Nursing paper. 2 pages Discusses possible outcomes of both positions. Present plans each for resolving the issue (for patient, family and the nurse).  Supports ideas with 3 scholarly literature nursin

I n y o u n g a d u l t s a g e d 18 t o 2 4 y e a r s , e-cigarette use (used 1 or more times within the past 30 days) more than doubled from 2013 to 2014 to 13.6%, and as of 2014, more than one-third had tried e-cigarettes. 4 E-cigarette use data among teenagers and young adults represent the various product t y pes of ENDS. 3,4 What the vaping culture entails Vaping refers to the vaporization of substances (nicotine, f lavorings, can- nabis, or other substances in popu- larit y) wherein oil, liquid, or plant material is heated to a temperature resulting in the release of aerosol- ized water vapor and active ingredi- ents (nicotine, cannabis) delivered via inhaled aerosol. 3-5 Tremendous controversy has arisen surrounding potential harm reduction or risks as-sociated with e-cigarettes/vaping in young persons. 3 Nicotine, a highly addictive sub- stance in any form, is commonly vaped. 3,4 Hea lt h ef fects of n icot i ne i n- clude hemodynamic effects second- ar y to catecholamines (eg, increase in heart rate and blood pressure; va- soconstriction of arteries and vessels; endothelial dysfunction; atheroscle- rosis acceleration). 3 During adoles- cence while the brain is developing, nicotine can result in addiction and harmful consequences such as be- havioral and cognitive impairments, memor y issues, inattention, and ex- ecutive function impairments. 4,6 Harmful effects have been found from e-cigarette aerosol and addi- tives. 4 Brief exposure to propylene glycol aerosol has been reported to PEDIATRIC-FOCUSED LINKS ON E-CIGARETTES AND VAPING AMERICAN ACADEMY OF PEDIATRICS: E-Cigaret tes and Electronic Nicotine Delivery Systems bit.ly/AAP-ENDS CALIFORNIA STATE UNIVERSIT Y FULLERTON: Electronic Cigarettes: Information for Parents bit.ly/CSUF-ecig-parent-info CAMPAIGN FOR TOBACCO-FREE KIDS:Electronic Cigaret tes: An Over view of Key Issues bit.ly/tobaccofreekids- ecig-overview CENTERS FOR DISE ASE CONTROL AND PREVENTION:

E-Cigaret tes and Young People: A Public Health Concern bit.ly/CDC-ecigs MYHEALTH.ORG: The Truth: Is Your Teen Vaping?bit.ly/myhealthoc-teen-vaping NATIONAL INSTITUTE ON DRUG ABUSE:Teens and E-Cigaret tesbit.ly/NIDA-teens-and-ecigs T V Spotlight on Electronic Cigaret tes:

YouTube bit.ly/NIDA-youtube-ecigs NEMOURS FOUNDATION, DUPONT PEDIATRICS: KidsHealth: About E-Cigaret tesbit.ly/KidsHealth-ecigs TeensHealth: E-Cigaret tesbit.ly/TeensHealth-ecigs US DEPARTMENT OF HE ALTH AND HUMAN SERVICES:

E-Cigaret te Use Among Youth and Young Adults: A Repor t of the Surgeon General bit.ly/HHS-ecigs- SurgeonGeneral-report Know the Risks: E-Cigaret tes and Young People bit.ly/HHS-ecigs-know-the- risks Know the Risks: E-Cigaret tes and Young People. Talk with your Teens About E-Cigaret tes: A Tip Sheet for Parents bit.ly/HHS-ecigs-parent-tip-sheet US FOOD AND DRUG ADMINISTR ATION:Vaporizers, E-Cigaret tes, and Other Electronic Nicotine Deliver y Systems bit.ly/FDA-tobacco-products FROM 2013 TO 2014 E-cigarette use among middle and high school students tripled, rising from approximately 660,000 to 2 million students 19 CONTINUED FROM PAGE 24 29 AUGUST 2017 | CONTEMPORARY PEDIATRICS.COM peer-reviewed be a respirator y and eye irritant in patients without asthma. 6 Contem- porar y generations of high-powered e-cigarettes comprising tank sys- tems have the capacity to heat nico- tine liquids to high temperatures that produce cancer-causing carcinogens such as formaldehyde and acetalde- hyde in the vapor. 4,6 Metals detected in some e-cigarette aerosol, includ- ing lead, silver, tin, nickel, iron, cop- per, and cadmium, may be products of the heating element (coil). 4 Secondhand e-cigarette aerosol exposure to nicotine, particles, and potentially tox ic chemicals have been found in emissions studies.

