you present on these
different devices, I'm also noting some
of the things I've heard out in everyday
experience. There seems to be almost a
subculture around like modding devices,
or that it's like a lifestyle for some
youth and young adults. Are you asking if
this is like a culture or if it's like a
identity that they, or? I am. Okay, to
some, it is an identity. It is part of
their own culture and part of their own
lifestyle. And to some, it's merely for
social reasons of youth. There are
various different kind of reasons for
use for cannabis. There's a
finding that is also for treating kind
of medically, really helping for medical
reasons that individuals use, and we have
some data that I'll show you in a second.
It's in the slide why individuals use
cannabis for, in King County, specifically.
Moving forward to the next slide, I'll
show you that. Now there's different
forms of vaporizing cannabis. What I'm
going to talk about is different; it's
not vaporizing cannabis, it's not vaping
at all. It's a completely different form
of taking in cannabis. So this is called
dabbing, and what you do is you heat up,
heat up an area on this bong on steroids
to 900 degrees with a blowtorch,
you take a scoop or take a dab of butane
hash oil, and then you press it down this
area where it's black on, and she's
pushing it down, it flash vaporizes, and
it goes into the mouthpiece, and there's
different water reservoirs to cool it
off. This is called dabbing, and it's a
completely different form of taking in
cannabis. It's, even, what I've heard and this is just anecdotal
stories – especially to individuals who
frequently use cannabis, and long
term users of cannabis, you get an
experience, a high that is sometimes, it's
really quick and really fast, and I've
heard frequent users don't appreciate
using or don't like using this.
That's not hard data, it's just
individual I've talked with and have
heard from. There's also a portable
dab rig as well that you can purchase. so you don't have to carry your blowtorch, and carry
all the different devices that you need
to dab, and this specific image is from
a cannabis, cannabis website, and so
it says right there heats up to 600
degrees Fahrenheit, so not as high as
doing it yourself, and it also says, "Do not
heat the device more than three cycles
continuously to avoid bodily harm and
injury." Now I hope everybody reads the
caution labels. I don't always do so, and
I don't know if everyone does as well.
Sorry, go ahead. In JAMA, in late 2018,
there was a study that was published
that showed that one in 11 teenage
students used a marijuana product, used
marijuana in a vapor product. Now these
are just images about what our retail
stores look like. There's all sorts of
types of products out there. There's
edibles that look very similar to
regular drinks that we see. There's a
juaracha sauce, there's cookies, there's
joints, there's a dab rig. If you click to
the next slide, you'll see various
different edibles that you see as well.
And if you look at it, there's the 'Not
for kids' sticker that we put on all the
edibles, and this was actually first in 2017 where all of edibles are, they have
to be on the, all the edibles have
to have a 'Not for kids sticker' on there,
to help communicate that it's a vapor
product, and that's it's not for kids, and
if something has happened, to call the
Poison Center. If you look at it, there's all
sorts of products. There's juaracha sauce,
there is drinks, there's mints, marmas, milk
truffles, brownies, etc. They look very much like the food that we see around grocery
stores. This is Washington Poison Center
data. Exposures has been increasing since
2012, and this is when I502 passed, and shops opened up in 2014.
Now, we don't really know why exactly
our trends is increasing, because we
don't know if people feel more
comfortable calling the poison center
because cannabis is legal, or if our
number is more available because it's
on the "Not for kids sticker' and the edibles
packaging, or if there is, there's more
access, or there's truly more exposures
to the poison center, exposures occurring.
So we don't know why this number is
increasing, but we see that it is, and if
you click to the next slide, you'll see
that it across the board.
It's increasing in all, in many different
categories, especially in our 0 – 5 year olds,
there's a significant
increase in our pediatric exposures
where they're getting access to this, and
exploring, and maybe the children explore
with their mouth; and so caregivers are starting to call in to the poison centers because they
either found their loved ones with,
exposed to this and need some support, or
want assistance on what to do. and our
Poison Center data is going to be
released really soon, so you'll see
what's happening. I won't share it with
you quite yet about what the trend looks
like. Now let Liz take it over from here.
