Florida House Business & Professions Subcommittee meeting packet, October 23, 2019
Summary
The meeting packet for the Florida House of Representatives Business & Professions Subcommittee meeting on Wednesday, October 23, 2019, 12:30 PM to 2:30 PM in Webster Hall, under Speaker Jose Oliva and Chair Heather Fitzenhagen. The notice and agenda list a single item: discussion of vaping, nicotine dispensing devices and Florida's regulation of tobacco products. The packet includes a presentation by State Surgeon General Scott A. Rivkees of the Florida Department of Health on the public health impact of e-cigarette and vaping use, describing the department's role in disease surveillance and interventions. It closes with materials from Heather Youmans, Senior Director, Government Relations.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
Business & Professions Subcommittee
Wednesday, October 23, 2019
12:30 PM - 2:30 PM
Webster Hall (212 Knott)
Meeting Packet
Jose Oliva Heather Fitzenhagen
Speaker Chair
Committee Meeting Notice
HOUSE OF REPRESENTATIVES
Business & Professions Subcommittee
Start Date and Time: Wednesday, October 23, 2019 12:30 pm
End Date and Time: Wednesday, October 23, 2019 02:30 pm
Location: Webster Hall (212 Knott)
Duration: 2.00 hrs
Discussion of Va ping, Nicotine Dispensing Devises and Florida's Regulation of Tobacco Products
NOTICE FINALIZED on 10/16/2019 4:03PM by Rigas.Amanda
10/16/20 19 4:03:23PM Leagis ® Pag e 1 of 1
The Florida House of Representatives
Commerce Committee
Business & Professions Subcommittee
Jose Oliva Heather Fitzenhagen
Speaker Chair
AGENDA
Wednesday, October 23, 2019
Webster Hall (212 Knott)
12:30 PM - 2:30 PM
I. Call to Order & Roll Call
II. Welcoming Remarks
III. Discussion of Vaping, Nicotine Dispensing Devises and Florida's Regulation of
Tobacco Products
IV. Adjournment
303 House Office Building, 402 South Monroe Street, Tallahassee, Florida 32399-1300
(850) 717-4873 Fax: (850) 413-0419
Public Health Impact of
E-CigaretteNaping Use
Scott A. Rivkees, MD
State Surgeon General
Florida Department of Health
-
Florida Department of Health
The role of the Department of Health is to:
• Identify, diagnose, and conduct surveillance of diseases and health
conditions in the state and accumulate the health statistics necessary
to establish trends
• Implement interventions that prevent or limit the impact or spread of
diseases and health conditions
• Collect, manage, and analyze vital statistics and other health data to
inform the public and formulate public health policy and planning
Vaping is the act of inhaling and exhaling an aerosol,
often referred to as vapor, which is produced by an
e-cigarette or similar device.
The term is used because e-cigarettes do not produce
tobacco smoke, but rather an aerosol, often mistaken
for water vapor, that actually consists of fine particles.
Many of these particles contain varying amounts of toxic
chemicals, which have been linked to cancer, as well as
respiratory and heart disease.
·ot
iliir' ///.. / Centers for Disease Control and Prevention
e,,::/ CDC 24/ 7: Sa\llng Lives. Protecting Peop le™
• Most e-cigarette devices have a battery, a heating
element, and a receptacle to hold a liquid.
• The devices heat a liquid - typically containing
nicotine, flavorings, and other chemicals - and
produce an aerosol. I
' -1
-- .
• E-cigarettes are known by many different names.
They are sometimes called "e-cigs," "mods," "vape
pens," "vapes," and "tank systems."
• They are also called by their brand names, such as
JUUL.
Dates of symptom onset and hospital admission for patients with lung injury
associated with e-cigarette use, or vaping - United States
Recent decllne in
reported onset and
180
hospitaliution due in
part to repor1ing lag
160
• Date of Ad mission (N=ll81) The current
14 0 • Date of Symptom On set (N=l027)
outbreak of
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lung disease
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- - 4/14 4/21 4/28 S/S S/12 S/19 S/lb b/2 6/9 6/l b b/23 6/30 1/7 7/14 7/21 7/28 8/4 8/11 il/18 8/2S 9/1 9/8 9/15 9/22 9/18 10/6
3/31 4/7
Number of Lung Injury Cases Reported to CDC as of October 15. 2019
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Legend
Number of lung Injury cases per state
The current outbreak of
O cases
1-9 cases
vaping-related lung disease
e 10-49 cases and deaths is a national
e 50-99 cases
problem.
