North Carolina Pharmacist Volume 97 Number 4 Fall 2017 A d v a n c i n g P h a r m a c y. Im p r o v i n g H e a l t h .
Inside This Issue: From the NCAP Office Call for Volunteers Convention Highlights Awards NCAP Socials New Practitioner Network Education and Practice
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Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649 www.ncpharmacists.org Click Here to Follow us! -
JOURNAL STAFF EXECUTIVE EDITOR Penny Shelton EDITOR/STAFF WRITER Ralph Raasch LAYOUT/DESIGN Rhonda Horner-Davis
BOARD OF DIRECTORS PRESIDENT Stefanie Ferreri PAST PRESIDENT Stephen Eckel TREASURER Thomas D’Andrea
BOARD MEMBERS Olivia Bentley Jamie Brown Jennifer Burch David Catalano Lisa Dinkins Ouita Gatton Macary Marciniak Kim Nealy Dave Phillips Justin Reid Jennifer Wilson
North Carolina Pharmacist Volume 97 Number 4
Fall 2017
Inside • From the President .................................................................4 • From the Executive Director .............................................................5 • North Carolina Health Facts ........................................................................6 • NCAP Names Pre-Grassroots Workgroup ....................................................7 • NCAP Call for Volunteers .......................................................................9-10 • Pnockout Pneumonia Campaign Update ...............................................12-13 • NCAP Socials..........................................................................................15 • Awards................................................................................................16-20 • NCAP 50 Plus Club...................................................................................21 • Interview with Charles “Micky” Whitehead.........................................22-23 • From the New Practitioner Network.....................................................29-32 • Education and Practice.........................................................................34-43
North Carolina Pharmacist is supported in part by: • Smith Drug Company.................................................................................2
NCAP STAFF
• Pharmacists Mutual Companies................................................................8
Linda Goswick Sandie Holley Rhonda Horner-Davis Teressa Reavis Ron Williamson
• Epic RX....................................................................................................30
North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharma-
• Pharmacy Technician Certification Board...............................................11 • NCAP Career Center...............................................................................33 • Pharmacy Quality Commitment..............................................................42 • VIP Pharmacy Systems............................................................................44
cist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.
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For rates and deadline information, please contact Rhonda Horner-Davis at rhonda@ncpharmacists.org
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•From the President • Stefanie Ferreri, PharmD
ing with Penny from her start date. Given the change in leadership at NCAP, the Executive Committee decided to have the president and president-elect serve 18-month terms instead of the typical 12-month term. Stephen Eckel Thankful. That is the theme of concluded his term as president my column for this Journal. As I in June 2017, and I will assume write this column we are enterthe role through December 2018. ing the holiday season. We are I want to thank Stephen for his getting ready to spend time with leadership and mentorship. I am family and friends and reflect on looking forward to our continued our lives. Much of the reflection relationship as he transitions to is personal and family focused, past-president. but we can also do the same in As I assume the presidential role, regards to our professional lives. I I look forward to working with the am thankful and humbled to serve Board on behalf of the members of the profession as the state associa- NCAP. I will have two main initiation president. In my short tenure tives during my 18-month term. as president, I have worked with a The first will be to increase memgreat group of leaders. bership. We have had a decline in At the center of our professional membership in the past 3-4 years. association is our Executive Direc- Given the turnover in leadership tor, Penny Shelton. She has been and the uncertainty of the Assowith us for a little more than a ciation, this is completely underyear. She has been instrumental standable. However, I can assure in working with the Education you NCAP is in a great place, and Committee to revise