Thanks Arti, ok next slide. So we wanted
to share a little bit of specifically
what we were doing in King County,
because we think that this is probably
reflective across the state. So the King
County Youth Marijuana and Education
Program, which I believe we've got that
type of programming and funding from the
Department of Health across the state. In
King County we conducted some listening
sessions with youth over the past couple
years, and what what we heard over and
over again from our youth, and they're about, the average age was about 15, 15
and a half, of the youth who responded,
is that they're youth. They say they
do it because their friends are using it.
They've heard that a lot of people are
getting sucked into vaping, and
particularly vaping marijuana, because
they're at a social gathering, and others
that they trust are doing that,
are engaging in that type of behavior. So
we know that that's kind of that passive
peer pressure, 'everybody else is doing it
so I think I should too'
type of response. And over and over again
this whole statement about, "Well, vaping
must not be, it must not be dangerous or
must not be as harmful, as again as
combustible cigarettes, so and you know,
and if it's a zero percentage of
nicotine, then it must be pretty harmless.
Well we have a challenge with
labeling, and it's not just the
labeling of our edible marijuana
products, but it really is the labeling
of our e-liquid products. There hasn't
been a great standardization and
regulation around how these products are
labeled in terms of the amount of
nicotine in them, so it could be very
easy for somebody to misidentify and
think that that a product that they have
does not have a whole lot of nicotine in
it, or or may indicate that it has zero
amount of nicotine. But as we had
demonstrated earlier in the webinar, that
some research was conducted and showed over and over again that there was some,
at least some level of nicotine even in
those that labeled it at zero. So it
really has been very interesting to be
able to listen to our youth, and hear
them say these statements that I think
we've heard over the decades, about why
kids use, and that, you know, using a JUUL looks pretty cool, and it's really easy
to disguise-when it looks like a flash
drive, when it could be recharged on a
laptop. Boy, that looks sleek. Boy, that
looks really easy. And so many adults
just don't see that.
So Arti, I'm gonna pass this one back to
you.
So for this specific graph, this is the Healthy Youth Survey and the past 30 days, and
what we're noticing is, that as students
go up in grade, the percentage of
students within that grade that used, who used the current, past 30 days marijuana use,
is going up. So the percent of students
as they're getting older, within their
grade levels, their past 30 days is
increasing. So I'll jump back in here,
this is Liz. So we just listed some of
the concerns that, that we see, some of
the implications for our prevention and
intervention work when it comes to vapes
and e-cigarettes, and specifically when
we're, we are talking about cannabis.
We know that today's cannabis,
today's marijuana is a very different
product from what we used
to have available 10, 20 and more years
ago. The potency is much stronger, the THC concentrations are very high, especially
when we're looking at edibles and
looking at concentrates. We can see up to,
easily as high as 60 some percent, and some products even higher, of THC. We know that
heating vapor devices and those coils to
really high temperatures, that there is
those release of metals, of formaldehyde,
of other chemicals that are connected to
cellular damage and cancer. And our concern about dependence – so one
in 11 who use cannabis develop some type
of cannabis dependence disorder.
It's on the rise. We frequently hear from
treatment centers and treatment
admissions for adolescents that they may
be coming in for another reason, but they
may cite when they come in the door that
it is a marijuana dependence. And one of
our other concerns is how often
withdrawal is misidentified. When we hear
that heavy users, especially young people
and our young adults who talk about
anxiety, and that they need to use
marijuana and cannabis on a regular
basis to keep their anxiety in check, and
many times that's just a
misidentification of withdrawal. That
anxiety is a withdrawal symptom, so
keeping that, keeping that dependence
going by
misidentifying and self-medicating
with cannabis to be able to take care of
mental health issues. Next slide please.
