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Health Risks

What NHS says about coronavirus risk to people who smoke and vape

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Severe E-Cigarette, or Vaping, Product Use Associated Lung Injury Requiring Venovenous Extracorporeal Membrane Oxygenation

https://journals.lww.com/pccmjournal/Citation/2020/04000/Severe_E_Cigarette,_or_Vaping,_Product_Use.11.aspx

Abstract

Objectives:

To report a severe case of e-cigarette or vaping product use-associated lung injury with complex course requiring venovenous extracorporeal membrane oxygenation.

Design:

Case report.

Setting:

PICU in an academic medical center.

Patients:

A 16-year-old girl presenting with gastrointestinal and respiratory symptoms was admitted to our PICU after having progressive respiratory failure and bilateral pulmonary ground-glass opacities on chest CT.

Interventions:

Venovenous extracorporeal membrane oxygenation

Measurements and Main Results:

After extensive infectious workup was unrevealing, she reported a history of vaping e-cigarette containing either nicotine or delta-9-tetrahydrocannabinol oil prior to symptom onset. She was given a presumptive diagnosis of e-cigarette or vaping product use-associated lung injury. The PICU team in consultation with pulmonology and medical toxicology started high-dose IV methylprednisolone 1 mg/kg bid. Despite initial improvements, she continued to require positive pressure ventilation and developed pneumomediastinum with progression to tension pneumothoraces and a persistent air leak. Unable to maintain her oxygenation, she was placed on venovenous extracorporeal membrane oxygenation for a prolonged course and had a tracheostomy placement. The clinical course, severity, and range of interventions in affected patients around the country have varied widely. Respiratory symptoms have been the most severe, but the constellation of symptoms in e-cigarette or vaping product use-associated lung injury include constitutional symptoms (fevers, weight-loss) and gastrointestinal symptoms (nausea, vomiting, diarrhea). In many cases, steroid use led to rapid clinical improvements. However, other cases with severe illness, like our patient, necessitated high-dose IV steroids, intubation, and venovenous extracorporeal membrane oxygenation. The underlying etiology and pathophysiology of e-cigarette or vaping product use-associated lung injury remains unknown. The Centers for Disease Control and Prevention in conjunction with state/local health departments and the Food and Drug Administration is actively investigating the outbreak.

Conclusions:

Clinicians need to be aware of the current outbreak of e-cigarette or vaping product use-associated lung injury and ask about vaping in patients presenting with gastrointestinal and respiratory symptoms. Treatment options are anecdotal and necessitate a multidisciplinary approach.

Vaping Could Compound Health Risks Tied to Virus, FDA Says

https://www.bloomberg.com/news/articles/2020-03-27/vaping-could-increase-health-risks-tied-to-covid-19-fda-says?sref=vEQJzSks

Vaping Could Compound Health Risks Tied to Virus, FDA Says

By

Anna Edney

and

Angelica LaVito

March 28, 2020, 4:28 AM GMT+8 Updated on March 28, 2020, 7:19 AM GMT+8

  • Heart, lung problems increase risk of Covid-19 complications
  • FDA says in email that e-cigarette use can damage lung cells

Vaping may leave users with underlying health conditions at higher risk of serious complications if they contract the respiratory disease caused by the novel coronavirus, the Food and Drug Administration said.

“People with underlying health issues, such as heart or lung problems, may have increased risk for serious complications from Covid-19,” Michael Felberbaum, an FDA spokesman, said in an email Friday in response to questions from Bloomberg. “This includes people who smoke and/or vape tobacco or nicotine-containing products.”

“E-cigarettes can damage lung cells,” Felberbaum said.

Some health experts have speculated that vaping is causing younger patients in the U.S. to be hospitalized with Covid-19 at a higher rate than anticipated. Felberbaum declined to comment on whether the FDA was investigating a possible connection.

Earlier this week, Nora Volkow, director of the National Institute on Drug Abuse, wrote a blog post warning that the coronavirus “could be an especially serious threat to those who smoke tobacco or marijuana or who vape.”E-cigarettes have been touted by some as less risky than smoking. But any increased harm associated with Covid-19, and the FDA’s direct language linking the products to lung damage, could boost detractors who have raised questions about the potential that vaping can lead to health problems.