e 100 149 cases
Territories AS OU MH FM PW PR • VI 4- [I({
US: 1,479 cases, 33 Deaths
FL: 68 cases, 1 Death
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Lung Injury Associated with Vaping
• No specific cause has been identified
• CDC and FDA are investigating
• Most patients have been young and otherwise healthy
• Report gradual onset of various symptoms over days to weeks
• Respiratory (cough, chest pain, shortness of breath)
• Gastrointestinal (GI) (abdominal pain, nausea, vomiting, diarrhea)
• Systemic symptoms (fatigue, fever, weight loss)
Lung Injury Associated with Vaping
Florida National
68 cases 1,479 cases
21 counties 49 states and 1 U.S. territory
1 confirmed death 33 deaths in 24 states
69% of cases are male 70% of cases are male
8% of cases are under 18 years old 16% of cases are under 18 years old
Age range of 15-72 years old Age range of 13-75 years old
Median age of 24.5 years old Median age of 23 years old
Product components associated with lung injury
Among 849 patients with information on substances used in e-cigarette, or vaping,
products in the 3 months prior to symptom onset:
•78% reported using THC-containing products; 31% reported exclusive use of THC-
containing products
•58% reported using nicotine-containing products; 10% reported exclusive use of
nicotine-containing products
Florida, Current Adult E-cigarette use by Age, BRFSS 2018
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Outbreak follows a
MIDDLE SCHOOL
STUDENTS HIGH SCHOOL large rise in
STUDENTS
e-cigarette/vaping use
in youth.
PERCENT OF FLORIDA HIGH SCHOOL USE
CURRENT E-CIGARETTE USE VS CIGARETTE SMOKING
2015-2019
30
= Cigarette = Vape
25.6
25 24.8
20 18
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Factors Contributing to Youth Vaping
• Flavored products
• Product innovation
• Marketing
• Access
• Nicotine is an addictive drug
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Nicotine
• Nicotine is addictive
• Nicotine is not the primary cause of most smoking-related
disease, but it is the reason people continue to smoke
• The large majority of e-cigarettes contain nicotine
• JUUL 5% nicotine vs. 1-2% for many others
Responding to the Vaping Lung Disease Outbreak
• Working closely with CDC and FDA
• Reporting cases
• Issued alert to medical providers 8/30/2019
• Media marketing
Responding to the Youth e-Epidemic
• Tobacco Free Florida is developing new
youth vaping content
• TV spots, radio spots, digital display ads,
social media posts, long-format social media
video
• Currently in formative testing
• Student-based activities
Centers for Disease Control and Prevention
CDC 24/ 7: Saving Lives. Pro1ectlng Peopler,.
CDC Recommendations (10/1s/19)
• People should not use e-cigarette, or vaping, products that contain THC.
• People should not buy any type of e-cigarette, or vaping products, particularly those containing THC, off
the street.
• People should not modify or add any substances toe-cigarette.
• E-cigarette, or vaping, products should never be used by youths, young adults, or women who are
pregnant.
• Adults who do not currently use tobacco products should not start using e-cigarette, or vaping,
products.
• People should refrain from using e-cigarette, or vaping, products that contain nicotine.
FDA Recommendations 10/4/2019
• Do not use vaping products that contain THC.
• Do not use vaping products-particularly those containing THC-obtained off the street or from
other illicit or social sources.
• Do not modify or add any substances, such as THC or other oils, to vaping products, including
those purchased through retail establishments. .,
• No youth or pregnant women should be using any vaping product, regardless of the substance.
• Adults who do not currently use tobacco products should not start using these products. If you are
an adult who uses e-cigarettes instead of cigarette smoking, do not return to smoking cigarettes.
• The FDA recommends contacting your health care provider for more information about the use of
THC to treat medical conditions.
No vaping product has been approved by the FDA for therapeutic use or is
authorized for marketing by the FDA.
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Cigarette & Tobacco Regulation
In Florida
Cigarette and Tobacco Regulation in Florida
Division of Alcoholic Beverages and Tobacco
House Business and Professions Subcommittee
October 23, 201 9
do~r
londa
De artment of Business
& iPr-ofessional Regulation
Introduction
• Division Overview
• Cigarette and Tobacco Regulation in Florida
• Licensing Population
• Excise Tax and Surcharge Collection
• Compliance Activities
• Revenue Distribution
do ~r
londa
De rtment of Business
& Wotessional Regulation 2
Division Overview
The Division of Alcoholic Beverages and Tobacco licenses the manufacture, distribution,
sale and service of alcoholic beverage and tobacco products in Florida.
Licensing Auditing Enforcement
• Processing license applications • Collecting and auditing of • Conducting routine
and renewals. the excise tax due to the compliance inspections.
state.
• Verifying an applicant's • Conducting minimum age of
qualifications for licensure • Conducting compliance purchase surveys.
under the Beverage Law and audits to ensure compliance
chapters 210 and 569, Florida with special licensing • Conducting criminal and
Statutes. requirements. administrative investigations.
49 FTE Positions 84 FTE Positions 188 FTE Positions
do~r
londa
· De rtment of Business
& Woress1onal Regulation 3
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• Cigarettes, defined in s. 210.01 ( 1), F.S.
• Any roll for smoking, except one of which the tobacco is fully naturally fermented,
without regard to the kind of tobacco or other substances used in the inner roll or the
nature or composition of the material in which the roll is wrapped, which is made wholly
or in part of tobacco irrespective of size or shape and whether such tobacco is flavored,
adulterated or mixed with any other ingredient.
