E-Cigarette Forum 051817

Nicole Aune: I think we’re going to go ahead and get started So, hello everybody Thank you all so much for coming out today, and we may have a few more trickling in, but, um, I just wanted to thank you guys for just taking time out of your evening to come here My name is Nicole Aune I am a program manager with the Montana Tobacco Use Prevention Program I oversee the policy and cessation work Um, and we’re really here today because there is a new product on the market and it’s really captured the attention of our youth and it is the most commonly used tobacco product among our high school students in Montana, and that’s E-cigarettes So there’s a lot of mis-information out there about E-cigarettes and, and it’s a confusing thing Um, there’s a lot of questions and, depending on who you talk to, you’re getting different answers So, we’re here today, um, to hopefully answer those questions for you and give you all the facts and information for you to go out and then talk to your kids and other young people about, about the facts and share this information with others We’re going to go into what we’re going to cover today, so we have some awesome speakers and we’re going to be covering what E-cigarettes are Um, looking at how many, how many kids in Montana are actually using them The appeals The why are kids actually using these products Why, why are they so into them, and the health dangers that, the health risks associated with E-cigarettes Um, and we’re also going to talk about how the tobacco industry targets kids with these products, and then mention what you can do And we have an excellent line-up of speakers Kris Minard: All right So Nicole mentioned this is mostly for adults right now, although it’s very important kids know about this too But this particular um, presentation is, is geared for you We’ll talk about Montana youth trends and um, let you know more about what electronic cigarettes are, their appeal to youth and then what’s actually in the E Juice Every time we give a presentation we have to remind people we’re talking about tobacco products and tobacco is still the leading cause of preventable death in the United States, killing almost a half a million people every year, which is the same as three fully-loaded 747’s crashing every day, with no survivors So, if something like that happened, I think people would really take up, take notice and we, we need to remember we still have a lot of, we’ve done some great work on tobacco, but we have a long way to go So, as far as Montana youth trends go, we have great data, stretching back into the early 90’s from the Montana Youth Risk Behavior Survey Our high school students are asked every other year, um, about their risky behaviors and how much they participate in them And, as you can see, these are the kids who say they have every tried smoking cigarettes, even one or two puffs We’ve got a nice trend down from the 90’s We’re at about 39% of our high school students who say they’ve even tried using tobacco These are the students we call current users The CDC says if a student responds that they’ve smoked a cigarette in the last 30 days, then we’re going to call them current users A lot of people might think that Montana has more smokers on average than the rest of the country, but our, our students have really much um, kept up with the national average all through these last 20+ years However, you can see in 2015, 13% of our high school students say they smoked cigarettes and only 11% um, in the nation said they are, so we are above the national average there Then we’ve got these guys, these fruity-flavored, cheap, inexpensive um, cigars, cigarillos, that are kids have, have noticed and, and started using We are well above the national average at about 13% compared to 10 Still a little bit of a decline, but nothing like, you know, it hasn’t been as high as the cigarette use, but it’s right at 12.6%, which is pretty, I mean, they’re both basically 13% Here’s where we stand out Our smokeless tobacco Still 12% of our high school students say they use smokeless, um, snoose, chew, and ah, compared to the national average of 7.3%, so our high school boys are huge users One in five of our high school boys report using smokeless tobacco,

fourth highest prevalence of use in the country Our girls also have the fourth highest prevalence of use, but it’s at a much lower um, prevalence, 4.5% So here are all three of the traditional tobacco products You can see they’re all at about the same level in 2015 So now we have these guys, these electronic cigarettes Well, they all basically deliver nicotine There are a very few that don’t have some of the E Juice, has zero nicotine in it, but by far most deliver nicotine and they almost all have lithium Well, I don’t know any that don’t have a lithium battery They look like lots of different things Some look like cigarettes Some look like marking pens The one on the right, I say kind of looks like a mini lunar lander, and they’re just constantly changing These things are evolving practically daily We also have um, electronic cigarettes we call mods that, these are the products that people typically drip the E-Juice into and they create the great big huge, we say vapor and vaping, but it’s really not a vapor, it’s an aerosol There are tiny particles of metals and, and it’s actually an aerosol You can see someone even ingeniously made a E-cigarette out of a Coke can But they all basically have a mouth piece and someplace to put the E-Juice, whether it’s already contained and in a cartomizer or if it’s a tank that you have to fill, or if it’s an atomizer that you drip onto a cotton swab with E-Juice Then they have the heating element, which is the atomizer which heats up, so there’s no combustion as with cigarettes There’s nothing burning It just heats up it and creates this, this aerosol in the lithium battery Here’s a video that NJOY has for anybody to watch on the Internet about how to vape (Video) This is NJOY’s vape pen You picked it up off the shelf or got it in the mail, but it might be intimidating No worries We’re here to help If you’re ready to vape watch on Part One: Assembling the Vape Pen First, you’re going to need a bottle of E Liquid, like this You can buy NJOY E Liquid wherever you purchased your vape pen Next, make sure the battery is detached from the tank Don’t try to fill the tank with E Liquid when it’s attached to the battery Unscrew the mouthpiece from the tank Open your E Liquid NJOY E Liquids are in bottles with child resistant caps So to open it, you’ll need to push down on the cap as you turn it You don’t want E Liquid in the center tube So when you fill your tank, tilt it and drip the E Liquid down the side You can check the milliliter amount by the markings on the side of the tank Remember to keep E Liquid away from your skin If you happen to get some E Liquid on your hands, make sure to wash them immediately We also recommend that you have different tanks for different flavors of E Liquid and that you discard any tank after about two weeks of regular use, depending on how you vape Changing your tank will assure that your vapor always tastes great Once you fill the tank, screw the mouthpiece back on Make sure the mouthpiece is on tight, then screw the tank on to the battery piece Now you’re ready to vape Part Two: How to Vape Your pen comes activated right out of the box To deactivate your vape or to reactivate it, quickly press the button five times in a row like this The LED light flashes five times when your vape pen changes state When your vape is activated, put your lips to the mouthpiece Inhale as you press the button, and just like that you’re vaping Part Three: Charging The LED light will flash 10 times during use when you need to charge your vape pen To charge, simply unscrew the battery from the tank and into the USB charger To preserve the battery, don’t charge it in a place that’s too hot or too cold You’ll know it’s charged when the LED light goes off Kris Minard: Anything, time for a little audience interaction Anything kind of catch you off guard on, on that one? Anything kind of noticeable? __: Wash your hands KM: (Laughter) If you get any of this E Juice on your hands, wash them immediately It’s okay to inhale it into your lungs, but by golly, if you get it on your hands, wash it off Well, nicotine absorbs through everything and um, Dr Shepard will talk to us more about the effects of nicotine All right, um, gimmicks, there are lots of gimmicks The industry, the tobacco industry has had gimmicks for years Coupons and products, give aways and things like this, and make no mistake, the tobacco industry is invested in electronic cigarettes

