Well, thank you all for joining us this morning. I hope you enjoy our session on what I think is a silent and still dangerous epidemic. We've got a new generation of nicotine addiction forming behind millions of current smokers, and many are going to be sick and die earlier than they would otherwise. And of course, this is due to the voracious appetite of companies making products that would not be legal if they were created today. We're here to describe this problem and to try to show how you can help turn it around, just like our forebears for old-fashioned combustible cigarettes. So let's start with an overview of the e-cigarette epidemic by Susan Wally, who's been a tireless advocate in this space and is a pediatric hospitalist at Children's National in D.C. Hi everyone. Good morning. Aloha. All right. Thank you so much for coming to pretty much one of the last sessions, although I know there's a poster session at noon. So really appreciate everyone being here. And as Evan said, I am a pediatric hospitalist, so a little out of my comfort zone with all of you pulmonologists, but definitely looking to kind of set the background and the framework for this amazing group to talk about vaping and what you can do both in your clinical practice and, even more importantly, on the advocacy stage to hopefully change the epidemic. You know, I'm seeing, and Sarah is actually a pediatric pulmonologist, seeing them in their pediatric years, and then, of course, as all children, we hope, we'll see you as adults and hopefully we can do something about it mutually before they end up with a lifetime of nicotine addiction and chronic medical problems. So I am at Children's National Hospital in D.C., and so our objectives today is I'm just going to be, again, setting up the issue around e-cigarettes and vape devices and the epidemiology of youth use, and then we're going to be talking about, because in advocacy, as with our clinical practice, it is so important to understand the evidence in terms of what tobacco companies, because they are performing their own research, about what factors really encourage youth to use and to keep using. And so we'll talk about, briefly, flavors, the targeted marketing and advertising, and the very high levels of nicotine. We also have some show and tell for those of you who may not be seeing these products regularly. And so we added this, this year, this is the second year that this group has done this talk, about what our reasons to advocate are, and I think all of you guys sitting in the audience certainly have lots of different reasons to advocate, from your patients to family members to your own children. I'm in Washington, D.C. now, but for 21 years, I spent my career in Birmingham, Alabama. Have any of you guys heard of Tobacco Nation, or maybe live in one of the states that Tobacco Nation, you can see in the map? I know there's a South Carolina person, probably some others from the South. And what this group, this not-for-profit group, called the Truth Initiative, which I definitely encourage you, in your advocacy journey, you know, to beg, borrow, and steal. Don't start from the beginning. Came up with this term, Tobacco Nation, which is, I think, 12 states that have much higher rates of smoking, and in both adults and youth, as well as all tobacco products. And then they also have a much higher rate of tobacco-related morbidity and mortality. So the Truth Initiative has a lot of data about the differences. And we know, you know, like, all quality is local, all advocacy tends to be local. You know, so when you say, like, the national data says X, Y, Z, that is definitely not going to be as compelling as if you could bring in your state data, your community or your city data. And so we're going to be talking today about new tobacco products. That is a little bit of a, you know, it's a huge term, or encompasses a lot of different tobacco products. We'll mainly be focusing on e-cigarettes and vape devices. And for purposes of this talk, and I think, in general, most people are using that, those terms interchangeably. And I would say probably the most common question I get at a talk about e-cigarettes is, you know, is this the same thing as vaping? You know, and what different products are included? And so we'll address that quickly on the next slide. However, there are also, the tobacco companies are very facile about putting out new products. And so there are nicotine pouches, which we actually have a sample of, you can see Xen, which is in the left bottom corner, and these Velo, Snooze as well. Nicotine gummies, which fortunately the FDA has kind of cracked down on that. That's in the bottom left. And then I-COS, which is, it actually stands for I Quit Ordinary Smoking. It is an FDA approved heat not burn reduced harm product. I will say, we were talking beforehand that a lot of the research that was published on that from, it's a Philip Morris product, was Philip Morris researchers. So, you know, not surprising maybe that that showed reduced harm. So but again, e-cigarettes and vape devices are what we're going to really be focusing on. And the reason for that is by far, it is the most common tobacco product that's used by youth. And the picture that you see in front of you has just a assortment as is the plastic bag that's going around a different vape devices. You see Juul on the left hand side, and then smoke. There's actually an example of smoke in the bag. And then a tank, which is third from the left. And then it goes into a lot of the disposable e-cigarettes, which are the most common e-cigarette now being used by our youth. And then, let's see, oh, that went away. As one part of advocacy, when I go to a new area and give a talk, as much as possible, I do pick up a e-cigarette or vape from the local area just to show how ubiquitous, how compelling for youth a lot of the products are. And so in the plastic bag, there is a pineapple mango Proud Mary, which I have never heard of that brand, but it is, it smells absolutely delicious. And so to that point, if you're thinking about from a tobacco company standpoint, how am I going to design a product that people are going to use? And while we certainly know tobacco companies explicitly for cigarette use figured out that they are killing their clientele, and how are we going to get replacement smokers? And so we don't have to look very far. Tobacco companies just within decades developed Joe Camel. So raise your hand if you are old enough to remember Joe Camel. Okay, I see a good number of hands there. So it wasn't that long ago. And when we think about this now, it's a cartoon character that is promoting