• Florida's cigarette distribution system includes three levels: the manufacturer (supplier),
the distributor (wholesaler), and the vendor (retailer).
dofi:)r
londa
De rtment of Business
& ~fessional Regulation 4
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• Cigarettes, continued:
• All cigarette packages intended for sale or distribution to consumers subject to taxation under s.
210.02, must have a stamp furnished by the Division affixed to the package, unless otherwise
provided by law.
• Section 210.185, F.S., prohibits selling, distributing, acquiring, holding, owning, possessing,
transporting, or importing cigarettes in this state under certain circumstances, including when
cigarettes are marked for export only, when the packages fail to comply with federal law (including
the Federal Cigarette Labeling and Advertising Act) , when the ingredients have not been properly
submitted to HHS, or when the package·has been altered to remove or obscure any required label
or warning, or to make the package non-compliant with federal law.
• All cigarettes sold or offered for sale in this state, or sold or offered for sale to persons in this state,
must be tested, marked, and have a written certification filed by the manufacturer with the Division,
in accordance with the " Reduced Cigarette Ignition Propensity Standard and Firefighter Protection
Act" (s. 633.142, F.S.).
do~r
londa
De rtment of Business
& Woressional Regulation 5
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• Tobacco Products, defined ins. 210.25(12), F.S.
• Loose tobacco suitable for smoking; snuff; snuff flour; cavendish; plug and twist tobacco;
fine cuts and other chewing tobaccos; shorts; refuse scraps; clippings, cuttings, and
sweepings of tobacco, and other kinds and forms of tobacco prepared in such manner as
to be suitable for chewing; but "tobacco products" does not include cigarettes, as defined
bys. 210.01 (l ), or cigars.
• Florida's other tobacco products distribution system includes the distributor (wholesaler) and
vendor (retailer).
• Distributor, defined ins. 210.25(5), F.S.
(a) Any person engaged in the business of selling tobacco products in this state who brings, or
causes to be brought, into this state from outside the state any tobacco products for sale;
(b) Any person who makes, manufactures, or fabricates tobacco products in this state for sale
in this state; or
(c) Any person engaged in the business of selling tobacco outside this state who ships or
transports tobacco products to retailers in this state to be sold by those retailers.
do ~r
londa
· De rtment of Business
& Wofessional Regulation 6
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• Tobacco Products, as defined ins. 569.002, F.S.
• "Tobacco products" includes loose tobacco leaves, and products mode from
tobacco leaves, in whole or in port, and cigarette wrappers, which con be used
for smoking, sniffing, or chewing.
• The Division does not regulate "nicotine products". "Nicotine products" ore defined in
s. 877.112, F.S. as" ... any product that contains nicotine, including liquid nicotine, that
is intended for human consumption, whether inhaled, chewed, absorbed, dissolved, or
ingested by any means, but does not include a ... [t]obocco product, as defined in
s. 569 .002."
do ~r
londa
De rtment of Business
& ~fessional Regulation 7
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• Retail Tobacco Product Dealer Permit (RTPD)-
• Each person, firm, association, or corporation that seeks to deal, at retail, in
tobacco products within this state, or to allow a tobacco products vending
machine to be located on its premises in this state, must obtain a retail tobacco
products dealer permit for each place of business or the premises where tobacco
products are sold ...
• Permits may be issued only to persons who are 18 years of age or older or to
corporations the officers of which are 18 years of age or older.
do~r
londa
- De rtment of Business
& ~fessional Regulation 8
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
• A dealer that sells tobacco products shall post a clear and conspicuous sign in each p lace of business where such products
are sold which substantially states the following:
THE SALE OF TOBACCO PRODUCTS TO PERSONS UNDER THE AGE OF 18 IS AGAINST FLORIDA LAW. PROOF OF AGE IS
REQUIRED FOR PURCHASE.
A dealer that sells tobacco products and nicotine products or nicotine dispensing devices, as defined ins. 877.112, may use
a sign that substantially states the following :
THE SALE OF TOBACCO PRODUCTS, NICOTINE PRODUCTS, OR NICOTINE DISPENSING DEVICES TO PERSONS UNDER THE AGE
OF 18 IS AGAINST FLORIDA LAW. PROOF OF AGE IS REQUIRED FOR PURCHASE.
Any dealer that sells tobacco products shall provide at the checkout counter in a location clearly visible to the dealer or
the dealer's agent or employee instructional material in a calendar format or similar format to assist in determining whether
a person is of legal age to purchase tobacco products. This point of sale material must contain substantially the following
language:
IF YOU WERE NOT BORN BEFORE THIS DATE
(insert date and applicable year)
YOU CANNOT BUY TOBACCO PRODUCTS.
do ~r
londa
De rtment of Business
& Woressional Regulation 9
Cigarette and Tobacco Regulation in Florida
Florida Licenses and Regulates Cigarettes and Other Tobacco Products
Responsible Retail Tobacco Products Dealer:
To qualify as a responsible retail tobacco products dealer, the dealer must establish
and implement procedures designed to ensure that the dealer's employees comply
with the provisions of this chapter. The dealer must provide a training program for the
dealer's employees which addresses the use and sole of tobacco products and
which includes at least the following topics:
• (a) Lows covering the sole of tobacco products.