Yes, there are mom and pop vape shops, but RJ Reynolds, Phillip Morris, Lorillard are all into, into these products blu is one that you may have seen ads for on T.V These are what they call the starter kits, and this particular thing costs about $75.00 a couple of years ago I don’t know what they cost now I would think that the price has gone down They look like a cigarette They charge right in these cases and their gimmick is each case has a little wireless transistor radio in it, a radio wave, that if you turn this on, this is, this it’ll, this is what it will do If you’re within 50 feet of another person who has one of these So they want you to know who’s around, who can you go buddy up with, turn it into a social experience again, and um, find somebody, you know, there’s somebody around who’s using this Let’s find out who they are They also do this if they’re within 50 feet of a place that sells the refill cartridges So, that’s their, that’s their gimmick on, on these The I Phone case It’s all set up It’s got it’s own battery and ah, I think this is for ah, I’m not sure, I think it was an I Phone 5, but it’s got a mouthpiece You can screw your own mouthpiece into the top and, and vape away Green Smoke They want to appeal to the environmentally conscious folks Our landfills are being filled by these batteries, these empty cartridges You know, a lot of really bad toxins and, and pollutants So they say, send us your old products and for every 50 old cartridges or old lithium batteries, whatever you send us, we’ll give you so many points to buy our products So it never ends Ah, this woman is going to show you how to use blu and a couple of the, of the other products (Video) Um, and this is a blu disposable We’re going to pull the little seal off of here Pull the little rubber cap off and puff That’s it, nice and simple Now the blu starter kit has um, two batteries, five cartomizers and a charger These are re-changeable Um, this same concept Screw the closed cartomizer Everything you need is mixed up in here already Screw it on and again puff Nice and simple Another company we carry Smoke Stick, same, same principle We have a disposable You have an E, the starter kit Again, screw it on That, as you can tell, is a little bit more vapor than the blu gave me Kris Minard: So she had a lot of quick hits of nicotine right there and you can tell she kind of liked that Smoke Stick brand, because it created a little bit more, more vapor Um, we’ll talk a little bit about these mods Um, the people build these themselves, and you can learn all about them on the Internet There are people who have their own YouTube channels that show you how to create these things, and they take great pride in creating the coils, and how many, how many turns and twists you have in them, um, relative to how many ohms it’s going to produce, and you want to heat it up just It’s all supposed to be red when it heats up and you put the cotton wick between it and that’s what you pour the E Juice onto This is an RDA, re-build able dripping atomizer, and this is a mod that has fully computerized This whole set costs about $140.00 here locally The battery is another $80.00 I did not purchase it, and you can set it to all sorts of different levels to decide how hot you want it to get, how much vapor your, how much aerosol you want to create, and, um, all these little buttons help you We’ll just pass this stuff around so you all can, can look at it There’s a great tobacco prevention specialist out, out east who told me, she likes to put things in pencil kits and pass them around and see if people can figure out what’s really a pencil and a marker, and what’s really a, an E-cigarette, and I said that is a great idea So I copied her and it’s pretty impressive Take a look through this pencil kit, see if you can pick out the E-cigarettes

This is the fellow who’s got one of the YouTube stations or channels and he’s got over four million views on, they call them clouds making this big huge cloud with a, with a mod So now let’s talk about teen vaping and why, why our kids are so, so interested in them The 2015 Youth Risk Behavior for their first time asked the question, “Have you ever tried an electronic cigarette and in the last 30 days how many times have you used one?” And you can see by the description they couldn’t just say an E-cigarette, they had to define it so that the kids would know what they’re talking about, because they’re called so many different things I mean now you might just hear the word vapes, um, but the responses in Montana really caught us off guard and we were alarmed Fifty-one percent of our high school students said they tried them compared to 45% in the rest of the country, which is also huge This is what the percentage of people, the high school students who have tried them, broken down by male and female, so not a big difference between the two Boys typically have riskier behavior than girls, but you can see it increases with grade level A, every year you have more kids using these products And granted by 12th grade, some people are 18 There’s no question It would not be illegal for them Another reason, as Nicole has pointed out, why it would be great to have 21 be the age for using tobacco There would be no question There are no 21 year olds in high school Not in Montana They don’t fund them Okay And this is a question of whether they’re current users Have they used one in the last 30 days So 30% of our high school students said they were current users Almost one in three And here’s that breakdown Same, same thing Male/female Pretty close to the same, but still more boys, and again the same kind of transition from nine through twelfth grade, increasing each, each grade level So here are the three traditional tobacco products and then the E-cigarettes in green It’s kind of a visual deal that boy, twice as many kids, more than twice as many kids are using this product and are smoking So anybody who tells you, oh it’s just the kids who are smokers who are using this product, that’s not true, and this shows you that Here’s a breakdown by groups Um, the state averages of cigarette smokers and vapers, um, on the left and then some of our middle schools actually take the very same Youth Risk Behavior Survey, so those that do have showed us that, wow, twice as many middle school students are vaping as are smoking NAR, our Native Americans on a reservation, so that is the only group who are smoking cigarettes is still higher than vaping, but, but not much NAU, our Native American’s in an urban setting, big difference NPA, Non-Public Accredited schools A lot of your private religious schools, um, like Central in Butte, Central in Billings ALT, those are alternative schools That’s where our risk takers are and we know that there are huge issues there, and we’ve got a few projects that we’re working on, but boy we, we need to do a lot of work there SWD, our Students With Disabilities So they’re attracting all, all users Yale had a great study a few years ago, where they asked 5,400 young people who did vape, what’s cool about it? What do they think makes them cool? They were not surprised by the answer, the flavors We’ve all seen and heard, and you’re going to hear more from Sara tonight about the flavors, but they were taken back by the fact that kids said we can do vape tricks with them So vape tricks We’re going to show issue, show you a few videos from on-line about what they’re doing with these products (Video) What’s up guys I’m ________ We’re here at Flawless Vape Shop in Anaheim Hills, California for the 8th Trick Qualified __________________________