smoking. Sounds like a bad idea, right? That we should have learned from. But unfortunately, tobacco companies right now are still doing pretty much the exact same thing. And so this is off the FDA website. This is a SpongeBob e-cigarette, and obviously compared to the cartoon, very similar in terms of how they're targeting youth. We also have for those, I see actually a child, but Lotso, Super Mario Brothers. Unfortunately, the FDA, this is on their website, but they did send warning letters to these manufacturers to say that this is specifically targeting our youth. And so we know that that's going on now. Again, it's no surprise that tobacco companies have learned from the playbook of just a few decades ago. Other reasons that youth now are using e-cigarettes is flavors. And we know there's about 17,000 flavors. Many of them are unapologetically directed toward children. You can see this Candy King, which looks very much like gummy bears or Sour Patch Kids, vanilla. And we know that 80% of adolescents who use an e-cigarette started with a flavored product. And that's, again, it's a lesson learned. The 2009 Family Smoking Act made cigarettes illegal for any flavor other than tobacco or menthol. And Sucharita is going to be talking a little bit about, or a lot, about some of the health disparities and menthol in particular, how it has targeted the black community in the United States. And so moving on, other reasons that adolescents are using e-cigarettes, these false perceptions of being sexy, cool. You can see here, talking more about the menthol story, on the left-hand side is a cigarette advertisement. And these were very blatantly placed in African-American communities. And 98% of African-Americans use mentholated cigarettes. That's not a reason other than the blatant targeting of that community. And then you can see on the right-hand side, blue e-cigarettes being popular. I had not seen this one, but it's Ronald Reagan advertising Chesterfield. And Juul was probably the tobacco company or e-cigarette company that really knocked the ball out of the park from a marketing and advertising perspective. And so we saw a huge increase in 2019 in e-cigarette and specifically Juul use. You can see young, sexy, very colorful advertisements, very similar to the ads of old. And then, of course, importantly, once youth were attracted by the flavors, by the advertising, there was nicotine. We think about nicotine addiction. We know that adolescents are uniquely susceptible to nicotine addiction. The adolescent brain is not fully mature. So even with intermittent use, over just a two-week period, we see some evidence of dependence. And then we'll be talking more about how the nicotine salts, which Juul really perfected in these newer e-cigarettes, really allowed higher levels of nicotine to be tolerable and used. And so what you see here is basically one pack of cigarettes is 20 cigarettes. I have to explain that to a lot of pediatricians because they never smoked, fortunately. And when you compare the amount of nicotine in just one Juul pod, which you saw, that's at least one pack of cigarettes, 20 milligrams. And then you see Fix and Soren, those are other e-cigarette brands that may be the equivalent of two packs, three packs. The Proud Mary that's going around in the plastic bag has 400 milligrams of nicotine in it. So that should be simple math, but what? That is 20 packs of cigarettes, 400 milligrams, 20 each. So it's a lot of nicotine. For Juul specifically, we know that anecdotally, some teens were using two or three pods. So that would be like two or three packs of cigarettes a day. So we're talking about very heavy nicotine addiction. And so all of those things combined led to sort of what you see in front of you, which is a National Youth Tobacco Survey that started asking about e-cigarettes in 2011. So that's that first dot on the far left. And then over time, the survey has changed to be a little bit more contemporary with what youth are calling these products. So they're not going to say, I use an e-cigarette, they'll say, I use Elf Bar or I Juul. And then in 2019, which is that big spike, is when we saw kind of the most aggressive advertising and marketing campaigns by Juul. And then in that year was where, if all of you guys probably remember better than I do, e-volley, e-cigarette or vaping-associated lung injury. There was a lot of media attention to that. At the same time, Tobacco 21 took effect, which is the federal law to increase the age of purchase, or sorry, the increase of sales of all tobacco products, including e-cigarettes. And we did see a drop. So this is where it's important for all of us in the room to remember that advocacy does work, legislative action does work. But unfortunately, dozens of people died from the e-volley epidemic, and hundreds and thousands were hospitalized. So in 2020 to 2021, obviously, there was COVID. And the NYTS, the National Youth Tobacco Survey, changed from in-school and in-person to online. And so the reason those lines are now dashed is that the CDC that puts out this survey basically says that it's really hard to extrapolate from year to year with that change in methodology. That being said, this is an FDA slide, so clearly we're doing it. But I think the most important thing is in 2022, we see that almost 17% of high school students are current tobacco users, so approximately one in five, and e-cigarettes are far and away the most common. And then we have cigars or cigarillos, those thin cigars that are, unfortunately, you can still find flavor. Cigarette use in adolescence, fortunately, is at a historic low, 2%. And then we have smokeless tobacco, still very common among rural white males, hookah, the nicotine pouches like Zen that you see, heated tobacco products, which is the I-Coast, that I Quit Ordinary Smoking, and then pipes. So as we start transitioning to what the health harms are of e-cigarette use, did want to just mention, you know, what are we talking about when we say tobacco product? Because this is also a very common question and very important when you think about your advocacy. Because right now, the FDA, Center for Tobacco Products, does have authority over all tobacco products. So of course, you know, there might be a teen or, you know, a patient that says, oh, I don't use a tobacco product. And in fact, I never ask, you know, if I'm screening, I don't ask, you know, do you use a tobacco product, because far and away, people will say no. But for us, in the room, we do need to know, because of the implications on regulation. So tobacco is a plant, I think everybody knows that, the leaves are processed for