• (b) Methods of recognizing and handling customers under 18 years of age.
• (c) Procedures for proper examination of identification cords in order to verify
that customers ore not under 18 years of age.
• (d) The use of the age audit identification function on electronic point-of-sole
equipment, where available.
do fb)r
londa
. De rtment of Business
& Woressional Regulation 10
"-..
License Population Statewid~
CD A I Cigarette D istribu tor A gent $1 00 I 5
CWD I Cigarette Wholesale Dealer $100 I 24 1
CIM P I Cig a re t te Import er $1 00 I 12
EXP I Cigarette Exporter $100 I 20
CG R I Cigar W holesale D ealer N o Fee I 6 15
TWO I Tobacco Wholesale Dealer for Other Tobacco $25 1 319
Total
1,212
RTPD Retail Tobacco Product D ealer W ith A lcohol License $ 50 23.705
RTPD Retail Tobacco Product Dealer Without A lcohol License $50 3 ,884
Tota l
2 7,589
do~r
lo11da
~ De rtment of Business
& Woress1onal Regulation ll
Excise Tax and Surcharge Collection
Tax and surcharge payments are collected at
intervals of one month, on or before the 101h of
each month, and the payment is
accompanied by statutorily required reports.
Tax and surcharge rates are dependent on the
type of product being sold.
The 2009 Florida Legislature passed the
Protecting Florida's Health Act, which levies a
surcharge on cigarettes , wraps, and tobacco
products other than cigars. Cigars are excluded
from surcharge and excise taxation per s.
210.25(12), F.S.
During FY 2018- 19, the Division collected over
$254,000,000 in cigarette excise tax, over The Division maintains an Elec tronic Data Submission (EDS) system .
$758,000,000 in cigarette surcharge, over
$38,000,000 in other tobacco products excise Approximately 90% of tax rem itting licensees are c urrently reporting
tax, and over $91 ,000,000 in other tobacco electronically
products surcharge .
do~r
londa
~ De rtment of Business
& ~fess1onal Regulation 12
Compliance Activities
In FY 18-19, the Division performed over 52,000 alcoholic beverage and tobacco inspections, with a staff of
188 dedicated Bureau of Enforcement employees across 12 district offices .
• Routine compliance inspections resulted in an approximately 64% compliance rate at the time of
inspection.
• The most common violations cited during inspections are related to a failure to post all necessary signage
and licenses, and failure to maintain records as required by law.
In FY 17-18 and FYl 8-19, the Division performed over 5,500 total tobacco compliance surveys to determine
whether licensees were complying with minimum age of purchase restrictions in Florida law.
Nearly 91 % of the aforementioned tobacco-related compliance surveys resulted in vendor compliance.
do fii)r
londa
De rtment of Business
& ~fessional Regulation 13
Revenue Distribution
Retail Tobacco Permit Fees:
10% of each retail tobacco dealer permits transferred Department of Education to provide for teacher training and for research and
evaluation to reduce and prevent the use of tobacco products by children .
Cigarette Excise Taxes:
8% to Service Charge to General Revenue Fund , and .9% to the Alcoholic Beverage and Tobacco Trust Fund to provide for operational costs.
Cigarette Excise Taxes Net (after the above reductions):
4.04% of Cigarette Excise Tax or $5,560,553 (whichever is greater) is transferred to the H. Lee Moffitt Cancer Center and Research Institute;
29 .3% of Cigarette Excise Tax collections is transferred to the Public Medical Assistance Trust Fund in the Department of Health for indigent
health care;
2.9% of Cigarette Excise Taxes transferred to Department of Revenue for the Revenue Sharing Trust Fund for counties;
1% (not to exceed $3M) is transferred to the Biomedical Research Trust Fund in the Department of Health for the advancement of cures for
cancer afflicting pediatric populations, and the balance of the cigarette tax revenue collections after payment of all of the above is
transferred to the General Revenue Fund.
Other Tobacco Products (OTP) Excises Taxes - 100% of collections are deposited directly into the General Revenue Fund .
Cigarette and OTP Surcharge Revenues - are transferred into the Health Care Trust Fund within the Agency for Health Care Administration.
do~r
londa
De rtment of Business
& Wofessional Regulation 14
Department of Business
& Professional Regulation
Contact Information
Gabe Peters
Legislative Affairs Director
gabe.peters@myfloridalicense.com
850-487-4827
do ~r
londa
~ De rtment of Business
& ~fess,onal Regulation 15
2019 Florida Youth Substance
Abuse Survey Overview
0
~
2019 Florida Youth Substance l
l
Abuse Survey Overview
Ute Gazioch, Director of Substance Abuse and Mental Health
House Business & Professions Subcommittee
_,,--
October 23, 2019
Background and Methods
• Since 2002, the Florida Youth Substance Abuse Survey is
administered each spring to public middle and high school
students across Florida.