(Music) Ricky was sad He just won the 8th Trick Qualifier for the BC Cog Championship How do you feel? I’m stoked Still a little nervous? Yeah (Laughter) What did you do to prepare for this competition? I vape every day because I work in a vape shop, so What vape shop do you work at? Vaper Hub P_______ Okay Would you like to thank any of your sponsors today? Of course Got to thank LindaLace, Good Vibes, Vape Socks, Native Wakes of course, you know Good Vibes is my sponsor too Good Vibes is awesome (Laughter) So before you go, ah, do a signature trick for us Kris Minard: Um, anything catch you off guard? Anything kind of impressed you with that? __: The sponsorships KM: Sponsorships They have sponsors It’s like NASCAR and these are young kids I mean, he, he was probably 18 or 20 To me he looked like he was 16 or so, but he said he vaped every day I mean, what is he doing to his lungs You have to practice a lot to, ah, when you see the next ones you’ll, you’ll be impressed (Video) Kris Minard: I just wanted to show you that girls are doing this as we know How’d you like to be the little brother pushed through the aerosol there? The last one is the, oh __: ________________ Is there an odor to it? Kris Minard: There is a slight odor to it, but that’s a really good question because someone asked last night, are they using marijuana in these things? And they are, they are __: Something like for the feel um, my parents said on the clothing Kris Minard: Oh, can’t smell the clothing, right Definitely not like tobacco There, there is an odor, but the thing about marijuana, is if they are using marijuana, there is no distinctive marijuana odor with these, so someone could be vaping pot right in front of you, um, and you wouldn’t know it So, but, but, they say there is not much of an odor with these, but I have smelled bubble gum I have smelled some of the flavors, when we have done some experiments with, with bottles Um, oh yeah, this, this guy, I think this is the one that use Oh, you’ll want to go back and then that one is a video This guy is a real professional (Video) Kris Minard: So, you can see There’s a challenge to them There’s a competition Um, this guy won $10,000, making as big of a cloud as he could possibly could So, there are competitions all around the country I’ve not heard of any in Montana, but you know how we are, a little bit behind other states sometimes on things We’ll hope, we’ll hope that we don’t get any here, but there’s money, there’s challenge and kids get good at it They take pride in it and who knows what they’re doing to their lungs So, we often hear well it’s just a harmless water vaper Well, it’s really not In fact, there isn’t water in these things The three main ingredients are propylene glycol, which is something that we use in the theatre in fog machines, and it’s generally recognized as safe as an edible, um, chemical But that doesn’t mean that it’s safe for our, for our lungs You know, eating something and inhaling something are totally different I often say it’s okay to eat a peanut, but if you inhale a peanut, you’re in trouble

The flavorings are another thing that’s typically in, in the E Juice and nicotine Um, and these have not been regulated by the FDA, so some have been found to contain all sorts of carcinogens as well as other toxic chemicals Um, the carcinogens on the left, Acetaldehyde, Benzene, Formaldehyde is created as the E-cigarette heats up and, and, so it’s actually the heating of the E Juice that creates the Formaldehyde Nickel, Nitrosamines, um, and then other toxins, other irritants A Diacetyl is an ingredient that has added to the flavorings to help make the flavorings work better And you may have heard of popcorn lung People who were working in microwave popcorn factories were getting this irreversible lung disease, and they finally figured out it was from the Diacetyl Well, Diacetyl is in a lot of E Juice I have, I always say if you have to dress like this to work with this product and develop this product in a hazemat suit, then why on earth would anybody want to be putting it into their lungs? Congress did pass a Child Nicotine Prevention Act because a teaspoon can kill a child In fact, there was a young toddler who died just before Christmas a couple of years ago He got into his parent’s E Juice, so, um, now they do have to have child-resistant tops Poison Control Center calls have grown exponentially In 2014 they increased from one a month to 215 a month for exposure to, to nicotine These, this is a little bit deceiving because the 2015 and 2016 data isn’t complete on this I’ve been looking for better, updated charts, but, um, it’s been a major increase for Poison Center Control calls And then you also heard about these exploding lithium batteries Um, the industry will tell you, oh it’s user error You know, it’s always user error, but I read an article about a man who opened a package and it blew up You know, he wasn’t even using them We have a, had a young student in Missoula who was vaping and ended up losing four teeth and I really, I mean that was a very traumatic experience He had a really hard time getting back to school I mean, you can imagine It caused a fire on the couch he was sitting on So, not good This is an example Watch the guy standing at the counter on the right (Video) Kris Minard: Huge vap, you know plume of, of aerosol and he had to take off his pants and you, you saw the burns ahead of time So that’s the end of my presentation and we have an, um, question and answer session So if you have some questions, we’ll do that at, at the very end But thanks a lot for coming and thanks for listening, and if I can help you in any way, let me know Dr. Kathy Rogers: Research suggests that compared to adults, teens value reward more than consequence And we kind of all know that, but that is really an integral part of brain development in adolescents It is part of what gets them to grow up and leave home To go on the adventure of leaving the security of a household where somebody feeds them and clothes them, and takes care of their needs, and goes out to where they’re going to have to figure it out And so it’s, it’s an important part of development, but it is also is what makes them take the risks that they do Brain development takes a long time, sort of from age 12 to age 25 And so at 18 and 19, when these kids legally can do a lot of things, they still don’t have a very mature brain They think they do and if you think back, you thought you did And then you got a little older and you realized your parents were not nearly as stupid as you thought they were And we hear that said all the time, but it really is true and there’s no way to explain it as we grow up You can say it to your kids and they nod and think you’re full of it, but it’s really the truth So it, brain maturation moves in really slow waves It starts at the base of your brain and kind of moves forward in very basic functions, so it starts with your vision, what you see, and then movement, and then fundamentally how you process things The more complicated executive functions So this front part of your brain, which is the last part that really puts together, if I jump off of this very tall building, I may break

my legs And the other part of it says, yeah, but won’t it be really cool if I don’t That part takes a long time to come together, and so there’s all these different parts of the brain that you’re going to hear talked about as, as more of the issues of brain development go on You’re going to hear them talk about your hippocampus, which is part of your memory The frontal areas set goals They weigh agendas and risk and that frontal part is really important Um, head injuries, a lot of frontal injuries impact how well we do our executive functions and this is sort of a side comment, but the whole business of concussion relates to what happens when you’re constantly impacting that frontal area, which becomes your consequence setting goals, agenda, risk assessment area Um, so ultimately development allows us to balance our impulse and desire and our self interest and put that together with ethics and rules, and to put all of that together But it takes time and you can have a kid who will say, I know I shouldn’t, but they still will until they get on the other side of that fence If you think of teen decision making like an equation, where consequences aren’t given the weight they should be, rewards weigh more heavily than they should, and where being friends throws the equation off any more So that plastic part of your brain really looks at thrill seeking, risk taking, and I don’t have a graph to show you, but when you look at higher risk and lower risk and then age, the ones who enjoy it the most are 16 to 17 year olds They just, that high risk is like a really good reward, and it’s interesting because at 18 and 21 it starts to drop, but it doesn’t get down to a level less than when you’re 10 years old till you’re 26 years old So, there’s a long time where that is all really important Most long-term drug use, alcohol, tobacco, nicotine, starts in adolescence And we all recognize that Teens do know they’re mortal They can estimate risk, often over-estimating risk They simply value the reward so much more heavily and the more risk they take, if the reward is good, is perceived as a better payout And what helps them add to the risk? Doing something with their friends So when you look at kids who are learning to drive, there’s lots of good valid studies that show If you put a kid in a car with an adult, their parent, they will drive beautifully They take Driver’s Ed, they do really well, and as long as they are in the car with the adult, they’re great You put one person in the car their age and all of a sudden they run through the red light You put two or three kids in the car with them and suddenly it’s what can we do? Where can we race? Why? Because there’s this huge reward of doing these things, taking these risks with their friends So, when you’re looking at kids related to cigarette smoking, vaping, it’s the same thing And so one of the key questions I always ask kids when I’m interviewing them, is do any of your friends vape? Because if you ask them directly, you may or may not get a straight answer, but they don’t have any problem telling you if their friends do And that’s a really good way to kind of come in through the back door when you want to find out what’s going on Because if their friends are vaping, you can bet that for them it’s a greater opportunity, even if they think they’re only going to do it once So, what their friends do does make a really big difference Now, this time of taking all these risks is important They need to do this It doesn’t make them obnoxious, although sometimes it feels like it does when you’re the parent Um, but that’s partly again what gets them to learn how to be independent and on their own So adolescence brings a peak in brain sensitivity to dopamine, which is a neurotransmitter, that kind of primes you for reward And it fires off the reward circuits So anything that improves and effects dopamine is something that they like, and nicotine will effect that as does marijuana and so these sort of spark that area and kids go, oh that felt good And feeling good is something you want to do Believe it or not, texting fires off that part of your brain, which is why those ridiculous texts of what’ch doing Not much Where’re you going to be? Not sure And yet they’re just addicted to it They literally fire off that little bit of dopamine over and over