3 The ef- fects of potentially harmful doses of heated and aerosolized ingredients of e-cigarette liquids including solvents, f lavorings, and tox icants are not fully understood. 4 Dual use of vaping nicotine and smoking cigarettes presents added health concerns. 3,4 An association has been identified in young persons be- t ween e-cigarette use and the propen- sit y to use other tobacco products, in particular the use of combustible prod- ucts (ie, cigarettes).

4 To illustrate, 58.8% of high school students in 2015 report- ed using e-cigarettes and additionally combustible tobacco products.

The evolving landscape of rec- reational and medicinal marijuana (cannabis) use has given rise to an in- crease in vaping cannabis. 5,7 In 2017, a study conducted among 3847 high school students in Connecticut was consistent with high rates of using e-cigarettes to vape cannabis (life- time cannabis user, 18%; lifetime dual users, 26.5%). 7 Besides the potential for nicotine addiction, addiction risk ex ists for cannabis and other illicit drug use. 4 Little is k nown about the long-term health effects of vaping and even less has been established about the potential harm of vaping other substances such as cannabis. 5 Targeted advertising Robust marketing and colorful adver- tising campaigns directed toward the youth population through social me- dia outlets, telev ision, and on the In- ternet proliferated between 2011 and 2013. 3,6 One study found television ad- vertisements soared 256%, reaching over 24 million young persons. 3 Ap- pealing, child-friendly flavorings are a marketing endeavor to attract ado- lescents, disguise harsh tobacco, and facilitate nicotine addiction. 4,6 In 2014, 466 brands and 7764 dis- tinctive f lavors of e-cigarette products were available. 3,4 Emerging evidence suggests that flavorings when vapor- ized at high temperatures result in chemical reactions of tox ic levels of carbonyl compounds such as form- aldehyde, although the health effects are not completely appreciated. 4,8 Flavorings/taste were among the 3 most commonly reported reasons for e-cigarette use among teenagers and young adults along w ith perceived low harm as compared with conventional tobacco products and curiosit y. 3 Emerging evidence of use patterns has revealed that e-cigarettes are being utilized by young persons for various alterative behaviors such as smoke tricks, vape competitions, and vaping other substances including cannabis and cocaine. 8 “Dripping” is one of the newest trends wherein e-liquid at high tem- peratures is manually applied direct- ly on the atomizer coil and the vapor produced is inhaled. 8 In the first study to evaluate prevalence rates for drip- ping conducted by Yale Universit y on h ig h s c ho ol s t udent s (n =70 45) f r om 8 different Connecticut schools, anonymous sur veys evaluated to- bacco use behav iors and perceptions.