consumption, they're ground and put in cigarettes, the nicotine is used for e-cigarette liquid, it is the same nicotine that's used in Juul. And then, so, really quickly, though, we talked about Juul, it's a pod-based system, and it uses these nicotine salts. The nicotine is from the tobacco plant. And then, right now, I mentioned that disposable e-cigarettes are the most common. And one of the things that I do want to just mention is that Puff Bar, which is a very commonly used disposable e-cigarette, is using synthetic nicotine. And this was sort of a loophole, unfortunately, about regulation. But in 2022, Congress did close that loophole, that it is now also regulated by the FDA. So I'm going to finish just by saying that we know this is, you know, obviously a picture from Vape Hawaii, that adolescents are getting their e-cigarettes from lots of different sources. And one of them, this is an online advertisement, one of them, you know, that there's a significant loophole is online. So thank you very much. And I am going to, we're going to just take questions at the end, and have Dr. Bauer come up. All right. Hello. Thank you so much for the opportunity to talk to you guys today. I am going to be talking about the adverse effects of e-cigarette use in the pediatric population. As you can see, my name is Sarah Bauer, and I'm a pediatric pulmonologist at Riley Hospital for Children in Indianapolis, Indiana. I don't have anything to disclose. And over the next 12 to 15 minutes, we're going to be talking about the health effects of both using and being exposed to e-cigarettes and nicotine in the pediatric population, and hopefully give you guys some talking points and some information that you can use when you go out and advocate yourselves. Why do I advocate? I advocate for a lot of reasons. A few of them is I am a pediatrician, and part of that role is being a voice for my patients who are unable or can't speak for themselves. I also am a clinician, and while I love to deliver individual care to each of my patients, it's really nice to go out there and be able to make an impact on all of those upstream effects that are causing my patients to come into clinic, and just generally making the world a better place or attempting to do so. So e-cigarettes, as we kind of mentioned before, they contain four major parts, and each of these parts have been associated with adverse health effects. So you have the battery that can explode and cause burns and traumatic injuries. The metal that's part of the atomizer that heats up the e-liquid into that aerosol can degrade and has the potential to cause contaminates to be inhaled into the user. As I'll discuss in the next couple slides, the e-liquid that's part of the cartridge contains a lot of harmful chemicals and substances, and finally, the mouthpiece that's used by the user to inhale the aerosol has the potential to contribute to the spread of disease and illness as individuals share these products among one another. Like I said, e-liquids and aerosols contain a lot of really harmful substances, most of which you would never, ever want to put in your body, let alone inhale. Some of them are approved for ingestion, but when we're talking about e-cigarettes, we're talking about inhalation, and these products are not approved or proven to be safe for inhalation. Just some of the substances you can find in these, nicotine, which is poisonous and highly addictive, propylene glycol or glycerin can degrade into formaldehyde, again, something you don't want in your body. It's also used to de-ice commercial jet airplanes, which if you have a substance that that's powerful enough, like that's not something that I want to put in my body. Diacyl and 2,3-pentadiene, they've been associated with popcorn lung and bronchiolitis obliterans, and then a lot of other heavy metals and toxicants that, again, you really don't want to be putting in your lungs. And I think this is just a great example of how corrosive some of these flavors can be. So this experiment and picture was provided by Ilona Jaspers in her lab at UNC, and what they did is they took some cinnamon-flavored e-liquids, just put a couple drops in your standard plastic well dish, left it to chill, and in only two and a half hours, some of the plastic had actually corroded or completely dissolved. So again, if there's a substance that can dissolve plastic in two and a half hours, probably not the thing that we want to be putting in our lungs. As mentioned before, so e-valley or e-cigarette or vaping product use-associated lung injury was a really good example of the acute potential injuries that e-cigarettes can cause. So this was first described in a cohort of patients in Illinois and Michigan in the summer of 2019, in patients that presented with an unknown etiology for respiratory distress and respiratory failure, and the only thing that was common amongst all these patients were that they used e-cigarettes. This presentation was soon spread throughout the country in the coming months. Unfortunately, the CDC stopped collecting data in February of 2020, but at that time, over 2,800 cases had been reported to all 50 states, Washington, D.C., Puerto Rico, and the U.S. Virgin Islands. Over a half, a little over half were male. The median age was 24, and the range was all the way down to 13, up to 85. And if you look at that pie graph down there, a little over half of these cases were in kids that were, or young adults that were less than 25, with 15% being in patients that were less than 18. So kids that should have never been using these products to begin with. And then there were additionally 68 deaths reported, with a range of 15 to 75. The overall presentation of eValley presents very similar to any other virus, influenza, COVID, with cough, chest pain, shortness of breath. You can get abdominal symptoms, such as abdominal pain, nausea, vomiting, diarrhea. A lot of times these preceded the respiratory symptoms and then quickly resolved. Other presenting signs and symptoms, fatigue, fever, weight loss, tachycardia, tachypnea, hypoxemia. When you did the laboratory workup, sometimes you could see a serum leukocytosis. Often this had a neutrophil predominance, elevated inflammatory markers, mildly elevated liver enzymes. On imaging, sometimes if you caught it early enough, you may not see gross abnormalities, but these do eventually develop. So on chest X-ray, commonly it's bilateral opacities, and chest CT, commonly ground glass opacities with often subplural splaring. And these are just a couple other examples of how a chest CT may present in patients with eValley. The etiology and pathophysiology of