again, which is a little pleasure center Um, for those of you are old enough, if you remember what it was like to get a letter in the mail and you would wait for the mailman to come It’s the same thing It just didn’t happen every five seconds So that’s part of the difficulty and again, anything that will allow them to get there Teen brains, neuro networks are being pruned, and so they’re still in that developmental phase And it’s really interesting, teens prefer teens So the things you say do make a difference, but they search out their friends and that’s, those people are their investment in the future They’re not going to spend their life living with you You guys are their mentors/directors, but they know you and you’re not exciting any more Their friends are exciting and that’s where they want to be So again, who they spend time with and we’re back to, what makes me feel good? What’s exciting? Um, you guys have the statistics and will probably go over them, so I’m not going to take about the percentages of kids who are using E-cigarettes But what I will tell you is, for child, for kids, it’s not a reduction of harm They use E-cigarettes and they talk about it for adults as a reduction of harm, getting them off of cigarettes It doesn’t do that for kids It becomes the gateway It addicts them to nicotine, and we know from both human studies and mouse models, that at the developmental point in your brain that you are when you’re a teen, your brain is more plastic and nicodine, nicotine is far more addicting We don’t know why We just know it is And it’s that developmental phase We also know that the various products like nicotine and marijuana at that stage long term will affect brain function So when you were talking about the different products that are in there So nicotine poisoning, what does it look like? Vomiting, sweating, dizziness, increased heart rate, lethargy, seizures, breathing difficulty, um, it’s a neural stimulant at low doses, but at high doses it’s a depressant, and it really gets them into trouble A couple of things that you need to know and that parents should share with each other; anti smoking actions by parents are a strong predictor of non-smoking in teens Anti tobacco opinions, anti vaping opinions and discussions with parents are factors that protect kids against tobacco, even if a parents smokes So even if you’re a parent who does smoke, the very fact that you say no, makes a huge difference The bottom line is, is that you want to make the risk and the reward enough like the reward for not doing this, greater than the reward for doing it, and because nicotine’s so addicting, you’ve got to find ways to sort of them, it’s like the toddler thing You have to distract them over here You keep them busy with other things that are rewarding and fun for them whether it’s school or trips with friends that you get to help plan and organize But it’s pretty basic and it’s pretty simple and I can go through all of the neurochemistry and, and all of the brain development doesn’t mean anything The bottom line is, they like what feels good and what you have to do is find things that make them feel better and make it new and exciting and just sort of distract them until their brain gets to that point and then you also make it clear that this isn’t something that you want them to do But that’s not what you harp on all the time You just do the distraction That’s my line Dr. Robert Shepard: Um, all right I entitled this Nicotine, Safe or Dangerous because I was up at the Legislature trying to get them to increase the tobacco tax, the bill supported by the Governor and Cancer Society and Heart Association, to increase the tobacco tax and ah, they were going to include E-cigarettes on that increase, and actually I was flabbergasted, is the best way to put it, at some of the claims that were made by the E-cigarette proponents about the safety of E-cigarettes and the safety of nicotine So, since nicotine is the predominant ingredient in all of the E-cigarette liquids that are set out, I wanted to talk a little bit

tonight about nicotine Now, before we get to there, we can talk about tobacco and several different oranis, several different kind of categories Obviously, there’s combustible tobacco, cigarettes, cigars, pipes, and those, those things have a completely different of chemistry After all, they’re, they’re burning, they’re burning at a very low temperature really, so they create all kinds of chemicals that get into the air, and that creates all the second-hand smoke and other stuff which is the primary motivation for second-hand smoke laws Ah, but we’re not going to really talk about combustible tobacco tonight You’ve got your various forms of spit tobacco I like to refer to it as spit tobacco to make sure that it’s overly glamorized Um, but in any case, you’ve got the various forms of spit tobacco and they also have their own set of chemicals, but they’re not heated They have chemicals that also that occur a lot during the curing process from the way the tobacco industry cures it, which creates a lot of extra stuff in the, in the leaf beyond just the tobacco plant And then lastly we have the E-cigarettes which you’ve heard about it, and they’re not really combustible, but they’re not exactly like ah, non-combustible chewing tobacco products because they are heated, and that also has a potential to create different chemicals Um, so, and I want to focus a little bit on nicotine now because, 90, somewhere around 97, 99% of all E-cigarette capsules and liquids that are sold are sold with nicotine in them So they talk about all the other stuff that goes on, but it really has to do with the nicotine So, is nicotine safe? Is it beneficial? Is it addictive? So let’s kind of explore some of that First of all, there, the way the body works is most of the cells in our body have little tiny receptors on them You can consider the receptive would be a lock A molecule, a chemical will come by and insert itself into that lock and that creates, causes the cell to do something That’s the way hormones work, whether they’re thyroid hormones or testosterone or estrogen or any of the other, you know, cortisone, any of the other, ah, hormones around the body all work by attaching to a receptor on a cell And each cell will have tens of thousands of receptors on it It’s hard to believe something so small can have that many receptors and there will be dozens of different kinds of receptors on every cell Some of these receptors then in the body are triggered by nicotine That’s how nicotine does what it does So nicotine will glom on to, you know, insert itself as a key into that lock and then tell the cell to do something And they’re really high in concentration in the brain, which should come as no surprise Secondly, there are a lot in the lungs and there’s, one important thing is that there are an awful lot in the lining of the arteries, what we call the endothelium That’s a lining of the arteries, incredibly important for the arteries being able to dilate and contract, and also important because when the lining gets torn or injured, cholesterol then leaks into the wall of the artery and that begins the plaque formation, ah, of heart disease And nicotine has profound impacts on that So there are impacts on the way the cell functions If you’re looking at an embryo that’s developing, these receptors will trigger development in different ways and consequently their impacts on the way the body develops as a result of that Ah, and this particularly in the brain impairs the development of neurons So as we are adding neurons as the fetus is growing it’s brain, it’s going to end up with fewer neurons in the brain because of nicotine exposure during pregnancy Now, how do we know all this? Well, there are lots of different ways that we know this First of all, there’s studies of animals that we can, we particularly use a lot of rats and mice in these kinds of studies They’re small, they grow quickly and we can study them a lot faster We also use primates, various kinds of monkeys and, and stuff in that Also we can know because we can look at systems in humans that are really vulnerable Systems like in pregnancy, where we have a growing, the fetus and the, that system is very very vulnerable to affects, so we can look for these sorts of things, ah, in that area We can also just grow the cells in a lab in a cell culture and then expose them to these products and see what impact it has on individual cells And there are not just multiple studies, but we’re talking about thousands of studies about the impact of nicotine studied through all these different systems Now, the nicotine system in the brain, the nicotine receptors in the