• In even numbered years, sample size is larger to produce
county-level estimates.
• In odd numbered years, sample size is only large enough to
produce state-level estimates.
• In 2019, students were surveyed in 40 out of the 67
counties.
• Final sample size was 9,819 across grades 6 through 12.
• The margin of error is less than 2.0 percentage po~ts for
middle school and high school prevalence rates.
FLORIDA DEPARTMENT
OF CHILDREN AN D FAMIU ES
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0%
2002 2004 2006 2008 2010 2012 2014 2016 2018 2019
[ ....: Mid~dl~~School --- High School ~]
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
5
N\yf lfAMI Ll ES.COM
Binge Drinking
Prevalence by Grade Cohort
40% ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
30% +-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
22.3 23.0
20% l-~~~~~~~~~~---=~~"""'"-1~~~~~~~~~~~~~~~~~~
•
9.6
• I
9.3
0% +-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
3.2 3.1
2002 2004 2006 2008 2010 2012 2014 2016 2018 2019
j _._ Middle School .,._ High School I
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
MYFLFAMILI ES.COM
6
Alcohol and Driving Trell·ds
Past-30-Day Prevalence Among High School Students
40% ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
30% -+-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-
20% .....__ _
10% - ! - - - - -
0% - + - - ---I
2012 2014 2016 2018 2019 2012 2014 2016 2018 2019
[ rtidi~g··~ith· ~· o;i~-ki~g . o~i~~;~j Driving after Drinking
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
~YFLFAMILI ES.COM
7
Cigarettes
Past-30-Day Prevalence by Grade Cohort
20% ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
14.9 15.0
15%-i-~ ~ - -...~:::::-~~~~~~~~~~~~~~~~~~~~~~~,
10%
7.1
I ........... • ....._ ~ ., r I
..
. 5%
I2 --..........._ 2.1
.......
• 1.0
0% -l-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-,-~~---t
2002 2004 2006 2008 2010 2012 2014 2016 2018 20
[ _._ Middle School .... High School I
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
8
;{.\yflfAMI LI ES.COM
Marijuana
Past-JO-Day Prevalence by Grade Cohort
25% ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~--,
20%
15%
17.2
. . • 7 18.6 •
. . _____
• 18.6
·~
16.3
-- -
15.4
---
10% 1-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~11
5.9 5.7
,I I
• J
5% I • • • •
3.7 3.7
3.2
0%
2002 2004 2006 2008 2010 2012 2014 2016 2018 2"019
j _._ Middle School .._ High School I
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
9
AAvF LFAM1 u ES.COM
Use of Any Illicit Drug (Other than Mari.juana)
Past-30-Day Prevalence by Grade Cohort ·
15% .-----~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-,
.
10.6 10.9
10% I ~ ~..
~ ---T
~ ""-..
. ..
............... \ 1
5.
s.
5% S.6 S.S
0%
2002 2004 2006 2008 2010 2012 2014 2016 2018 019
,~~ -+- Middle School -D-·· High Scho~ I
10 1 FLORIDA DEPARTMENT
OF CHILDREN AND FAMIUES
'MYFLFAMlLI ES.COM
Prescription Pain Relieve~s
Past-30-Day Prevalence by Grade Cohort
10% -,-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~---,
5%-+-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
4.4 . • •
2.4 .
. . t
.- 1.3
1.0 1.1
0% ---~~~~~~~~~~-,-~~~~~~~~~~-,-~~~~~~~~~~-,-~------<
2002 2004 2006 2008 2010 2012 2014 2016 2018 2019
[ ~ ..;:.~~~ddle School _.. Hig~~~~~~J
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
MYFLFAMILI ES .COM
11 11
Vaping Nicotine and Vaping MariJuana
Lifetime and Past-30-Day Prevalence
40%
I
30% ,
20%
10%
0%
H.S. Full
I
M.S. H.S. Full M.S. H.S. Full M.S. H.S. Full M.S.
Sample Sample Sample Sample
Lifetime Past-30-Day Lifetime Past-30-Day
Nicotine Vaping Nicotine Vaping Marijuana Vaping Marijuana Vaping
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
'MYfLFAMIU ES.COM
12
Vaping Nicotine and Smoking Ciga~ettes
Past-30-Day and Lifetime Prevalence
[~~v~pi~~ Ni~~1:in~ .·1 Tried Cigarettes
71.9% of current vapers have never tried cigarettes.
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
iNi_yf LfAMI LI ES.COM
13
Trend Summary
• Among high school students, alcohol, cigarette, marijuana, and
Rx pain reliever use continue their long-term decline.
• Among middle school students, the substance use decline has
stalled.
• The majority of students who vape nicotine did not
transition from smoking cigarettes. Their vaping is
independent of cigarette use.