eValley is still an area of ongoing research, but what we do know is that THC-containing products, particularly from informal sources, were most often linked to the cases, and vitamin E acetate was strongly linked to the eValley outbreak. However, the evidence is still not sufficient to rule out any other contribution of other chemicals. Amongst our pediatric population, eValley has been linked with bronchiectasis, HLH, macrophage activating syndrome, secondary pulmonary alveolar proteinosis, diffuse alveolar hemorrhage, and hemoptysis. Unfortunately, and to date, we still have very limited data on the long-term effects of eValley. There have been a few case reports and case series that have come out reporting the pre-discharge and follow-up lung functioning. Often spirometry tended to be abnormal before you left the hospital. Unfortunately, it was an obstructive defect with a decreased diffusion capacity. The data does suggest that pulmonary function, imaging, and respiratory symptoms resolve and improve over time and with discontinuation of these products. However, you can get a persistence and recurrence of the respiratory syndromes with return to vaping and e-cigarette use. And I can say anecdotally, I've seen this in my clinic as well as at least in our hospital. We had two or three cases of patients that came in with basically a second e-Valley, and they had all stopped, then returned to use of these products. Generally, there have been a lot of studies that have showed that e-cigarette use is associated with wheezing and asthma in adolescents. There's also a number of studies that say e-cigarette use is associated with cough and bronchitis in adolescents, and a number of other health risks or associations. So spontaneous pneumothorax, bronchiolitis of brethrens, a number of studies linking e-cigarette use with poor oral health. So periodontal disease, gum disease, bone loss around the teeth, permanent tooth loss from non-traumatic causes, and a study amongst adolescent e-cigarette users showed that you had increased odds of cracked or broken teeth, pain in the tongue, and or inside the cheek. And I think when you're talking to adolescents who maybe aren't thinking wholeheartedly about their lung function or long-term effects, I think this has always been a really great talking point for myself in clinic is, sure, but like, do you really want your smile to be all messed up? So kind of hitting hard on the like egotism of an adolescent mind. Another great talking point is previously sometimes e-cigarettes have been advertised as to help with sports performance, which is a huge lie. It does not help with sports performance. So trying to meet adolescents where they're at. And like I said, an increased risk of traumatic injuries and burns. As far as exposure, e-cigarette exposure is also associated with adverse health effects. So increased odds of reporting an asthma attack, shortness of breath. There was a study two years ago that looked at e-cigarette use during pregnancy, and it had an association for an increased prevalence of low birth weight. And as was mentioned before, nicotine just in these products, it's poison. So e-liquid nicotine can poison through ingestion or skin absorption. And children, especially young children, are really at risk for this unintentional exposure. Less than half a teaspoon of nicotine can be fatal to a toddler. And ingesting 1 to 4 milligrams of nicotine can be toxic to a child under 6 years of age. So a lot of those things that we were passing around, that one had 40 milligrams of nicotine, or 400, sorry, 400. So we're looking at multiple times over carrying around something that could kill a child in your pocket. So nicotine toxicity generally of any age can produce nausea, vomiting, abdominal pain, high blood pressure, tachycardia, seizures, respiratory failure, coma, and death. And unfortunately, calls to the poison control for exposure to these products has increased. There was a recent article from the MMWR that came out, and it showed calls to poison control centers from April 2022 to March 2023 related to e-cigarettes was nearly doubled compared to 2018. And if you look at those pie graphs below, that big chunk of green is calls relating to kids less than five. So really kids that are at increased risk of being accidentally exposed to these products. And again, nicotine is highly addictive and toxic to the developing brain. We know that 90% of adult smokers started using tobacco before the 18 years of age. And the early you start using nicotine containing products, the harder it is to quit and the stronger that addiction is. There was a study last year that showed that using or starting tobacco later in childhood, so this looked at kids that were nine, 10 years old, was associated with inferior cognitive performance and brain development. And then that was sustained over a two-year follow-up period. And adolescents are more likely to experiment with substances and they're more vulnerable to addiction. Again, the nicotine disrupts normal brain development and can prime behavioral susceptibility to drugs of abuse. And e-cigarettes themselves have been associated and shown to be an independent risk factor for cigarette smoking and associated with increased risk of future cigarette smoking and initiation in current cigarette smoking. And we have decades of data that shows that cigarette smoking is bad. It's also been e-cigarette use in adolescents have also been shown to be associated with increased likelihood of future cannabis use. And finally, e-cigarette use is associated with depressive symptoms, anxiety, and stress in adolescents. So the National Youth Tobacco Survey in 2021 showed that among middle school and high school current e-cigarette users, one of the most cited reasons for their current use was them feeling anxious, stressed, or depressed. So I think really hitting home, both also advocating for substance but mental health in that co-work together. So finally, in summary, e-cigarette use is associated with adverse health effects. E-cigarette exposure is associated with adverse health effects. Nicotine is highly toxic and addictive. In just flat out, children and adolescents should not be using or exposed to e-cigarette or other vaping products. Thank you so much. I'm going to pass the baton. Thank you, Dr. Bauer. Great. My name is Sucharita Kher. I am an associate professor at Tufts University School of Medicine. I'm thrilled to be here. Changing gears a little bit, I am an adult pulmonary and critical care physician, mainly taking care of folks greater than 18. So over the next 10, 12 minutes, I'm hoping that we'll talk about