brain, have impacts on memory, how well we think, how well we focus our attention, and also on emotional responses Now, some people think that in adults, I’m going to say that again, in adults, nicotine might slightly enhance our memory, our ability to think and our ability to focus There are no good human studies that prove that that’s the case None When I was up at the state they were talking about the study in Discover Magazine, I like Discover Magazine I read it cover to cover every month when it comes out, and there was this highly speculative article about the im, the positive impact nicotine might have on the adult brain And it says right in the center of the article, there are no studies that show that this is true And yet, this, this journalist was making this great case for how wonderful nicotine was going to be on our brains Well, it ain’t true Well, at least it’s not been proven true yet However, when we are talking about a developing brain, again we’re talking about fetuses, infants, toddlers, and we’re also talking about adolescents as we hit, hit that period of time when that judgment part of our brain between 15 and 25, when we develop judgment in our frontal cortex, that presence of nicotine changes the way the brain develops, and that’s not a good thing So there are fewer nerve cells, some of the nerve cells are damaged There are fewer connections between the nerve cells and there’s all kind of changes in the brain chemistry Nicotine is a very powerful stimulant of the dopamine system Dopamine is our pleasure reward system When you get dopamine you feel good There are all kinds of things that give us dopamine Nicotine is one of them So, what about the fetus? Well, nicotine crosses the placenta There are more nicotine receptors in a developing brain because the body uses those receptors to guide the development, but when you add a bunch of nicotine to that and over-stimulate those receptors, you end up with some brain cells dying and some brain cells getting malformed and the number of some brain cells not forming the connections to other brain cells that they’re supposed to have We know in human studies we haven’t really been able to check this because for obvious ethical reasons, you’re not going to take 1,000 women and say you get to take the nicotine and take another 1,000 women and say you don’t get to take any nicotine, and see what happens to the baby Nobody is going to do a study like that But, we have seen what happens in smokeless tobacco from the nicotine We’ve done lots and lots of studies on animals to see how the brain develops in animals, and what we can see is there’s a real strong correlation between the affects of nicotine and the effects we see on human studies that are using nicotine, in human subjects that are using nicotine as well So in other words, they’re consistent with each other Now, let’s talk about one other thing here for a second and that is, what do you do about nicotine in pregnancy and nicotine replacement? And how do you get women to quit? Well, first of all 40 women who are pregnant, 40% of women who are pregnancy find that to be a powerful motivator and they will in fact quit smoking An unstressingly amount of them will go back to smoking once the baby’s born, which doesn’t help the baby a whole lot either, but they will quit during pregnancy Nicotine replacement therapy has been something that medicine has used a long time to help people quit smoking, but both ACOG and the FDA say that’s a last choice in pregnancy, because we just don’t want to expose the fetus to nicotine Well, what about harm reduction The concept is here that perhaps if we do something that’s less dangerous, there will be fewer people that are hurt by it So, if we move people from tobacco to pure nicotine like in an E-cigarette that that’s going to be good for them I just want to point out that the lowest possible risk is from quitting nicotine all together At that point, you’ve reduced your risk to zero in terms of the nicotine So E-cigarette are counted as great because they’re going to reduce the harm But what happens with the 40% of women who successfully quit smoking, instead switch to E-cigarettes and still get the nicotine? I would just suggest that that’s not going to be helpful for their baby and this case the harm reduction isn’t really going to be a harm

reduction at all So, this is just theoretical again This is smokeless tobacco again, because we don’t have studies on E-cigarettes yet, but several studies, and I’ve just given you some quotes from a couple of them, have looked at the impact and what we see is the impact on fetal exposure mirrors what we see in animals, including adverse behavioral outcome, such as attention deficit disorders, disruptive behavioral disorders and other things that we all struggle with in the school system today And, I’m not going to spend much time but I just do want to mention that nicotine has an impact The receptors alone decrease the number of lung cells along size and volume, the lungs become less elastic and impacts the lungs too Okay, are there any studies then on children with E-cigarettes? And the answer is no, not yet But we’ve looked at this and second-hand smoke a lot, and we know that children who are exposed to second-hand smoke at the home, in the home have more difficulty with reading and arithmatic comprehension Their school test scores are lower, ah, and, so we know that there are effects from, from that We aren’t absolutely certain that’s just the nicotine, but it’s certainly consistent with pure nicotine research in animals There is also a concept called third-hand smoke and third-hand smoke is what’s left after the second-hand smoke dissipates So you smoke a cigarette in a room, the smoker gets the primary smoke, everybody else in the room gets the second-hand smoke that’s just out in the room When the smoking stops, what happens to the smoke? Well, it goes some place Some of it’s absorbed onto the walls, onto the ceiling Cigarette smoke is composed of lots and lots of little particles These particles fall like rain onto the carpeting When you have a little rug rat rolling around and anybody who’s ever had an adorable six-month-old crawling around, of course, they never put their hand in their mouth, and they never touch anything on the floor And you can show that these kids have nicotine levels that are equal to our, almost equal to the kids that are exposed to second-hand smoke So when you move into an apartment where somebody has been smoking in that, that out gassing continues for six months to a year Everything that was absorbed onto the walls starts coming out again when the smoking stops Everything that’s in the carpeting gets picked up and blown again through the air when you vacuum And if you’re down on the carpeting, ah, the five-second rule doesn’t apply because it’s going to be full of nicotine Okay, last third-hand smoke What we know from that that’s pure nicotine in a lot of cases and that sort of gives us a good clue that those sorts of things are still happening with nicotine And as mentioned earlier, ah, children get into these E-cigarette cartridges and 40% of the tobacco related calls and Poison Control Centers are related to nicotine So, and this is really alarming Now we’re seeing this incredible increase in E-cigarette use in adolescents Adolescence is a time when higher cognitive functioning begins Nicotine impairs that Development of the prefrontal cortex, which is this area, this part of the brain, which is where our judgment comes in Um, and the receptors are a major influence on how this executive kind of control mechanism that we all have to control our impulses, ah, begin to occur This animal studies again show that nicotine has a major impact on the way that these, the brain develops at this point and adolescents are going to be really a problem with this And if we go back and think about just how many percentage of kids are using E-cigarettes, we’ve got a real cause for alarm here now Now, adolescents are also much more likely to become addicted to any substance they use A Dr DeFrance, a guy in Boston who’s been studying this for a long time, just shows that nicotine really is the true gateway drug people become addicted to nicotine and that leads to experimentation with other, ah, ah, drugs He shows that an adolescence, meaning say from 14 to 18, smoking one cigarette a week for six weeks is enough to get 50% of the kids that are addicted, are addicted to it at that One cigarette a week for six weeks and 50% of kids become addicted But the really scary thing and the really kind of interesting thing is that about 5% of kids will literally become addicted on their first cigarette And he, he says you can pick those kids out because they’ll tell you when they had that cigarette, it was the greatest sensation they’d ever felt