the annual we need ideas from our members meeting and our continuing eduto make it even greater! I chalcation programs. In addition, her lenge current members to recruit leadership has brought renewed just one non-member to join. I energy to the Association. She has have a couple of folks that I will reviewed membership benefits, personally be bugging to renew; by-laws, finances, resources and Watch out: I’m coming for you! committees for the Association. Increasing membership will help She has been heavily involved in with my second initiative, which is advocacy. NCAP has benefited advocacy. All of the practice settremendously from her leadership tings in North Carolina require an in a short period of time. For this, advocate to seek public support for I am extremely thankful. causes or a particular policy. The I have had the pleasure of workpast year NCAP hired a part-time 4
lobbyist, Tony Adams, to advocate for the profession. Tony has been working in Raleigh to make sure our voices are heard. NCAP needs your help to continue this advocacy role. Therefore, funds raised at the annual meeting from the silent auction and the 50-50 are going toward advocacy efforts. I am thankful for those who participated in those fundraisers. Transform through Innovation. That was the theme of the NCAP annual meeting in September in Winston-Salem. North Carolina has been a leader in transforming pharmacy practice through innovation. The roundtables, posters, workshops, and networking activities were great opportunities to learn from others. If you have not been to a meeting in recent years, consider placing it on your calendar for next year! While there will always be frustrations in your professional lives, the positives of our profession and what is happening in our state far outweigh our concerns. Now I need to hear from you! What ideas do you have? What changes do you want to see? How do you want to get involved? Feel free to let me know your thoughts via email at stefanie_ferreri@unc. edu or follow me on Twitter @ stefanieferreri I want to wish each of you a Healthy and Happy Holiday Season, and I am thankful that I get to serve our state association this year.
•From the Executive Director• Penny Shelton, PharmD, CGP, FASCP
Positioning NCAP for Success First and foremost, I extend a warm “Happy Holidays” greeting from the NCAP staff to all our readers and NCAP members. This issue comes to you during that time of year which brings great joy to many of us, while at the same time can be extremely busy, overwhelming and exhausting for all. I hope that as you read this column you are doing so while taking some quiet minutes to relax and break away from all the yearend hubbub. At NCAP we are taking some break-away time to analyze 2017 and to prepare for 2018. I have recently spent some time with President Ferreri discussing strategic initiatives for the upcoming year, prioritizing and reviewing our volunteer needs. You can find more on these initiatives and volunteer opportunities on pages 9-10 in this issue of The North Carolina Pharmacist. This is also the time of the year when many of us are reviewing our health insurance coverage and making sure we are signed up for an appropriate plan. As is the case for an individual’s health, it is also important for an association to periodically assess its organizational health. In the past, some of you may have heard me speak to the health of NCAP. Organizational health has a lot to do with operational metrics such as appropriate staffing numbers, productivity, and positive finances. However, much of an organization’s health is also determined by its agility and adaptability. Healthy organizations are both stable and dynamic, because both attributes are required of associations to function effectively. In order for NCAP to bring
meaningful value to its members and to effectively represent our profession, the leadership teams, the Board and I have worked hard in 2017 to strengthen our operational metrics: finances, membership, services, resources, policies and procedures. In addition, much attention has been devoted to both internal and external partnerships. NCAP’s mission is to “unite, serve and advance the profession of pharmacy for the benefit of society.” To fulfill this mission (i.e., to advance our role in healthcare), we need to share “our story” with others. How many times have we seen local, state, even national task forces or committees established to address healthcare issues with no pharmacy representation? In order for NCAP to effectively represent “pharmacy” in our state, NCAP needs to be at the healthcare decision-making table. We need to position the Association among other non-pharmacy organizations in order to influence and bring about pharmacypositive change. In 2017, we have broken down some of these siloes, and NCAP has been an active