Results of the anonymous sur veys re- vealed that 26.1% of e-cigarette ever users (n=1080) reported using the device for dripping, equating to 1 in 4 adolescents. Reasons for dripping included: thicker vapor clouds (63%); better-tasting f lavors (38.7%); and a stronger hit produced in the throat (27.7%) by dripping. Safet y studies are not available on the practice of drip- ping, although some research sug- gests e-liquid exposure may have a considerable increase in toxic vapors (eg, acetaldehyde, formaldehyde, ac- etone) and may increase exposure to high levels of nicotine. Promoting public awareness Adolescents encompass over 20% of the population in the United States. 9 Harm reduction prevention and ear- ly inter ventions of risk y behav ioral patterns established during the de- velopmental periods of youth are not only significant for inf luencing adolescents’ current health status, but also their future health status In 2014, the products most commonly used by high school students were: 19 e-cigarettes 13.4 % || hookah 9.4 % || cigarettes 9.2 % cigars 8.2 % || smokeless tobacco 5.5 % || snus 1.9 % || pipes 1.5 % CONTEMPORARY PEDIATRICS.COM | AUGUST 2017 30 peer-reviewed into adulthood. In 1 study in which teenagers were asked why they used e-cigarettes, more than half the stu- dents stated the main reason was simple curiosity. 10 Of concern was that when asked what they were in- haling when vaping, more than 60% reported that they were vapor- izing “just f lavoring,” not realizing e-cigarettes contain nicotine. Only 10% of the adolescent research par- ticipants stated they were using e-cigarettes in an attempt to quit smok ing regular cigarettes.

Another alarming problem is the increase (161% to 333%) in calls to poison control centers that involve children aged younger than 5 years suffering potentially fatal poisonings through the ingestion, inhalation, or absorption through the sk in or eyes attributed to access to the liquid nicotine cartridges, which are not re- quired to be childproof. 3 Concentra- tions of e-liquid nicotine for refilling e-cigarettes are ample enough to re- sult in a fatal overdose sometimes as high as 1000 mg/10 mL and are com- monly sold in colorful bottles or car- tridges attractive to children. 3,4 The use of ENDS has achieved no- toriet y to the adolescent population in particular v ia the Internet through social net work ing and by the promo- tion of tobacco products using v iral strategies from tobacco companies that have been directly and indi- rectly marketing via social media. 11 The traditional dissemination of re- search findings, health information, and regulator y actions using journal publications and government reports to stakeholders involved in this public health problem may need to be recon- sidered. 12 Technologic advancements w ith communication and advertis- ing outlets may have implications for public health advocates who will need to explore alternative strategies to engage and inform the communit y at large on emerging health concerns, promotion, and prevention. Parental support and guidance A national endeavor issued by the office of the US Surgeon General, E-Cigarette Use Among Youth and Yo u n g A d u l t s, outlines 6 goals and strategies to reduce e-cigarette use among adolescents and young adults. 4 Strategies to accomplish these goals encompass areas where stakeholders (eg, individuals, par- ents/caregivers, families, teachers, coaches, youth inf luencers) can be- come involved. One way parents can engage is to become educated on t he risk of e-cigarette use, enabling the parent/caregiver to educate their own children about the harmful ef- fects of e-cigarettes, other nicotine products, and vaping of illicit sub- stances. Being tobacco-free role models, opening discussions about the harms of tobacco and nicotine products, and protecting young per- sons from indirect exposure, such as tobacco smoke or aerosol from e-cigarettes, are illustrations. Role of healthcare providers Lack of k nowledge can be a result of healthcare providers’ receiving lit- tle or no formal training in either their academic or practice settings on screening, treating, or provid- ing referrals to young patients and their families in regard to vaping.

Healthcare prov iders may not even be screening for the use these prod- ucts. If asked about tobacco use, ado- lescents and young adults who are us- ing these products may not consider them tobacco, and respond that they are not using them. A recommenda- tion would be to add vaping to the electronic medical record’s tobacco screening tool when screening for to- bacco use in the pediatric population.

Healthcare providers can play a key role both in clinical practice and as faculty in higher education. The provision of sk ills necessar y to ad- ICD-10 CODES VAPING The following are suggested ICD-10 codes for the diagnosis and treatment of tobacco/ nicotine use or abuse in children. Check with your contracted plan and individual state Medicaid program for coverage policy.