For that moment, they felt better than they’d ever felt in their life And those kids are the ones that are going to get hooked really on just one cigarette Now, the other thing is is that we’ve now follow, had an opportunity, cigarettes have been out long enough to follow these kids over time And kids who use E-cigarettes but don’t smoke and have never smoked are three to five times more likely to start smoking than kids who have never used E-cigarettes So they clearly are an initiator for the use of cigarettes as a whole So, well, doesn’t that mean that this is addictive? I couldn’t believe it They actually tried to make the claim, the state, the Legislature, that nicotine was not addictive God, I so wanted one of the, the Representatives to ask me a question about that, Senators, I guess it was, ask me a question about that I was just absolutely flabbergasted that anybody would make that claim But, let’s go back and look at it I had the opportunity once to share the stage with Victor DeNoble He was one of the guys that used to work for the tobacco industry They hired him in the 1970’s to produce a heart-safe cigarette Um, he says he was successful at it, but since Phillip Morris never really brought the cigarette out, we don’t know if he was successful or not But, be that as it may He started studying He had to get the rats addicted to nicotine and he was using pure nicotine I.V and was just a steady drip He was having a little trouble with rats would kind of like it but they didn’t seem to be very crazy about it And he was sitting in the cafeteria watching people smoke one day and he realized that people smoke intermittently They take a puff, they put the cigarette down They take a puff, put the cigarette down So he went back to the lab and changed his pump for the rats, so that it pulsed the nicotine and those rats went crazy for nicotine That pulsing creates a surge of dopamine, a drop off, a surge of dopamine and a drop off, and that leads to powerful addiction There are now dozens and dozens, if not hundreds of studies showing that nicotine is in fact addictive So, that, we ought to be able to put that aside Are there other substances in tobacco that also produce physical dependence? Certainly Okay But it’s nicotine that the tobacco industry manipulates One of those things that was in cigarettes is formaldehyde Formaldehyde is also found in tobacco Formaldehyde’s that really great smelling stuff that they used to put the, the frogs and the rats in in your biology class to preserve it You have to wear gloves when you use it because it’s a carcinogen It also is mildly addictive That is, you actually get physically dependent on it I can’t imagine something that would be worse than that However, it’s real value to the tobacco industry is that formaldehyde increases the addictiveness of nicotine So the more formaldehyde there is in a cigarette, the same amount of nicotine is more likely to make you addicted So, ammonium does the same thing and there’s a fair amount of ammonium in cigarettes I haven’t seen any reports about ammonium in E-cigarettes So the tobacco industry deliberately manipulates the content of other chemicals in the cigarettes to potentiate the nicotine and make it more addictive They wouldn’t be doing that if nicotine weren’t addictive in the first place They’d be manipulating whatever it is that really is addictive They’re not They’re manipulating the nicotine Okay, so what about addiction Well, if you dabble with alcohol, about one out of every 10 people is going to become an alcoholic Okay But hey, if you dabble with cocaine, about one out of every six people is going to get addicted to cocaine Okay, now take a second and just think about what the addictive potential is of nicotine And the answer is, that one out of every two is going to get hooked in the long run As I said half of them will be hooked in adolescences, one cigarette a week for six weeks, but you keep going and at least 50% of people are going to get hooked Okay This isn’t scientifically proven, I should say This is the opinion of the addiction experts at John Hopkins So I would take that as a reasonable effect Okay, what about quitting? Well, nicotine replacement, you may have already heard about that’s

the gum, the patch They make an inhaler now, a nasal squirter Different ways of replacing nicotine They work about 5% of the time The inhaler works a little bit better than that But the gum and the patch will help about 5% of people who quit smoking Some antidepressants have been tried and they’ll help about 10% of people who quit smoking Chantix, which is the, another smoking aid will help about 20 % of people who quit smoking Counseling is in the 15-20% range and counseling and medication get up to 30%, sometimes 35%, in that range Ah, to put that in perspective, when a doctor tells a patient to quit, about 2% of people will quit So, I always used to say I’ll take my 2%, but I’m not very effective at getting people to quit smoking, just by telling people to quit smoking I have to do something else So, what about E-cigarettes? Well, first of all let’s point out that E-cigarettes are not FDA approved as a quit aid Let’s also point out that no company has applied to the FDA to present data to say that they’re a quit aid Okay So making a claim that they’re a quit aid is completely bogus from a scientific point of view or a regulatory point of view Now, you, it is important that you do long-term followup when you do these kinds of studies Your quit rate in 30 days is always going to be better than your quit rate at a year, always Okay Um, survey with some other, early studies did that suggest that E-cigarettes could be a reasonable help in quitting, helping people quit smoking The trouble was there were methodological problems They didn’t follow them long enough They didn’t check to see that they were really quitting exactly They didn’t double-check them Some of the questions that, were whether or not they still smoking So they didn’t really get rid of the dual use group So, they kept working at the studies and the studies kept getting better and they eliminated the methodological problems and as they did, they began to see that there really was no impact That is, people using E-cigarettes did not quit at a greater rate And recently they did what is called a Meta-Analysis, which is one way of combining a whole bunch of different studies into a much larger number, so you get bigger numbers and you get better statistical probabilities because you’ve got more people And when they do that, they showed that E-cigarette users were actually 28% less likely to quit smoking than people who used other quit aids Okay So, another thing is, is that 80% of E-cigarette users in several surveys, but somewhere between 60 and 80% also use traditional cigarettes That is, that they’re dual users So they’re really not getting the benefit of cigarette cessation anyway Okay So, ah, first of all we can build a little bit We’ve been researching cigarettes for more than 40 years Okay And we have learned a lot about how cigarettes cause disease, whether it’s cancer, whether it’s heart disease As I mentioned, some of the effects of the brain, but we’re still really, research into pure E-cigarettes Okay Still, there are some effects that have been shown So for example, at heart disease, one of the things you need to be able to do is to make the arteries open up, so when you’re heart’s stressed, your coronary arteries have to get larger so you can pump more blood to your heart too, and the heart can work harder You can’t do that effectively if you’ve had nicotine in your system, because nicotine, wants the ability of an artery to open up It can’t open it up It just stays stuck Now, you get under some stress and you can’t get enough oxygen or blood going to the heart muscle, and that can cause a heart attack This is due to the adverse impact on the endothelium, and we know that nicotine actually kills endothelial cells When you give somebody nicotine and then filter their blood, you can find dead endothelial cells floating around their blood stream When the endothelium is damaged like that, it tears more easily just from the normal movement and then you start getting stuff from the blood stream into the artery wall, and that’s how plaque forms Also, there are these things called platelets Platelets are little tiny cell particles and their function in the blood is to clump together, so when you get a cut, they clump and plug the end of the blood vessels like a cork in a bottle and stops