FLORIDA DEPARTMEN T
OF CHILDREN AND FAMILI ES
'N\yflfAMI LI ES .COM
14
Questions?
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
%\vF LFAMI LI ES.COM
15
Pathology of Vaping-Associated
Lung Injury
MAYO
CLINIC
Pathology of Vaping-Associated Lung
Injury
Andras Khoor, MD, PhD
Mayo Clinic Florida
©2019 MFMER I slide-1
Tht NEW ENGLAND JOURNAL of MEDI C INE
I CORRESPONDENCE ·····~~~----·1
Pathology ofVaping-Associated Lung Injury
TO THE EDITOR: Despite the accumulating data criteria for a "confirmed" diagnosis of \rapin~-
on the clinical and imaging features of vaping- related lung injuryi the remaining six met the
associated lung injury, 1•2 its pathology is poorly criteria for a u probable" designation. In aJ I cases
understood. We reviewed lung biopsies from 17 bistopathological findings showed patterns of
patients (13 men; median age, 35 )fears (range acute lung injury, including acute fibrinous pneu-
19~67]), all of whom had a history of vaping monitis, diffuse alveolar damage, or organ izin
(71% with marij uana or cannabis oils) and were pneumonia, usuaJly bronchiolocentric and accom-
clinically suspected to have \raping-associated llllg panied ~ , bronchiolitis (Fig. li also see the Supple-
injury. Presentation was acute or subacute in all mentary Appendix, available with the fuJl text of
cases, with bi latera l pulmonary opacities; all but this letter at NEJM .org). No histologic findings
n,vo patients presented in 2019. E]even met the were specific, but foam y macrophages and pneu-
A
Butt YM, et al. N Engl J Med. 2019 Oct 2. [Epub ahead of print]
Authors
• Mayo Clinic Scottsdale, AZ • Mayo Clinic Jacksonville, FL
• Yasmeen M. Butt, M.D. • Andras Khoor, M.D., Ph .D.
• Maxwell L. Smith, M.D. • Isabel Mira-Avendano, M.D.
• Henry D. Tazelaar, M ~D. • UnityPoint Health Peoria, IL
• Laszlo T. Vaszar, M.D. • Aiyub Patel, M.D.
• Karen L. Swanson, D.O.
• Mayo Clinic Scottsdale, AZ
• Mayo Clinic Rochester, MN • Brandon T. Larsen, M.D.,
• Matthew J. Cecchini, M.D., Ph.D.
Ph.D.
• Jennifer M. Boland, M.D.
• Melanie C. Bois, M.D.
• James H. Boyum, M.D.
• Adam T. Froemming, M.D.
MAYO
CLINIC
~ ©2019 MFMER \ sltde-3
Introduction
• Use of electronic cigarette ("e-cigarette")
devices has exploded in popularity in recent
years
• These battery-operated devices
• heat liquids, oils, or waxes containing
nicotine, cannabinoids, synthetic
cannabinoids, illicit drugs, and other
chemical compounds,
• producing an aerosolized vapor
• that can be inhaled, or vaped, by the user
MAYO
CLINIC
~ ©2019 MFMER I s!lde-4
Aim
• To characterize the pathologic changes that occur
in the lung:
• Exogenous lipoid pneumonia?
• Much recent attention has been given to the
possibility that vaping-associated lung injury
may represent exogenous lipoid pneumonia
• Acute lung injury pattern?
• Acute lung injury patterns include:
• acute fibrinous pneumonitis,
• diffuse alveolar damage, and
. . .