what the concept of health equity in tobacco means, to understand the racial and the ethnic disparities around electronic cigarette use, and then see what we've learned from the cigarette epidemic so far and how we can apply some of those lessons to the electronic cigarette epidemic with the goal to ultimately achieve health equity. So what is health equity in the tobacco context? So you might know this. Disparities are really differences in health outcomes based on somebody's experience of greater hardships. These hardships might come because of their lower socioeconomic status, their education level, race and ethnicity, disabilities, et cetera. And the bottom line here is that disparities are really unnecessary, and they should be avoidable, right? And if you look at the tobacco realm, disparities exist right from the time the entire spectrum. So right from the time who gets exposed to secondhand smoke exposure? Who starts smoking? Who continues to smoke? Who stops smoking? How much do they smoke? How do they stop smoking? And ultimately, all of these weave on to give rise to poor health outcomes for those who are exposed to these disparities. And the concept of tobacco-related health equity is really the opportunity for every person to live a life that is healthy, irrespective of whatever social factors that they may be exposed to. And so to achieve health equity, we really have to eliminate health disparities. And disparities in the tobacco realm were first discussed several years ago in 1998 by the then Surgeon General in this report. But really, before we know where to target, we need to know what these health disparities are. And so you might have seen this graph before. This shows the cigarette smoking rates over the last five to seven decades. Steady decline. We're thrilled at this. This is both for youth and for adults. But really, while this decline is very encouraging, it is not similar across all populations. And specific populations have a much steeper decline in smoking prevalence than others. And this is what I mean when I say this. So overall in the United States, about 12 out of every 100 adults smoke. And when you look at the number among black and white, it's higher. But if you look at those who are American Indians and Alaska Natives, this number is much higher. While the number is much lower among Asian and Hispanic population. And so if you look at the trends between 2011 to 2020, the adult prevalence and the estimated number of those who have smoked have actually gone down for white, black, and Hispanic adults, but actually have gone up for American Indians and Alaskan Natives. So I showed you data for cigarette smoking so far, combustible cigarettes. Just changing gears a little bit towards electronic cigarettes. About 4.5% of the adults use electronic cigarettes in the United States. This number is higher among whites and much lower and statistically significantly lower among black, Asian, and the Hispanic population. Going to our high school students. So when high school students are asked if they've ever used a vaping product, and by electronic vaping product, they club together a lot of the products that Dr. Wally showed earlier today. About one in three high school students said that they have ever tried. So this is experimentation, right? That's the time when kids want to experiment with things. This number was much higher among Hispanics, as outlined in this graph, and much lower, about 19% among Asian population. When asked if they use electronic vapor products every day, about 5% overall population of high school students said they do. Again, much higher in Native Hawaiians and other Pacific Islanders, white and multiracial, and much lower among Asian, black, and Hispanic population. This is the trend. So if you look at the trend between 2015 and 2021, among these demographic groups, black, white, Hispanic, Latino, and multiracial, there was a consistent increase in the prevalence of electronic cigarette use over those seven years. But if you look at Asian, not only was the overall prevalence low, that level was, there was actually no linear change, even though there was change in some of the other demographics. And so what this might highlight, these authors concluded, was that there might be social and cultural influences that perhaps might increase the risk of some populations using the product, but actually there might be social and cultural influences that actually might be protective of certain populations, and recognizing what those risk factors might be to increase the risk or to limit the use might be useful as we think about building youth tobacco prevention and cessation programs to address various needs of population. We heard from Dr. Bauer that electronic cigarettes are often gateways for adult smoking. A lot of people who use electronic cigarettes, youth who use electronic cigarettes become adult smokers. And we know this. This data shows this. So prior use of electronic cigarettes, cigars, as well as other tobacco products is significantly associated with subsequent initiation of cigarette use among people who've never used cigarettes in their lives, right? But if you break this down in stratified analysis, this data actually found racial and ethnic differences regarding which non-cigarette products were most strongly associated with youth cigarette initiation. So as you can see, the blue bars are the percent of cigarette initiation attributable to electronic cigarettes. Orange bars are the cigars, and then the gray bars are for other products. And among white and Hispanic youth, it's really the prior use of electronic cigarettes that's associated with cigarette initiation, while in black youth, it's mainly the use of cigars. And so the corollary or the implication of data like this, these authors reported, was that if our healthcare policies only target electronic cigarettes and leave cigars out of the picture, we actually have the potential of widening the disparities between white and black, for example, in this case. And it's not just race and ethnicity. There's tremendous amount of intersectionality between race and ethnicity, with race and socioeconomic status, race and education level, gender identity, sexual orientation. To give you some examples, sexual minority black girls were more likely to currently use electronic cigarettes compared to heterosexual black girls. Or a higher education attainment was inversely associated with the risk of electronic cigarette use among white, but that data did not pan out among black. And so there's a lot of intersectionality and tells you how complicated this new research data is coming