So I'm thinking that this particular slide and this piece
of the webinar is something that's
familiar to probably everybody again who
is, who is part of the webinar today. And
we know that we have concerns for our
youth because of adolescent brain
development continuing into what has
been documented now, to at least around
the age of 25. And so cannabis really,
that regular use really does affect
the system that is developing for the
brain, and actually can create pathways
for dependence; and that might not be
something, that it might not be a
cannabis dependence that continues, but
some other drug dependence. We also
know that the perception of harm from
cannabis use with our youth continues to
drop. That, as as long as we keep it
equating it with medicine and the amount
of advertising and promotion of legal
marijuana, that impacts what our
young people believe in terms of risk.
So we do see a bit more now of adolescents who equate marijuana with medicine.
So a little bit about alcohol,
because we did want to make sure that we
covered the specific drugs right now
that our adolescents are most interested
in. So as we have seen the huge increase
in, they've used JUUL use with our
adolescents, alcohol still is the most
widely used substance among our
adolescents and our young adults; so we
have researched over the years to see
that the average age of our young people
having their first drink is 14. And we
know that there is a relationship
between a child and a parent and a
parent who binge drinks, but that
normalizes the behavior, and that those
youth are more likely to also binge drink later in life.
I think that piece that Arti was
talking about earlier, that our kids
between 11 and 14 see a whole lot of
alcohol ads, whether that is online,
whether that's billboards, other print
materials, so over a thousand alcohol ads
a year, that's a lot!
So just reiterating
that the teen brain is really, is very
vulnerable to alcohol, and developing
those pathways to rewards for consuming
the substance. And mixing alcohol and
marijuana, we have found it to be a
dangerous combination, really impacting
judgment. And our partners with the
Washington Traffic Safety Commission
have quite a bit of research over the
past year and a half, looking at bringing
marijuana on board with other substances,
and driving, and with our young
people as well as our adults.
We know that mixing alcohol and prescription medication is
dangerous at any level, regardless of age.
And I think one of the things that is
something that our adolescents don't
always look at, is those consequences of
consumption and overconsumption-
particularly with alcohol, and a variety
of ill effects that some, which are just
annoying such as headaches, to those that
are more far more dangerous, such as
internal bleeding and heart problems.
So we just wanted to highlight
a couple of the prevention strategies
that we see in Washington State
related to our young people, and trying
to create healthier opportunities for
them. Next slide please.
So a list that we usually talk about
here, many times when Arti and I present
with parents, we thought that this might
be something that could be useful to
those of you on the webinar and the type
of work that you do, whether it's
directly with youth,
or it's with adults, that are adult, that
have influences over young people. So, one of the things that's really important is
for us to understand what the laws are
regarding cannabis, around alcohol, and
other drugs, and what that means for
adults and what that means for youth, and
how those laws are different.
It's really important to consider how
important norms and perceptions are, and
we know that risk factors that talk
about availability of various substances
also equals what is the perception of
the availability, so perceptions are
extremely important and very powerful
with our kids, and norming is as well,
as we learned particularly during our
King County listening session with kids saying that other kids were doing these
things, were vaping, so that the norm is
set there. We talk with parents and make
sure that they are familiar with what
their own mental health and behavioral
health issues are within their family,
what those risk factors are that are
family related, and to have those
conversations with their kids. We hope
that most parents and other adults that
work with kids acknowledge the role of
impulse control, and the development of
that in our adolescents. And we shouldn't
overlook the fact that there is a strong
influence of pop culture, on what our
kids use, and vapes and JUULs and
cannabis use are definitely susceptible
to that. So keeping that in mind, and
then the other pieces that our youth have
said of why they use: boredom and lack of
confidence, an opportunity to be able to
escape, and there are recordings of youth who talked about
self-medicating using particularly
cannabis. The other and the other most
important part is for us to correct any
misinformation with our
young adults and our kids, to make sure
that they have accurate information
about these substances. Next slide please. So again, calling out what parents can do
to help really prevent youth use. We know that parents are the first line
of defense; they really are the first
line of prevention, so expressing a "No
Use" attitude and doing that in a way
that helps a young person to be able to
have that conversation about why it's a
no use message that's being expressed by
the parent. We ask parents to not
make substances available to their teens
or their teen's friends.