• organ1z1ng pneumonia
MAYO
CLINIC
~ ©2019 MFMER I slide-5
Methods
• The study was approved by the Institutional
Review Board at Mayo Clinic (IRB# 19-008434)
• In all cases,
• a diagnosis of vaping-associated lung injury
was favored clinically, and
• biopsies were performed to confirm this
clinical impression and rule out other causes
MAYO
CLINIC
~ ©2019 MFMER I sltde-6
Methods (continued)
• Cases were classified using criteria for vaping-
related lung injury recently proposed by the CDC
• "Confirmed"
• 1) use of an e-cigarette or vaping device
within 90 days of symptom onset
• 2) presence of pulmonary infiltrates
• 3) absence of clinical and laboratory
evidence of infection
• 4) absence of evidence for alternative
diagnoses
• "Probable"
• Identical criteria with the exception of #3
MAYO
CLINIC
~ ©2019 MFMER I slide-7
Results: Patient Demographics
• A total of 17 patients met the inclusion criteria
• Most patients were
• young adults (median age 35 years, range
19-67) and
• most were men (76°/o)
MAYO
CLINIC
ctP ©2019 MFMER I sllde-8
Results: Clinical Findings
• Eleven patients met CDC criteria for a
"confirmed" diagnosis, with the remaining six
patients meeting CDC criteria for a "probable"
designation
• All patients had a history of vaping in the weeks
and days prior to presentation
MAYO
CLINIC
~ ©2019 MFMER J shde-9
Results: Clinical Findings (continued)
• Two patients were vaping in an attempt to quit
smoking tobacco
• Twelve patients (71 °/o) reported vaping
• tetrahydrocannabinol (THC),
• cannabis oils,
• cannabidiol (CBD), or
• other non-nicotine products
• Both manufactured prepackaged vape pods
and open access tank style vaporizers were
used
MAYO
CLINIC
~ ©2019 MFMER I slide-10
Results: Pathologic Findings
• In all cases, pathologic findings showed
patterns of acute lung injury, including
• acute fibrinous pneumonitis
• diffuse alveolar damage, or
• • •
• organ121ng pneumonia
.• None of our cases showed histologic evidence
of exogenous lipoid pneumonia
MAYO
CLINIC
~ ©2019 MFMER I slide-11
Supple1nentary Table S3. Frequency of Histopatbologic Feah1res in Vaping-
Associated Acute Lung Injury
Histologic Feature ~umber of cases ,vitb feah1re I
~umber of cases with relevant
struch1res present for evaluation (0/o)
Foa111y I Vacuolated Macrophages 17 I 17 (100)
Foamy I \ i acuolated Pneu1nocytes 17 I 17 (100)
Intraalveolar Fib1in 16 I 17 (94)
Organizing Pneu1nonia 14 I 17 (82)
Bronchiolitis 7 I 9 Q_~
Bronchiolar Iviucosal Ulceration 6 I 9 ( 67)
Interstitial Edema 11 I 1 7 (§_~
Neutropbils 9 / 17 (53)
Chronic Interstitial hrllammation 9 I 1 7 (53)
Pigmented Macrophages 7 I 17 (4 1)
Eosinophils 5 I 17 (29)
Hyaline Membranes 4 I 17 (24)
Pe1ibronchiolar Metaplasia 2 I 9 (22)
Organizing Fibrinous Pleu1itis 1* I 7 (14)
Interstitial Fibrosis 1 I 17 {§)
Pleural Fibrosis O I 7 (Q}
Granulomas O I 17 {Q2
Exogenous Lipoid Pneumonia O I 1 7 (0
Case #17
• 19-year-old man presented with
• cough,
• pain when swallowing,
• nausea, and
• vomiting
MAYO
CLINIC
~ ©2019 MFMER I slide-13
Chest CT
;,
Case #17 Normal lung
MAYO
CLINIC
Cry ©2019 MFMER I sllde-14
Chest CT
Case
'-0" #17 __J
""""'"ER,'"''·"
'
L. ..
E
E
M
~
~
Q)
Cl)
co
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L..
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Q)
en
ro
()
Results: Outcomes
• Information was available in seven patients:
• two patients (both with diffuse alveolar
damage) died of their illness
• the other five were improving or improved at
the time of last follow-up
MAYO
CLINIC
Cry ©2019 MFMER I slide-19
Conclusions
• We believe that the histologic changes suggest
that vaping-associated lung injury represents
• a form of airway-centered chemical
pneumonitis from one or more inhaled toxic
substances
• not exogenous lipoid pneumonia
• The agents responsible remain unknown
MAYO
CLINIC
~ ©2019 MFMER J slide-20
::::,
'U
Q)
0
>.
ro
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@)
(/)
~
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c
ro
~
0
0
..c
~
E-cigarette Liquid Composition
• Propylene glycol
• Glycerin
• Contaminants, including
• polycyclic aromatic hydrocarbons,
• nitrosamines,
• endotoxins,
• diacetyl, and
• a wide variety of other organic and inorganic
chemicals and flavoring compounds
MAYO
CLINIC
Cry ©2019 MFMER I slide-22
Regulating Tobacco Products
• ..
Cancer Action
NetworksM
Regulating Tobacco Products
Florida House of Representatives
Business & Professions Subcommittee
Wednesday, October 23, 2019
Heather Youmans
Senior Directo~ Florida Government Relations
•
fflj
~"cancer Action
Network·
••••••••••••••••••••••••••••••••••• ~-
• Regular and significant increases in taxes on all tobacco products,
including e-cigarettes
• Comprehensive smoke-free laws that include e-cigarettes
• Fully funding and implementing tobacco control programs in
accordance with US Center for Disease Control's (CDC's) Best
Practices
• Comprehensive coverage of US Food and Drug Administration
(FDA) approved cessation treatments and individual, group and
phone counseling
•
•
~t.ancer Action
••••••••••••••••••••••••••••••••••• ffili i
• Raising the age of sale to 21 for all tobacco products
(Tobacco 21) with strong retailer compliance and
active enforcement
• Restricting the sale of ALL flavored tobacco products,
including menthol cigarettes
• Protecting authority to pass local laws, stronger than
the minimum standard set by state laws
•
Policy Background - •
~ancer Action
Electronic Cigarettes
••••••••••••••••••••••••••••••••••• ~-
• Sottera., Inc. v. Food & Drug Administration., 627
F.3d 891 (D.C. Cir. 2010)
- In 2008, the FDA stopped shipments of e-cigarettes into the United States
- The FDA claimed the products were unapproved drug-device combination
products under the Federal Food, Drug, and Cosmetic Act that were
intended to help treat the withdrawal symptoms of nicotine addiction
- Two e-cigarette distributors sued the FDA requesting a preliminary
injunction. They claimed the products were tobacco products for "smoking
pleasure," not drug-device combination products
•
Policy Background - •
ffli ;~twork~
~ancer Action
Electronic Cigarettes
••••••••••••••••••••••••••••••••••• )!..-
Between the filing of the lawsuit and a decision for a preliminary injunction, Congress
passed the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act)
and it was signed into law.