out. And given the complexity of these disparities, there's really a need, especially as our population in the United States is getting more and more diverse. Remember, one in five people in the US speak a language other than English at home. And so we really need to have tools that are linguistically appropriate, culturally sensitive, and target to the person's literacy level, whether that's for youth, whether that's for an older adult. And so this is just an example of what I have used in my, a tool that I've used in my advocacy efforts in schools, or even with patients sometimes, from the Asian smokers quit line. We see a big Asian population in the institution that I work at. So in the last few minutes, I want to talk a little bit about what are the lessons that we've learned from decades of being in the cigarette epidemic, and how can we use some of those lessons to tackle the vaping epidemic now. And so I'm going to read this. Lopez and colleagues developed or wrote about this descriptive model of the cigarette epidemic in developed countries back in the 90s. And what they said was, in countries where tobacco companies first marketed their new product, cigarette smoking was promoted as a lifestyle choice for the rich and the powerful. In the United States and the UK, for example, it was affluent white men who took up the habit. Having and smoking cigarettes conveyed the economic and social privilege. When cigarette smoking became a widespread social practice, its symbolic value eventually declined. And today, smoking in high-income countries is a marker of social disadvantage, increasingly confined to areas and communities scarred by long-term employment, poor housing, and limited public services. So what else can we learn from the impact of tobacco or combustible cigarette-related disparities? Well, we know that people who are exposed to disparities have a higher tobacco use. They have higher secondhand smoke exposure. They experience higher costs of health care. And ultimately, what we'll all hear for, they have poorer health outcomes. And why do these disparities exist? You know, you heard about some of the marketing and the advertising that goes on. That started with the combustible cigarette epidemic and now continues to focus on the youth over the last several years by the tobacco companies. Flavors are there to entice. There was a flavored pineapple and mango flavor e-cigarette in that bag there that it took almost five minutes to get that smell off of my fingers after I touched it. And so menthol was the flavor in the past that cigarette companies really promoted. And we know that youth and young adults are more likely to try a menthol cigarette as their first cigarette. And those who try a menthol cigarette are more likely to continue smoking. We know that with combustible cigarettes, and now a lot of these fruity and candy-type flavors are sort of doing the same thing for the e-cigarette population. Then there are pressures of discrimination, poverty, and other social determinants of health that can increase tobacco. Certain populations need more protections, right? So we know that African-American young adults see more advertising and actually lower prices of products in their neighborhoods. People, for example, in public housing need more protections, specific protections with the form of policies. There may be barriers to accessing health care and tobacco-dependent treatment in the United States. It really depends on the state you live in and what you get covered for, for treatment, for tobacco dependence. And then all those several policies that do exist, they're not consistently adopted. They're not consistently enforced. And so how do we, knowing all of this, how do we achieve health equity, right? There really needs to be a triple-pronged approach, clinical, research, and then targeting policy. And so on the clinical side, we really need a diverse health care team. We know that patients who have congruent health care providers, if the health care providers looks and talks just the way they do, patient outcomes are better, adherence to treatment is better. Our teams need to be culturally competent. We need to standardize tobacco screening at every entry point that the patient touches the health care system. Our tools need to be linguistically and culturally appropriate. We need to have multilingual quit lines. There has to be an equity lens on the entire tobacco program, every aspect of it. And community engagement has to be key. On the research side, we have to encourage disparity-based research. Our researchers need to belong to various backgrounds. We need to have bias and DEI reduction training. And importantly, our subjects in our research projects, research studies, have to mimic the population that we serve. So minority participation is going to be key in really supporting our minority researchers. And then finally, from a policy standpoint, it's important to collect data from all the populations. There's tons of data that has come out, even in the last year, compared to when I prepared for this talk a year ago. Policies, whether it's a smoke-free policy, increasing the price of the taxes on tobacco, prohibiting marketing to vulnerable populations, flavor regulation, making sure that our patients have barrier-free access is all important. And I think most importantly is to include electronic cigarettes in all of these policies is going to be key to make a difference. So to take home, in summary, racial disparities in electronic cigarettes and vaping exist. They're complicated, and we're just learning a lot more about it in the last couple of years. Our healthcare communities, such as ours, should utilize the lessons learned from disparities in cigarette use and combustible cigarette use to tackle the electronic cigarette epidemic. And we really need a multipronged approach using clinical research and policy-related solutions to achieve health equity. And so I'm going to leave you, just as a segue to Dr. Stepp's talk, about why I advocate. I'm a mother. I'm a mother of two elementary school kids, soon to become middle and high school children over the next few years. I advocate because of my patients, because I don't want this whole new generation of under-18-year-old kids to ever have to see an adult pulmonologist later in life. And most of my advocacy, in the past, I have advocated through the Department of Public Health and the governor's office. But what I really enjoy and value most is going into schools, talking to children, talking to teachers, talking to parents. And we know that, from data, that when these conversations with kids happen with a