voice for pharmacy in a number of important external partnerships and public health initiatives. NCAP is an active member, and I have had the privilege of representing our Association as a member of The North Carolina Opioid Prescription Drug Abuse Advisory Committee Workgroup. This is an appointed group of about thirty individuals or organizations working with our Department of Health and Human Services and Division of Public Health to problem-solve and devise solutions to address the opioid crisis and implement the NC Opioid Action Plan launched earlier this year by Secretary Cohen and Governor Cooper. NCAP is also an active member of two advisory groups with the North Carolina Association of Hospitals: opioid coalition and pneumonia workgroup. NCAP is representing pharmacists’ roles among our state’s health systems in addressing the opioid crisis; and NCAP is serving to ad5
vise in how our Association and pharmacists can help with NCHA’s “Pnockout Pneumonia” campaign. Another more recent external partnership initiative, for which NCAP has taken the lead, is the establishment of a statewide “Pharmacy Technician Educators Coalition” where NCAP is working with the community college pharmacy technician programs to identify among a number of initiatives ways that the Association can better serve pharmacy technicians. Another positive metric for the Association indicative of improved health of our Association and also a direct result of enhanced internal and external partnerships is a resurgence in educational grants. In recent weeks we have partnered with Alliant QIO for a CMS Specialty Innovation Project grant which will be devoted to identifying eligible patients and increasing naloxone dispensing. The North Carolina Governor’s Institute for Substance Abuse provided funding to produce and edit NCAP-developed educational webinars on a number of substance abuse related topics. Most recently, on November 21, the NC Board of Pharmacy voted to provide financial support to NCAP to implement regional workshops across North Carolina designed to help pharmacists transform their practices and increase the role of pharmacists in helping curb the opioid epidemic. How healthy is NCAP? This year has proven to be year of resurgence and one that will set us up for greater effectiveness and success. I believe even greater performance and opportunities await us in 2018. In closing, this is the time of year for giving thanks and sharing joy. I thank you for your support and membership. I wish you and yours a joyous holiday season. Pharmacy Proud, Penny
Created By: Ashley Pope, Doctor of Pharmacy Candidate East Tennessee State University 6
From the NCAP Office
NCAP Appoints Pre-Grassroots Workgroup By Penny Shelton In 1998 North Carolina became one of the first states in the union to allow collaborative practice agreements between physicians and pharmacists. At the time, to help with the passage of collaborative practice authority (CPA), a number of restrictions were incorporated to help ensure safe implementation of this new type of practice. During the two decades since, the uptake and implementation of collaborative practice has been limited at best. Significant changes have occurred with healthcare in the U.S., including a shortage in primary care providers, greater chronic disease burden and increased overall healthcare costs. Also, pharmacy education has significantly advanced during this same time frame, including the transition to the Doctor of Pharmacy as the entry-level degree, and multiple ACPE standards and guideline revisions designed to ensure pharmacists are taught the fundamentals of disease management and ongoing monitoring of treatment. It is time for North Carolina to modify its CPA statute to enable optimum use of collaborative practice agree-
ing teams of physicians and pharmacists willing to share their collaborative care experience with legislators and others. Watch the NCAP Enews for “Calls to Action� and other information related to this and other important adThe North Carolina Associa- vocacy issues. tion of Pharmacists appointed a workgroup to conduct NCAP CPA Pre-Grassroots pre-grassroots work on our Workgroup collaborative practice authority. Workgroup members are Amina Abubakar noted below. The group be- Olivia Bentley gan their work on November Patrick Brown 20th, and they are charged Jennifer Burch with identifying the pivotal Matt Gibson elements of the statute for Cathy Huie which a new bill is needed Jerry McKee along with the messaging that Cortney Mospan NCAP will use in advocating Dave Phillips for change. The workgroup Mollie Scott is also charged with identify- Betsy Shilliday ments in all care settings and to improve access to care for patients by reducing barriers and making it easier for physicians and pharmacists to engage in collaborative practice agreements.