Last year, some vapers began coming down with a mysterious and sometimes deadly lung illness. Those cases have been linked to products containing THC, the active ingredient in marijuana.

The FDA under President Donald Trump originally took a largely hands-off approach to regulating e-cigarettes, but began to change course in 2018 to stem an epidemic of youth use. After multiple delays, e-cigarette makers have until May to apply to the FDA for clearance to continue marketing their products. None have received FDA approval to market themselves as less risky than smoking.

STOP the virus spread – BAN VAPING – BAN ENDs

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ENDs products no safer than cigarettes- generate dual users – designed to keep youth and adults addicted to nicotine

Dear Panel members,

the enhanced addictiveness of RECON used exclusively in iQos HEETS

iQos Heets use cast leaf technology aka RECON (reconstituted tobacco)

The veins, stalks and stems, leaf dust (named OFFAL) from the cigarette production process are mixed with chemicals in a slurry to create a Recon sheet.

https://startobacco.biz/reconstituted-tobacco/

The manufacturer can fine tune the addictiveness of the RECON product and using a smaller amount of RECON.

http://www.jeffreywigand.com/theinsider.php

see The Insider Dr Wigand’s expert report under –‘Testimonies’ – ‘Dr Wigand’s WHO Expert Report’

Search the report for ‘Recon’

The Report is eye opening and informatory.

For your ease of reference I attach some sections on RECON from the WHO Expert report:

Quote:

“The use of RECON is the one of the principal methods of introducing acid base ammonia  chemistry and other additives into the USB non-menthol cigarette blend. RECON can be  considered a chemical-additive delivery system in addition to the casing process of tobacco.  Ammonia chemistry is utilized for several reasons; 1) to scavenge nicotine from each blend  component; 2) to equalize the concentration of nicotine in the tobacco column rod; and 3) to modify pH such that nicotine becomes a free base.

Free nicotine, which is controlled by smoke pH, is a more potent form of nicotine that is in the gas phase rather than bound nicotine that is in  the particulate phase.  The extensive use of ammonia chemistry in RECON converts the salt  linked or protonated nicotine into “free” nicotine that has a higher potency than its salt/protonated form.  Free nicotine it is not detected by the smoking machine analysis of tar and  nicotine since it is in the gaseous state not in the particulate state of matter.

The primary importance of RECON is neither the utilization of manufacturing waste nor  the enhancement of economy of manufacture.  Rather, RECON is important because it  introduces a significant amount of additives into the cigarette blend. These additives accomplish  two distinct purposes: 1) they increase the addictive capacity of the cigarette and 2) they facilitate the ease of smoking by ameliorating the effects of inhaling smoke.

 RECON tobacco comprises about 20-30% of a USB cigarette’s blend formulation on a  w/w basis.  It is a chemically manipulated material using abundant additives, such as glycerol, licorice, cocoa, honey, polyethyleneglycol (PEG), simple sugars, invert sugars and ammonia based additives such as ammonium hydroxide, urea and diammonium hydrogen phosphate  (DAP). The ammonia based additives in RECON play a key role in the manipulation of nicotine.

The finished product is a highly energized chemical matrix which forms the basis of many of the  chemical reactions occurring in the tobacco rod column, such as nicotine scavenging, generation of free nicotine, smoke pH manipulation, and formation of some flavor reaction products.

  1. Raw material components and composition of RECON

RECON is produced utilizing by numerous by-products of the cigarette manufacturing process.  There are three (3) distinct RECON types; Paper I, Paper II and band cast. The raw material used to make RECON contains the following components:

1) Offal or the tobacco dust generated in either the Green Leaf Trashing (GLT) plant or in the Primary manufacturing process.  The GLT Plant strips and removes the veins of the tobacco leaf into large strips of lamina and produces a by-product called stems.  Stems can be utilized either as a cigarette blend component or as one of the sources of raw material for RECON.

 

2) The primary portion of the manufacturing plant produces the fines and winnowers when tobacco, a moisture sensitive biomaterial is moved rapidly through the

manufacturing process, either pneumatically or via high-speed conveyor belts. This aspect of the manufacturing process causes dehydration and brittleness of the tobacco material, and therewith the formation of tobacco fines and dust (offal).