trusted adult, compared to those kids who have not had these conversations with a trusted adult, the kids who've had the conversations with the trusted adults actually use a lot less substances, illicit substances, down the road than people who've not had. And so I think those are some of my reasons to advocate. So I'm going to pass it on back to Dr. Stepp to close us out. Thank you for your time. All right, everybody. You've made it this far. We'll take you to the finish line. So Evan Stepp, I'm a national Jewish adult pulmonary and critical care in Denver. And hopefully my three co-speakers have gotten you all fired up about all the terrible things that e-cigarettes can do, particularly to kids. And so I'll try to provide you a way to turn that energy into positive action. I have no disclosures. And why do I advocate? I just ask, who needs more of a voice? Is it, I just put the two of the biggest tobacco companies here who are swimming in giant piles of cash and have direct access to Congress, and trust me, every little city council meeting that discusses a flavor ban statute, I've encountered tobacco professionals there, too. So do they need a voice or do these kids need a voice? These are my kids, but they may as well be your kids or your grandkids or nephews or nieces or whoever, but they don't get a voice in this. They just get the potential burden of nicotine addiction kind of clouding over their entire generation. So that is why I got into this. So briefly, basic learning objectives. I want you to understand that you have an important voice. I also want you to understand how you can get involved and use that voice against big tobacco or big nicotine, I call it anymore. And just to make the obvious point that tobacco and nicotine products offer no known health benefit. So what's the problem? I'm going to try to summarize this last 45 minutes on one slide here, just to oversimplify the basic points. These products are extremely addictive. Big tobacco needs a new source of users because they managed to kill off a bunch of the others and then we advocated away the rest. These products are flavored to conceal high nicotine content. They're being used by vulnerable young brains that are easily influenced by these drugs, each other, social media, everything. We've got a poorly informed population that's getting mixed messages about these devices and many people think that they are safe. And we've also got racial, ethnic, LGBTQIA plus minorities that are specifically targeted and suffering from certain subsets of these products. Clear links to illness, it's one advantage these things have been around long enough now. We've had enough longitudinal studies, it's obvious that these actually make you sicker as well. It's a low bar to get over, hey, they're not as bad as combustible cigarettes, but they do make you sicker. And we've also got unused resources like parents, educators, and potentially you. So all this adds up to our next nicotine addicted generation. So to make the next obvious point, to me anyway, is that yes, you can make a difference. You know, this problem is a knowledge gap, really, to me, and we can't compete with mountains of money. I mean, our strength instead comes from the simple fact that we're on the right side of the argument. We just have to reach and teach one person or group at a time, which is why I'm so glad that you all are here. There might be some extra voices in that regard. So if you are getting fired up about this sort of thing, you can consider assessing your strengths in your current network. Are you an introvert? Are you an extrovert? Both have amazing strengths in this regard. Where are you in your career? Are you worried about your kids, your grandkids, nieces, nephews? And then if you're interested, you want to get informed. These are a bunch of free and curated, up-to-date resources that, and just a few to mention. There are many. But, you know, you can start with your notes from today, of course, but CDC, FDA, Truth Initiative, Tobacco-Free Kids, the Stanford Tobacco Prevention Toolkit. You can make presentations, interactive sessions, an entire course, a media campaign. All of that is kind of curated and they're just waiting to be plucked. So search around there, educate yourself, and consider what you might be able to do with it. And after you're kind of up to speed, you can consider what your target audience might be. Some might resonate or be more accessible to you than others. This is just a partial list here, but children and students, patients, parents, educational professionals, legislative bodies, and just et cetera. So I'll run through a couple of these in more detail. As I say, children and students are easy or interesting for you to reach out to. There are a lot of established organizations, of course, schools, Boy Scouts, churches. So that's, and there are, all of those organizations are generally going to have an intrinsic interest in the kids' health that they are kind of involved with. So it's pretty easy to get in the door there. Your patients, if you're a clinician, might be an easy thing to do. Of course, you have to ask about e-cigarettes. A lot of our dated intake forms just ask if you smoke. And then if they say yes, of course, you have to be prepared to discuss it. And one point I want to make to anybody that at least is not in England right now is that e-cigarettes are not a standard smoking cessation tool. They may well have a place. I use them sometimes in selected patients, just weighing the risks and the benefits of the alternatives. But it is a choice to try to weigh such highly nicotine-concentrated substances to trade even for combustible cigarettes. It is not a no-brainer. So that is something that I like to discourage. Moving on to parents, this is a very underutilized group for themselves, but also for their kids. They are just as misinformed about everybody else. They are trusted, though, and they can be reached, say, in clinic visits, whether you're an adult or a pediatric practitioner, or through, say, school district programs. I just want to highlight this study, Journal of Adolescent Health, a couple years ago, Do Parents Still Matter? The Impact of Parents and Peers on Adolescent Electronic Cigarette Use. And I'm just showing this table that is with a multivariable model demonstrating what made kids say, out of 176 e-cigarette-naive kids and parents, that's who this studied, what made that kid say, hey, man, I am less likely to use e-cigarettes because of this, this, or this. And the two strongest influences were the perception that their parents thought e-cigarettes were harmful, or that their peers, that's