We know that there is research from the
social development research group at the
UW that has talked about
the opposite effect when parents
actually use a norm of indicating that
they want to teach their kids how to
drink at home, and what they consider a
safe place. That tends to
backfire and has a boomerang effect of
leading to more problems when kids are
launched out of the home into college or
on their own, that that actually creates
far more of a problem than it creates
safety. So helping our kids
to be able to practice feeling
comfortable and saying no, and really
being those big shoulders, so
that those kids can go ahead and point
back and say that their parents would
really be upset with them or whatever
language works there, as a way to escape
being in that situation of having to
make a choice about using or not. And so
we remind all parents to keep track of
your teens. Know who they're hanging
out with, get to know the parents of your
teen's friends, keep those lines of
communication open, make sure to set
those guidelines and stick to them; but
also to grow those boundaries with our
kids, that at one age they may be very
effective, but those boundaries also need
to grow as the child does, and as they
demonstrate their ability to be
responsible and make healthier
decisions. Next slide please.
So Arti and I listed some of our
favorite parent resources here. So there
are, they're mostly websites, and so with
Prevention WINS, we do have a parent's
guide to preventing underage marijuana
use. That booklet is available online and
in hardcopy.
It's available in a variety of
different languages as well, and it's,
though it is specific to marijuana, it
has many of the tips and tools in it
that could be used by parents as well as
other adults, regardless of what the drug
is, and as you can see, we've listed the
Washington Poison Center and the Start
Talking Now website, which is a website
hosted by a collaboration of state
agencies, providing quite a bit of
information again for parents, adults, and
community members. And maybe some of you
are familiar with the "You Can" campaign
in our state that the Department of
Health launched last year. And I'd also
suggest the Alcohol & Drug Abuse Institute
at the University of Washington and the
Clearing House NIDA, the National
Institute on Drug Abuse. And then a
couple of specific King County resources
here that I think have, that have reach
across the state, King County Public
Health put together a short video
animation called 'Escape the Vape."
It's just a couple minutes long.
It's geared towards youth talking about, well it's the
animation of several of the chemicals
that we talked about today, that would show
up in vapor, and those chemicals are
talking to each other about their roles.
So I think it's a, it's a great
opportunity to be able to educate kids.
And then we also listed "Take Back Your
Meds." So not to, you know, not to leave out
the fact that prescription and
over-the-counter medications continue
to be a significant issue in our state,
at both the adolescent young adult
age, but also with adults, so we
wanted to make sure that we listed that
resource.
So I think that that brings us probably
to the end of our our scripted webinar
at this point, so Mandy, I guess I will
hand it over to you in terms of
questions. Thank you so much Liz and
Arti, we have been monitoring the chat
box and we've had a couple questions
come in, and through your presentation I
think that they were, most of them have
been answered. We had additional
questions about, do all JUULs contain
nicotine, or all JUUL pods? So just to
confirm that yes, all JUUL pods do
contain nicotine. Are we right? Yes, that's
correct.
Also, we had some clarifying questions
about students who might be purchasing a
flavor only or zero nicotine ejuice, or
they think that it might just be flavor
pods, but it's very likely that they are
actually vaping nicotine, is that also
correct? We don't know, that could be
definitely a potentially a concern after
finding, the research findings that we
saw, but even though the label would say
zero milligrams per milliliter, there is
potential for nicotine to be inside of
it as well, according to that research
finding. Thank you. Another question we
had was about the price of JUULs and
vapor devices compared to buying
cigarettes, or the taxes I'm sorry.
Will they, do we know if the taxes will
be applied? The vapor product tax, sorry Liz,
would you like to answer? I didn't mean to jump in, thank you. We did just pass, legislature did just pass
a vape tax bill, and I'm not sure when it
comes into effect; I don't believe it has
started yet. So there is a comparison
that shows what the percentage of
tax will be on each of the products, and
I would reference, I'm going to call out
a great resource which is Scott Neal
from the King County Public Health.
He was able to look at what
the relationship is between the amount
of nicotine in the vapor devices and the
percentage of tax, so it is, it seems to
me like it's a little bit more complex.