3) Stems produced at the GLT Plant

4) Tobacco fines or winnowers

5) Product Reclaim.  Finished product that is collected from the distribution channel is returned to the manufacturing plant for reprocessing.  This includes the finished goods that, due to moisture content loss, are deemed unsuitable for smoking due to increased irritation, harshness and the fact that they pose a fire hazard.

 6) Unique tobacco cultivars are used either to augment nicotine content or to augment or enhance flavor attributes of the final RECON product.

 7) Cellulosic material from wood pulp added for fiber content

 3. Band cast reconstituted tobacco (Dark RECON)

Band cast uses the same starting raw materials but differs fundamentally from the paper  making RECON process. Unlike the paper process, band cast is made by adding the stock raw  tobacco materials (see list above) and prescribed chemical additives into one reaction vessel. 

The tobacco material is then pulverized with the additives forming a thermally and chemically reacted slurry mixture.  The sheet is made by pouring the slurry into a “doctor blade” which  regulates the amount of slurry that is applied to a moving S/S non-perforated belt.  The basis weight can be controlled at this point.

The slurry mixture then goes through three separate heating zones where the water content is reduced forming a solid sheet.  This solid sheet is then cut into irregular pieces and boxed in a similar manner to the paper RECON.”

 

See also

https://www.who.int/news-room/q-a-detail/q-a-on-smoking-and-covid-19

Kind regards,

James Middleton

Chairman

Clear the Air NGO

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Vaping and e-cigarettes: Adding fuel to the coronavirus fire?

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Regulating Vaping — Policies, Possibilities, and Perils

https://www.nejm.org/doi/full/10.1056/NEJMp1917065

Smoking rates peaked in the United States in the mid 1960s and have since declined to historically low levels. In contrast, use of e-cigarettes has recently soared, particularly among young people. In 2019, more than 27% of high school students reported using e-cigarettes during the past month, as compared with about 6% who reported using combustible cigarettes.1 Use of Juul products accounts for much of the doubling of vaping rates between 2017 and 2019, and these products represent 75% of the multibillion-dollar e-cigarette market. The growth in vaping among young people has alarmed policymakers and many others.

Federal and state governments have implemented numerous policies to combat the growth of vaping. To promote the health of the population, however, policies should protect young people without diminishing the ability of e-cigarettes to help adult smokers transition away from more harmful combustible cigarettes or to serve as a cessation aid for people attempting to quit smoking. This tension presents a quandary for policymakers, since vaping policies often promote one goal at the expense of the other. Furthermore, the facts that certain state and federal policies complement, substitute for, or undermine each other and that some federal policies supersede state policies add another layer of complexity to policymaking in this arena.

Because e-cigarettes vaporize liquid instead of burning tobacco, they are generally thought to be less harmful than combustible cigarettes.2 However, the long-term health effects of inhaling liquid flavoring chemicals and nicotine are unknown.

Juul is a cartridge (“pod”) type of e-cigarette — it is a reusable, rechargeable device that holds a liquid-containing pod, rather than a refillable open-tank system or a disposable device. Juul pods contain higher levels of nicotine than many other e-cigarette products, which makes them a better substitute for combustible cigarettes for smokers. However, high nicotine levels increase the risk of addiction among young people and can harm their cognitive development. Vaping e-cigarettes adulterated with tetrahydrocannabinol (THC) and vitamin E acetate recently caused an outbreak of acute lung disease and deaths.3 Although these harms are seemingly linked to the addition of THC and to the use of e-cigarettes obtained from informal sources rather than to e-cigarettes in general, these complications heighten concerns about e-cigarettes.

Capture5

State and federal policymakers are focusing on two key policies for preventing vaping among young people: minimum sales age laws that restrict the sale of e-cigarettes to adolescents and bans on flavored e-cigarettes. Some states have also implemented e-cigarette taxes (see table).

In December 2019, Congress passed so-called Tobacco 21 legislation, which immediately sets a federal minimum age of 21 for purchasing tobacco products, including e-cigarettes. Twenty-four states and the District of Columbia had enacted policies that set the minimum age for purchasing e-cigarettes at either 19 or 21; in other states, the minimum age was 18.

Because most tobacco use begins before 19 years of age, the new federal law has the potential to dramatically reduce current tobacco use among young people and prevent some people from ever using tobacco. However, enforcing bans on sales to minors is difficult in retail locations and even more so online, and young people often obtain e-cigarettes from family members and friends. To reduce access to e-cigarettes among young people, federal and state governments could increase funding for enforcement efforts and collaborate to find better ways to prevent sales to young people in stores and online.