what the adolescent bit is, thought e-cigarettes were harmful. So these are hugely influential on those kids that we are most concerned about. And then, of course, you can consider going into schools, be it teachers, principals, or school boards. This is, generally speaking, kind of an easy audience with an implicit interest in children's health. You just have to convince them that these efforts are worth their time, because they got a lot of things to balance, of course. You should tell them that school bans work, and that's just not a panacea, but it's one part of things that can be relatively easy to implement, if hard to enforce. And then, also, there are many sources of validated free educational programs that can be woven into health education, or whatever. And this is just a few examples. The Real Cost Campaign, Catch.org, and the Stanford Tobacco Prevention Toolkit, again. These are just some studies, just a small selection, that demonstrate efficacy in schools, showing that kids that go through this, which might be an hour, twice a week, for three weeks, or something like that, come through the other end much better educated about e-cigarettes. And also, just as a case in point, we're all here. If you know more about it, you're just going to be less likely to use it, because you're like, oh, my god. So you can move all the way up to legislative bodies, of course. City councils, generally accessible to pretty much anybody. You live near one of these, and they may take up a flavor ban, or something like that, at some point. State legislatures, of course, are depending on your connections and network. Congress. This is a picture of me testifying at the State House in Colorado. And if this textbook introvert can do that, I'm sure that you can, too. This was a flavor ban. Unfortunately, I didn't make it. It was right before the pandemic. But it's going to have a second life here soon. Speaking of flavor bans, it's a good talking point to touch on. It's one point to make, is that kind of everybody wants to do it. Just to illustrate with this study in nicotine and tobacco research a couple years ago, who surveyed 2,700 parents of middle and high school students that were selected to be representative of the US population, they showed high rates of support for five specific tobacco control policies. And this even included current tobacco users. So it was kind of like, yeah, I do it, but I don't want my kid to do that. And fully three-quarters of parents, smokers or nonsmokers, supported a flavor ban. And this is partly why we get lots of municipalities, like in Colorado, Carbondale, and several other towns. And if you look at a map, they're scattered all over the country have passed flavor bans. But then when you kind of get to the bigger cities, like Denver, where our city council passed a flavor ban, but the mayor vetoed it because he's paid by you-know-who. So this is just another, live to fight another day, but illustrative in my local experience of what pretty much pans out in most places. Except New York, this is a good example, I think, to go through. This is published in Pediatrics two years ago, restricting the sale of electronic nicotine delivery system flavors. And I'll just very briefly mention that this started with years of adequacy and coordination of multiple groups that kind of worked their way to a T-21 law passed in 2018. But then it took one municipality here, and then it didn't work in some other place in Long Island, and then another one, and it kind of just had a ripple effect. And then within a year or two, it was a statewide flavor ban. So you don't have to blanket every single municipality, starting local works. And if you kind of just change the conversation there in the right way, you can expand. I'm very briefly going to mention tobacco endgame policies. This is just another thing that a lot of people don't necessarily hear about, but it's a completely different, it's kind of an end run around flavor bans and taxes and all these other things that you hear about in terms of trying to limit either just tobacco product use in general or accessibility to kids, say. This is a human rights-based approach where it's kind of like, hey, governments, you actually are responsible for the well-being of your citizens, and you let these products be sold that have no benefit at all and can kill people, and do kill people, in fact, kill most people, more than most other things. And so it's a legal kind of approach to try to take to getting around all of the other things that big tobacco throws up. So that's something you may hear about going forward. And this is another good time to mention that any policy that you might support that might limit access to nicotine in whatever form, I think you also have to consider supporting cessation resources as well, because you don't want to leave these people. It's not their fault they're addicted to this ridiculous substance. We've got to support them, too, if we're going to be trying to take things away. So how do you start? My last two slides here, you have nothing but options. I've mentioned a bunch of these already, and additional ones would include Youth Health Coalitions, local health departments, your ALA chapter is in every state, very well organized, local lobbying groups, of course, even your professional organizations, like CHESS has a Health Policy and Advocacy Committee, ATS has a Tobacco Action Committee. This is obviously of concern, and so if you're interested, ask around, get on a committee, start talking to people, and learn and network. That's what I've been doing over the last few years. And then just a couple of easy examples. Say you've got 60 minutes, and you want to make a school presentation to students. Well, go ahead and get some resources from those examples that I gave you several slides ago, and go make a presentation at a school. If you've only got 30 minutes, no problem. Get a list of approved e-cigarettes. It's short. It is way shorter than the list of things that you're going to see when you go to vape shops, and you can just go to the local convenience store and see how many unapproved products are being sold, and just report that on the FDA website. That's a couple of clicks away. So just a couple of examples. I hope that we've been able to share with you kind of the reasons why we are so concerned about this, and that you understand better how you can get involved yourself. Thank you so much for your attention.

e-cigarette epidemic

advocacy

addictive nature

targeted marketing

vulnerable populations

risks

educating children

advocating for policies

health equity

call to action