And also, I'm not the best
person to be able to give you that
information,
and I would again, I would point to Scott
for that. There's going to be more
information rolling out about that
because it is a new tax that
I believe does start this year, but hasn't
started yet, so sorry that I don't have
more detailed information about that. No,
I think we're, the issues with having a
webinar on this topic matter is there are
so many, it's the seed ground for so many
other questions. And for combustible
cigarettes, if you don't mind if I just
speak on that, it's about 98 percent for
a pack of cigarettes, so it's about
on average like 10 bucks, 9 bucks to for
a pack of cigarettes. Thank you. We have
some additional questions. One question
we have right now is, "Are we able to
provide any model policy that schools
can implement for students that use or
possess nicotine or marijuana or vape
devices?" And this is Mandy here at OSPI.
So I'm going to go ahead and field that
question first. You know it's a, it's a
really big topic in schools, especially
because this year we have some rule
changes related to school discipline, and
student discipline, so it
doesn't have a quick easy answer. There
are some policies and for model
policies for schools to look at, they
might be referred to WASDA. I would also
say that we have a one pager on the rule
changes and how they are related to
substance abuse on our website, so that's
another resource you can access. We would
also refer folks to the behavior menu of
best practice for more information on
what works for behavior, because
oftentimes substance use or substance
possession in schools is seen as a
discipline issue, but it's also a health
issue, so we're really looking at ways to
open up the perception for how
adolescent substance use is both a health
issue in addition to a discipline issue.
Another question we had was of course,
"How can we assess for cannabis use in
young children and older students?" So Liz
and Artie, we responded that one way to
assess is to do a screening and/or, in a
medical setting that actual tests or
medical tests could be run, but the
follow-up question to that was, "In school
settings that have a nurse, counselor, and
intervention specialists on-site, is
specialized training required for
screenings?" And I think that that would
get back to the protocol and procedures
that are in place at your district level.
So there, I also want to differentiate
for the folks out there interested in
screeners, that the word 'screening' and
the word 'assessment' can mean
different things in different settings,
and that we would be really careful
about that, because in some settings, an
assessment is a clinical tool, or
screening can be thought of as a
clinical tool, but there are also
screeners that are not clinical or
diagnostic in nature, so those questions
I think have a little bit more nuance
then we'll be able to answer on this
webinar. There is also a question, this is
Emily from OSPI. There's one question about the Escape
the Vape, and the email, or the URL for
that, and I believe it's "escapethevape.org"
are they, Liz can you verify that for
me? Yeah, correct, yep. Okay
thank you. One more question- can we
include these resources that we just
mentioned in the email? Yes we can, I'll
make sure that the school discipline
one-pager and the behavior menu of best
practice both get sent out. And there's
also another question about resources in
general, about vaping insights on the
OSPI website, there's a link of resources
on one of our pages and we can send you that out as well.
Yep, all right, so I'm looking at the
time, it's 2:22, which gives us just a few
last minutes if you have any additional
questions. We'll give that about 30
seconds and we'll monitor.
So Liz and Arti, we're seeing some folks
asking for some really specific
resources. We will send out the slides so
you can look at the resources that Arti
and Liz listed here as one list of
resources, but in our follow-up email
we'll also be able to link to some of
the things that were discussed in the
last few minutes. I wanted to say a really
big thank you to our presenters today
for making the time not only to put this
slideshow together, but also the time to
do such a thorough presentation. So you
can expect from OSPI some follow-up
emails, and one last check in with our
presenters Arti and Liz, any last
comments? Mandy I'm happy to send you the actual links. I do have just, you know, a
Word document and a PDF of links of the
resources, and I'm excited to add OSPI on
to our favorite parent resources, thank
you for that. Wonderful. All right, well
this is OSPI with Emily and Mandy. We'll
be signing off. We wanted to say thank
you so much for joining us today. We had
over a hundred folks present with us.
This will be made live and posted to the
OSPI website, for folks who registered
you'll get a link directly notifying you of
that. So thank you so much for
everybody's participation today and have
a great one.
Thank You Mandy, Thank You Arti and Emily. This is Liz, I really appreciate everyone who was with us
today, thank you.

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