the bleeding Which is why we tell people to take aspirin when they have a heart attack because aspirin tells the platelets don’t clump, and we know people can get a heart attack because the blood literally clumps inside of the blood vessel, instead of when it’s bleeding like it’s supposed to, and that cork in a bottle can cause a heart attack because it stops the blood flowing through that artery into the heart We tell people to take an aspirin because it keeps the platelets from clumping together like that However, nicotine in the particles, particularly the particles which are in E-cigarettes, that’s why you see the cloud of smoke Those particles tell the platelets to clump together faster so they make it worse Okay Now, we actually do have one study that just came out in March of this year that showed people who used E-cigarettes had an increased risk of having a heart attack of 42% compared to people who didn’t use the E-cigarettes So we now have one study That by the way is very consistent with the studies on second-hand smoke, which is about in the same ballpark So, harm reduction Well, my analogy is this You have a ten-story building, you jump off the building you really don’t expect to survive I apologize, this has only nine stories if you count the roof I didn’t have a ten-story building Okay So my idea, my thought is, is, sure when you do E-cigarettes, you might be jumping out of the third floor instead of the tenth floor You’re still likely to get hurt and you might survive That’s harm reduction That’s what they mean by harm reduction The best thing to do is to walk out on the ground floor because it’s the safest way to get out of the building, not jumping Now, if the data on heart disease pans out the way I’ve outlined it, after all we only have a few studies and we’re still working on this a lot, we only have to move that from the third to the fourth or fifth floor Okay, on my last slide and then I’ll shut up, is that again, and this is a slide that Kris showed you earlier about this dramatic decrease in ah, of Montana of people using cigarettes But remember, I don’t have, do I have a pointer on this thing? Oh yes, okay The, there’s 30%, somewhere around here, is where the E-cigarette use is Now, stop and think about this Those kids are three to five times more likely to start smoking I don’t know what’s going to happen to this number, but with this dramatic increase in E-cigarette use, we may be seeing this bottom out and starting back up again Only the future will tell us that, but I’d be really alarmed at what we’re seeing Okay Thank you Sarah Shapiro: All right So, I’m Sara Shapiro, I work for Lewis and Clark Public Health and I’ll be talking about the tobacco marketing, um, in Montana, specifically the point-of-sale marketing So each year 9.6 billion dollars is spent on marketing tobacco That’s 26 million dollars every day and that’s over 1 million dollars an hour In Montana that’s 30.5 million dollars spent a year from big tobacco and 95% of that money is spent at the point-of-sale location So when I’m talking about point of sale, I’m talking about where we buy our milk Where we buy our soda Where we buy candy It’s where tobacco is sold So that is at convenience stores, gas stations, pharmacies, etc So this also mainly what I’m talking about This is what you see when you’re checking out of those places So you’re being marketed to at all aspects of these locations, so this is the outside, the advertisements, the price discounts Inside you go look where the Slushies are, there’s something about Marlboro By the ice cream you’ll see it, and then you also see it near the drinks You see it on all angles No matter where you go you’re going to see these advertisements Some price discounts right above where you’re checking out And so I’m mainly going to talk about this power wall So this is where the majority of the tobacco products are located So when you go to check out you really can’t miss it Raise your hand if you recognize this Yeah So big tobacco is targeting for specific groups

They’re targeting people who are using They want them to continue using the product People who quit, they want them to start using again Would be users, those are the social smokers, the every once in awhile, the when they’re drinking smokers, and then youth, who is what I’ll be talking about most of my presentation Nine out of ten tobacco users start before the age of 18 and once they start, most are hooked for a long time, or the rest of their life, and so they’re trying to get these replacement smokers So I’ll go over the tactics that are specific to big tobacco is specifically using to hook these populations The first is eye level is buy level so most of the tobacco products are in front of the counter are at about three feet, so that’s definitely not my eye level It’s a younger population’s eye level and it’s mixed in with the candy So they already know that kids are looking at the candy, looking at the bright colors and the flavors and ah, that is where they’re putting these tobacco products, and so I’m talking a lot about cigarillos, the flavor chew, E-cigarettes as well So as you can see, it’s at this young girl’s eye level, mixed in with this gum So, the, the kid is at 45 inches and the poster is at 45 inches, the tobacco poster Another thing is flavors So E-cigarettes, cigarillos, they come in a million flavors There’s bubble gum, fruit loops, strawberry, mango, root beer float So these are definitely flavors that are targeting the inner crowd that is looking for that candy already, and sometimes these are mixed in so they look like candy If you’ve seen the commercials recently, you can look them up and they look identical, and they also look identical because of the packaging A lot of these products have the really bright colored packaging, so it looks like candy Another tactic is price discounts, so younger populations tend to not have as much spare money So using discounts, coupons, buy one, get one free, um, helps it seem more affordable and seem like something they could try to hook people I’ll read this quote It’s “The industries extensive use of price-reducing promotions has led to higher rates of tobacco use among young people than would have occurred in the absence of these promotions.” The U.S Surgeon General, 2012 And so that’s saying that these are working, that more people are using because of these price discounts So why are they going after youth? Is cause they want their replacement smokers So Phillip Morris, one of the main tobacco companies, has been noted saying “The ability to attract new smokers and develop them into a young adult franchise is key to brand development.” So, they’re older population is getting older, getting sick and they need to replace, they need to replace people who are going to use it for the rest of their lives So that is why they’re going for youth Place is really important Can we raise our hands if you’ve been inside a gas station or convenience store in the last week Okay So normally when I go to the gas station, I don’t go inside any more I pay at the pump and I leave and I don’t really go inside very often, but 70% of youth go into gas stations and convenience stores weekly So they’re extremely vulnerable to this number, um, because of all the different advertisements They go during lunch to get candy They go on their walk home Um, it’s kind of like a right of passage to be able to go to one of these places with your friends And so place is really important because of the amount of them in Helena alone and then Broadwater This is just our area and how many places you can see it and be victim to this advertising So adver, this pays off There’s a reason that 30.5 million dollars a year is spending in Montana So each day 3,300 youth under the age of 18 will try their first cigarette, 700 of these children will become regular smokers So it’s a scary number Um, but it’s showing that this advertising is working And again this is another graph showing that same thing It’s showing how the green bars are showing the dollars spent on E-cigarette advertising and the line is showing the past 30 day great use among youth, and as you can see, as advertising goes up, so is the use among youth So this is just another graph showing that um, the amount of