F17.290 Nicotine dependence, other tobacco product, uncomplicated F17.298 Nicotine dependence, other tobacco product, with other nicotine- induced disorders F12.90 Cannabis use, unspecified, uncomplicated F12.10 Cannabis abuse, uncomplicated F12.21 Cannabis dependence, in remission T65.291A Toxic ef fect of other tobacco and nicotine, accidental (unintentional), initial encounter (For children who accidentally ingest a liquid nicotine refill) Z71.6 Tobacco abuse counseling Z72.0 Tobacco use Z87.891 Personal history of nicotine dependence CONTEMPORARY PEDIATRICS.COM | AUGUST 2017 32 peer-reviewed dress the health and safet y implica- tions of pediatric nicotine use and exposure needs to be incorporated into clinical practicum course objec- tives. Education initiatives in medical and nursing practice can enhance the abilit y to assess and synthesize data, make clinical judgments, and initiate diagnostics decisions. The develop- ment of appropriate plans of care and anticipatory guidance may be a sus- tainable, long-term solution related to this evolving public health epidemic.

Recommendations for policy and practice Regulatory policy lagged behind the rapid revolution of e-cigarettes and vaping resulting in risk to children, ad- olescents, and young adults. 13 In 2014, the US Food and Drug Administration (FDA) expanded regulator y authori- t y under the Family Smok ing Preven- tion and Tobacco Control Act of 2009 to include all tobacco products includ- ing e-cigarettes and hookahs.

4,11 Con- cerns by public health advocates ex ist because the proposed regulations do not include regulations of marketing practices or f lavored nicotine products targeting young persons. 13 E-cigarettes presented a paradigm shift in the to- bacco landscape. Vaping has gained huge popularity among the younger population and is an area wherein ex- panded tobacco control policies and enhanced surveillance of current and emerging patterns of use are needed. 4 Although recent regulations are now restricting the sale of these products to minors nationw ide, the marketing of these products in col- ored refill packages and in a variety of candy f lavors is aimed at attract- ing the younger generation with the misperception of being a harmless habit. 9 Added hazards include a rise in vaping other substances such as the concoction of chemicals, canna- bis, or synthetic drugs. Legalization of medical marijuana and recreational marijuana use in some states are rea- sons rooted in escalating use of va- porized cannabis use among youth.

Emerging patterns of alternative use, such as dripping in 1 in 4 high school students, support the need for regu- lations and restrictions on e-cigarette devices to avoid easy manipulation for novel experimentation. 8 Globally, taxation has been used as an effective means to reduce ciga- rette consumption. w ith approx i- mately a 10% increase in price re- sulting in a 1% decrease in smoking prevalence. 12 There is wide variabil- it y in the taxation of non–cigarette tobacco products in some markets where ENDS have not been subject to tobacco taxes. Consumers, particu- larly adolescents, may seek more cost- effective products, thus switching to other tobacco products or substitut- ing related ENDS. The FDA could evaluate risk/exposure claims pro- viding opportunities for tax advan- tages to products as a way to draw users away from more hazardous products. Such regulations could also bring about changes in non–cigarette tobacco products that could impact public health by reducing attractive- ness and/or tox icit y. The New Jersey State Assembly and Senate are reviewing a legislative bill (S298/A3704) 14,15 to ban all flavored electronic cigaret te products.16 If the bill passes in both legislative houses and is approved by Governor Chris Christie, the opponents of the new law are concerned that vape stores statewide would be out of business.

17 This bill would expand on the 2008 New Jersey law that already restricts the sale or distribution of flavored electronic smoking devices, cartridges, and liquid refills to adults, except for 3 flavors: clove, menthol, or tobacco. 16 The current law also prohibits the sale or distribution of electronic smoking devices to individuals aged younger than 19 years, the same as cigaret tes. 17 Although many understand the marketing concerns and potential health risks of vaping as related to minors, the opponents of the bill resent the limited sale of flavors to adults and the potential impact on positive anecdotal experiences of quit ting traditional tobacco products by vaping instead. 17 Proponents of the bill and public health advocates are concerned these products are marketed toward young persons and may increase the incidence of tobacco use among children.