Another important policy is banning flavored e-cigarettes. Because flavors are more attractive to young people than to adults, a flavor ban could reduce the appeal of e-cigarettes for young people without diminishing their role in harm reduction for adult smokers. Nine states have passed flavor bans, but most have been short-term emergency bans or have been blocked by legal challenges.

In December 2019, the Food and Drug Administration (FDA) announced that it will use its market-review authority to essentially ban all flavors except tobacco and menthol in cartridge (pod-based) e-cigarettes. These changes became effective in February 2020. Disposable e-cigarettes and e-liquids for open-tank–system e-cigarettes typically sold in vape shops are not covered by the policy. The effect of the ban may be limited because of these important exemptions.

Banning all flavors in all tobacco products with few or no exemptions could be more effective than the current narrow ban for several reasons.4,5 First, menthol cigarettes, which remain on the market, have been shown to be appealing to young people. Second, although young people prefer fruit- and candy-flavored pods to menthol-flavored pods, the latter might become more attractive if they are the only flavored pods available. Third, under the current ban, young people may switch to e-cigarettes that are still permitted to contain flavoring. Indeed, adolescents have recently been favoring new flavored, disposable e-cigarettes that resemble Juul devices but have higher nicotine concentrations and cost less.

Another concern is that it is unclear how committed the FDA is to enforcing the flavor ban for cartridge e-cigarettes. The agency has largely declined to act on its authority to regulate e-cigarettes and to fulfill an obligation established by Congress to force products that do not protect public health, such as Juul devices, off the market. State bans on flavored e-cigarettes may therefore still be important.

A final policy is taxation of e-cigarettes. Twenty-one states and the District of Columbia tax both e-cigarettes and combustible cigarettes; the federal government taxes only combustibles.

The effects of such taxes on public health are complicated for several reasons. Levying taxes on e-cigarettes raises their price, thereby deterring some people from vaping. However, such taxes will also drive some vapers toward smoking, since taxes tend to increase the price of e-cigarettes relative to the price of combustibles.4,5 Consequently, the tax rate on e-cigarettes should be set so that it is cheaper to vape than to smoke. Determining optimal tax rates is complicated by the multiple types of e-cigarettes available, the fact that devices and pods are often bought separately, and the ability of companies — not the government — to set prices. Furthermore, too high a tax on e-cigarettes will encourage vaping of lower-priced or black-market e-cigarettes, thus undermining the benefits of the tax.

Given these considerations and the lack of evidence regarding how people respond to taxes on e-cigarettes, it may be preferable to rely on greater enforcement of Tobacco 21 policies and flavor bans to prevent vaping among young people. The appeal of tax revenue, however, may be too strong for governments to resist.

But at what level of government — state or federal — should e-cigarette policies be implemented? There are several advantages to states taking the lead. States may be more nimble regulators than the federal government, each state can regulate to meet its own needs, and state policies can serve as experiments and generate useful evidence. State laws can fill voids when federal regulations are absent or ineffective. States can also provide an impetus for federal action by demonstrating nationwide political will, as they did by passing Tobacco 21 laws. However, differing state policies risk leaving young people in some states unprotected and promoting the flow of e-cigarettes across state lines.

On the other hand, implementing regulations at the federal level has potential advantages over relying on state-based regulation of e-cigarettes because of the broad reach of national policies and their capacity to reduce trafficking across state borders. Nevertheless, as compared with states, the federal government has been slow to implement certain regulations.

Soaring rates of vaping among young people and associated problems have resulted in great urgency and important challenges for policymakers. Despite the urgency, policies should be evidence-based and thoughtfully designed. They require effective, collaborative, and well-funded enforcement by federal and state governments. Policymakers should aim to reduce vaping among young people while maintaining avenues to help smokers quit. Finally, policies should be forward-thinking, since the e-cigarette market is rapidly changing and e-cigarette companies can be more agile than regulators.

COVID-19 AND TOBACCO INDUSTRY INTERFERENCE

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COVID-19 Likely Worse for Vapers, Smokers

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Group Urges Statewide Vaping Ban Amid Pandemic

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