E-cigarette users is going up every year So this tobacco marketing is working and why we should be scared of it is because it normalizes the presence of tobacco products, meaning when youth go into these locations and they see how much tobacco is and where it is all over the place, it seems like more people are using it And when more people use it, the way to fit in So, it normalizes the idea of it It encourages youth to use tobacco and eventually get hooked It makes it harder for current users to quit You know they want to buy the milk, but they’re seeing this tobacco product every time they try to check out It encourages people who quit tobacco to start using again So these are some pictures that I did from a recent scavenger hunt that I’ve been doing with the youth What I do is I take youth to these different locations and they have check marks and they have to check if they see products below three feet, what flavors they’re seeing, what discounts are seen Can you see it from the road Things like that And so I’m able to work with youth to understand this and it tends to be empowering because they don’t like being targeted You know, they want that independence and that freedom, and so they don’t like how these companies are targeting them Um, I’m also doing presentations to multiple groups trying to get the word out because once you learn these tactics it’s really hard to not notice them So that’s one thing I encourage everyone here to do, is to go into these stores and notice them and realize them, and then tell your friends Tell your peers Tell the youth, um, to keep educating Nicole Aune: So, I’m just going to do a final wrap up here and kind of leave us with, so now what We’ve heard all these things What do we do next? What are our actions steps? So, just to talk a little bit about the, the laws that are in place now In January of 2016 Montana set a law that you have to be 18 in order to purchase E-cigarettes Before that anybody, any age, could go and get these You could be 7 years old and walk into a store and be able to buy an E-cigarette, which is just absolutely atrocious So at least now we do have that law in place That was set here in the state in January of 2016 and then the FDA came and set it, set a law in May of 2016 at the national level So now that’s a national law that you have to be 18 in order to purchase these products Um, they are also not allowed to be sold in vending machines where kids can, where kids are present Um, they’re not allowed to give out free samples And starting in May of 2018, um, if we get there with this administration, um, warning labels ah are, are going to be required And I thought that this, this is kind of interesting this warning label right here, because um, it, you’ll hear as Dr Shepard said many times, you hear the E-cigarette industry saying, oh nicotine is, is actually good for you It’s not harmful at all Okay So, now you’re being required to put a warning label on that explicitly states that nicotine is harmful and extremely addictive So, just putting that out there All right So then, we actually have some other laws here in, in Montana So we’ve had a few counties that have taken it upon themselves to include E-cigarettes in their local Clean Indoor Air Act protocols and actually Lewis and Clark County was the first county to do that So, yeah, Lewis and Clark County Yes Round of applause And there are actually four other counties now from Montana that have E-cigarettes in their Clean Indoor Air Act protocol That’s Sanders County, Carbon, Powell, and Granite recently added there then too I’ll just mention too that in addition to those businesses in other, in other counties where this isn’t a law, businesses have the authority and, and the um, and the right to ban E-cigarettes in their business So different businesses or housing authorities, um, hospitals, they can, they can choose to ban the use of E-cigarettes on their property Okay So I did want to mention that lots of other localities across the national have taken it upon themselves to enact some policies that are even, even more strict on these products, and help protect our youth So in California, and Hawaii, they have made it illegal to purchase any tobacco product, including E-cigarettes, um, if you (cough)

(excuse me) if you are under the age of 21 So there are at least 225 other localities where it’s illegal to purchase tobacco if you’re under the age of 21 So this is really good for a number of reasons Um, one is because it reduces, or it delays the age of initiation and then two, it helps keep tobacco out of schools, um, as Kris had mentioned earlier You have, have 18 year olds who can buy these products and they’re still in high school When you raise the age to 21, you don’t have a lot of 21 year olds who are still in high school, so it makes it difficult for those kids to be buying a tobacco product or E-cigarettes and passing along to their friends in high school And then the other reason is, um, it reduces sales to minors because it’s harder to pass off as a 21 year old than it is to pass off as an 18 year old So, so doing that, that’s a really, that’s a really good policy that the Surgeon General promotes In Minnesota, they’ve applied a tax to E-cigarettes You heard Dr Shepard talk about how we’ve, we recently tried to do that and it didn’t go so well But raising the price, raising the price on tobacco products is one of the most effective mechanisms to re, to prevent youth initiation of tobacco products So, like some other, um, some of our counties in Montana, New Jersey and our neighbor North Dakota, the whole state has prohibited the use of E-cigarettes in indoor public places So that’s something that a whole state can do, is, is include that in the state Clean Indoor Air Act Um, Chicago has actually banned the sale of flavored products within 500 feet of a school So they’re taking action on these flavors, because E-cigarettes, they come in 7,700 different flavors I mean, that, that’s insane and, as Sarah mentioned, they’re in all these different flavors that are appealing specifically to kids Um, Providence, Rhode Island has prohibited discounts like coupons and buy one, get one free And then New York City has actually had a law that requires that all of their tobacco products be placed behind the counter or in another area that’s not freely accessible and can’t just be picked up by a kid and walked out So this is just kind of a sample There are a lot of other localities across the nation that have taken action like this This is just a sample of some of the, some of the policies that are in place across the nation All right So what can you do? What we’re wanting from the community outright is to, to know the facts so you’ve taken the right step today coming and hearing, hearing what we do know about E-cigarettes, so I applaud you for doing that The other thing is, talk to your kids and other young people about the risks associated with E-cigarettes, not just water vapor and now you guys know that And you know, find the right time to talk to them It may not just be, oh I’m going to pull my kid aside and we’re going to have a sit down conversation in our living room Maybe take the opportunity when you’re in a convenience store with your kid or with another young person, and you’re seeing those tobacco products placed right next to the candy bars Take that moment to stop and say, “hey what do you think about this?” And get their thoughts on it Or if you see somebody, you’re walking by somebody who’s using an E-cigarette or if you’re hearing, hearing advertisements on E-cigarettes Um, the other thing is, you know, reach out to other, other adults and, and talk to your decision makers, educate your decision makers about these products Like, like I said at the very beginning, there’s so much misinformation about these products and depending on who you talk to, you’re getting different types of, of facts So, it’s really important that you’re communicating to your decision makers and your legislatures, the real facts about these, about these E-cigarettes and what they’re doing to our kids and why we’re, why we’re concerned And this can look at, look in a lot of different ways, it could, it could also take the form of, you know, writing, writing a letter to the editor for your newspaper, going and speaking at different groups So, so just getting, getting your voice out there is a good way too And the last one that I’d like to mention is, is really important, is lead by example You know, be tobacco-free yourself So if, if you are a tobacco user, there is help for you There’s a Montana Tobacco Quit Line It offers free nicotine replacement therapy which is little gums and

gum and lozenges and patches It offers reduced cost medication and free coaching These, these things like Dr Shepard mentioned, combined offer you the greatest success rate that you can get So there is help for you and, and it doesn’t help to, it’s harder for you to have a conversation with your kids about tobacco products and E-cigarettes, if you yourself are using them It’s harder to get that message across So there is hope for you and your set, 1-800-QUIT-Now