Despite the protests, the controversial bill appears to be enduring the debate paralleling antivaping legislation that is prevailing worldwide. NEW JERSEY DEBATES LEGISLATIVE BAN ON SALE OF FLAVORED ELECTRONIC SMOKING DEVICES CONTINUED ON PAGE 38 CONTEMPORARY PEDIATRICS.COM | AUGUST 2017 38 clinical brief ment is believed to be influ- enced by age, frequency of res- pirator y track infections, and social factors such as daycare exposure. The American Academy of Otolar yngol- og y–Head and Neck Surger y (A AO- HNS) currently recommends t ympa- nostomy tube placement for children w ith bilateral OME if they are aged 3 months and older and have hearing difficult y, the study notes. Tube place- ment also may be indicated in chil- dren with unilateral or bilateral OME if there are other symptoms present, such as ear discomfort, vestibular problems, and reduced qualit y of life or school performance. Likew ise, the American Academy of Pediatrics sup- ports t ympanostomy tubes for chil- dren who have experienced recurrent AOM, w ith 3 episodes over 6 months or 4 episodes in a year.

In children with OME, researchers found that mean hearing thresholds increased by 9.1 decibels after t y mpa- nostomy placement, and that t ympa- nostomy tubes, t ympanostomy tubes w ith adenoidectomy, and myringoto- my w ith adenoidectomy were the most effective inter ventions when it came to hearing improvements. There were no differences, however, in hearing thresholds bet ween children treated with tympanostomy versus watchful waiting after 1 to 2 years. For long-term hearing improve- ments, the research team found that tympanostomy tube insertion with adenoidectomy and myringotomy w ith adenoidectomy were the 2 most effective interventions, while t ympa- nostomy tubes alone, antibiotic pro- phylax is, and watchful waiting were the least effective strategies.

For AOM, researchers compared tympanostomy placement to a placebo group and found that 3 of 20 children in the placebo group had no further episodes of AOM, while 12 in 22 who received tympanostomy tubes were without additional episodes after the inter vention. Another study analyzed by the research team found that 40% of children in a placebo group had no further episodes of AOM compared w ith 35% in the t ympanostomy tube group. Researchers noted, however, that children in that study who were treated with tympanostomy tubes had a shorter duration of AOM episodes than the placebo group.

Although evidence does support short-term positive results, research- ers note that the lack of long-term hearing benefits bet ween watchful waiting and tube placement supports the hy pothesis of the preferred natu- ral, spontaneous resolution of middle- ear effusion that most children experience.Despite some limited evidence of improved qualit y of life after tube placement, neither of the 2 studies that evaluated parental stress or health-re- lated qualit y of life found a significant difference between tympanostomy tube placement and watchful waiting, according to the researchers. Also, adverse events were difficult to track as they were not often reported, and many cohorts did not follow up post– tympanostomy tube placement until the extrusion of the tube.

Researchers note that they were not able to predict which children would be most likely to benefit from tympa- nostomy tube insertion for chronic middle-ear effusion, although there was evidence that tubes might be par- ticularly effective in young children attending daycare or in older children with persistent hearing impairments lasting more than 3 months.

Steele says his report does not offer recommendations on when or if tubes should be placed, but says the findings are in line w ith recommendations al- ready established by the A AO-HNS. He says he hopes the report w ill encour- age shared decision making between parents and pediatricians. Summary There is the potential risk that public misperceptions and regulator y prac- tices do not often coincide w ith the actual risk for tobacco products. 12 The per vasive tobacco control movement based on strong science has been in- strumental in driving numerous pol-icy changes. Some of these positive strategies include indoor smok ing restrictions, advertising bans aimed at children, taxation (providing an economic disincentive for smokers to continue), and education. These effective methods can inf luence strategies regarding the use of non–cigarette tobacco products that may result in beneficial outcomes in pub- lic health for the future. Teen vaping CONTINUED FROM PAGE 32 For reference, go to ContemporaryPediatrics.com/ tympanostomy-tubes For references, go to ContemporaryPediatrics.com/ teen-vaping Copyright ofContemporary Pediatricsisthe property ofAdvanstar Communications Inc.and its content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.