Ultimately, The D.C. Circuit found that under the Tobacco Control Act, all products made
or derived from tobacco and intended for human consumption that are "marketed for
therapeutic purposes" are subject to FDA's drug and/or device provisions, whereas
"customarily marketed tobacco products" are subject to regulation as "tobacco
products".
The FDA decided not to appeal the decision to the Supreme Court and instead issued a
statement of its intent to regulate e-cigarettes as a tobacco product .
•
What is considered a ''Tobacco •
Product''?
ffjj
~""cancer Action
Network~
•••••••••••••••••••••••••••••••••••
FDA finalized a rule, effective
~-
August 8, 2016
• Hookah (waterpipe)
• Cigarettes
tobacco
• Smokeless tobacco
• Pipe tobacco
• E-cigarettes and other
Electronic Nicotine Delivery• Cigars
Systems (ENDS) • Nicotine gels
• Dissolvables
•
•
~ancer Action
fflj
~~twork•
••••••••••••••••••••••••••••••••••• ~-
• FDA has yet to require e-cigarettes to go
through premarket review and receive a
marketing order from the FDA
• FDA has not removed flavored e-cigarettes
including, mint and menthol, from the market
Current State Regulations •
of E-cigarettes ffii
~tancer Action
Network~
••••••••••••••••••••••••••••••••••• ~-
• Only 4 states fund tobacco control programs at more than
50% of CDC's recommended funding level
• Only 18 states and DC have excise taxes on e-cigarettes
- Only 7 of these states come close to taxing them at a
rate parallel to the state tax on cigarettes
• Only 18 states and DC prohibit the use of e-cigarettes in
100% smoke-free venues
•
•
~"cancer Action
••••••••••••••••••••••••••••••••••• ffi! iii
• E-cigarettes are not defined as tobacco products
- E-cigarette retailers are not required to obtain a tobacco license
• No excise tax on e-cigarettes
• E-cigarettes were just added to the Florida Clean Indoor Air Act
(Amendment 9), but all smoking is still allowed in stand-alone bars
• E-cigarettes were added to the program of work for Tobacco Free
Florida, but the program is only funded at 36.3% of CDC's
recommendation and additional spending authority provided for
education exclusively focused on youth
•
•
ffii
~"'cancer Action
N.etwork~
••••••••••••••••••••••••••••••••••• ~-
• No type of counseling (individual, group, or
telephone) and no FDA approved tobacco cessation
medication coverage for Medicaid enrollees
• 2 local jurisdictions have Tobacco 21 laws
•
•
fflj
~tancer Action
)!;i -
Network~
Tobacco 21 - Evidence-Based Policy
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
What Does a Comprehensive Tobacco 21
Law Include?
• Covers all tobacco products, including • Does not create new categories of
electronic cigarettes products, which would exempt them from
• Provides public education and training and other tobacco control laws
technical assistance
, to retailers • Does not penalize youth
• Implements measures for active • Does not preempt other jurisdictions from
enforcement, such as retailer licensing and passing strong tobacco control laws
penalties, including license suspension and
revocation
•
•
fflj
~!ancer Action
Network*
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ~-
• State & Local State-of-Play
- 18 states, DC and at least 500 localities now
have T21 laws
• Strength of the laws vary widely
State Tobacco Retailer •
~t.ancer Action
Licensing Laws
••••••••••••••••••••••••••••••••••• ffil &
• 37 states and DC require retailers that sell
cigarettes to obtain a license or permit
• 36 states require a retailer license to sell other
tobacco products
• 20 states require a retailer license to sell e-cigarette
•
~"cancer Action
••••••••••••••••••••••••••••••••••• ~-
• Florida needs to take a comprehensive approach to
combating the tobacco and e-cigarette epidemic
- Update the definition of "tobacco products" to include all products that are
available on the market
- Require tobacco retail licensing for all retailers, including e-cigarette retailers
- Legislation increasing the age of sale for tobacco products should include all
products, all people and preserve local control
- Impose a State Tax: 85% of wholesale price would put e-cigarettes inline with
the tax on other non-cigarette tobacco products
•
•
fflj
~"'cancer Action
Network~
••••••••••••••••••••••••••••••••••• ~-
Heather Youmans
Senior Director, Government Relations
Heather.You ma ns@cancer.org
www.FightCancer.org
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