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Call for Volunteers NCAP Needs and Welcomes Your Help Membership and members who volunteer are the life blood of any non-profit association. The North Carolina Association of Pharmacists is no different in its need for volunteers. We recognize that “time” is a precious resource and people are selective regarding where, how and for how much time they volunteer. This is why NCAP has changed how we “get things done.” We recognize that some standing committees are necessary strategically. However, we also know that most people cannot or are not interested in serving on a year-long committee that may have a number of different charges. We recognize more members might be willing to help the Association if they could help with a specific project or if their time commitment was shorter or more flexible. We are preparing for 2018, and we need volunteers: pharmacists, retired pharmacists, technicians and student pharmacists. We
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need volunteers to serve on traditional standing committees. There are five of these committees (see below). Standing committees meet virtually on average once a month. We also have an array of special projects, as noted below, for which small teams of volunteers will work together virtually to complete the task. If you have some time to give, even if you are not really sure how best to serve, please send Penny Shelton, Executive Director an email at penny@ncpharmacists.org (or call 984-439-1646). In the subject line of the email type “Volunteer” and in the body of the email provide your contact information and list committees and/or projects for which you are interested in helping. [Note: If you answered the online volunteer interests survey or filled out a volunteer card at conven-
tion, we do have your interests on hand and will be contacting you soon.]
Standing Committees 1. Communication 2. Education 3. Membership 4. Policy & Advocacy 5. Resource Development
Potential Special Project Teams 1. Plan 2018 convention 2. Plan Campaign for National Pharmacy Week 3. Develop library of on-demand CE 4. Make the website ‘phabulous’ 5. Develop advance practice training for opioids 6. Develop med-assisted treatment programs for opioids
7. Develop state-wide pilot-RPh using CDC tools to improve care for patients with chronic diseases 8. Write pharmacy-related editorials for newspapers 9. Develop an academic network 10. Develop residency program directors network 11. Develop special interest groups (e.g., peds, oncol, etc.) 12. Operationalize regional structure for NCAP 13. Create video vignettes for collaborative practice 14. Find teams of MDs and Pharmacists to speak to legislators 15. Create membership video testimonials 16. Develop pharmacy technician coalition 17. Journal content and editorial needs 18. Help with NCAP award nominations 19. Help with developing vendor/exhibitor relationships
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NCAP Partners with The North Carolina Hospital Association to
“Pnockout Pneumonia”
An Update November 2017 Ralph H. Raasch, Editor, North Carolina Pharmacist
As a reminder, here are the goals and estimated
impact of the Pnockout Pneumonia campaign:
1. Over 2 years (2017-2019), reduce the annual mortality rate for pneumonia from the 2016 North Carolina baseline by 7.5%. Such a reduction would equal the national average for pneumonia mortality of 16.3%. 2. Over 2 years, reduce pneumonia readmissions by 5.4%, which would result in the inclusion of North Carolina Hospitals in the top 25% quartile of hospitals nationally. The Impact of these Goals on an Annual Basis 1. 1000 North Carolina Lives Saved. 2. 950 Readmissions Prevented. 3. $8,835,000 Saved. The following link shows the current roster of North Carolina Hospitals that have taken a
Pledge to reduce the pneumonia mortality rate and number of hospital readmissions as above: https://www.ncqualitycenter.org/initiatives/ pneumonia-knockout/hospitals-pledged-toknockout-pneumonia/ Important background information regarding the campaign can also be found at: https://www.ncqualitycenter.org/initiatives/ pneumonia-knockout/pneumonia-knockoutcampaign-resources/ The first three months of the campaign have focused on efforts to increase awareness regarding pneumonia mortality and re-admissions in North Carolina. Evidence for the success of these efforts to date has been the pledge commitments made by the many hospitals noted above. Educational and clinical strategies to accomplish the campaign goals have also begun. The focus of these initial efforts will be for primary care 12
practitioners and pharmacists. A toolkit has been prepared that focuses on improving statewide pneumococcal vaccination rates. This toolkit follows, with the first part addressing the possible efforts of how providers can participate in the campaign. Multiple resources for both patients and providers are listed in the second part of the toolkit. Ways to Participate in the Immunization Campaign: • Share the resources below with patients/ caregivers and providers. • Contact your local media and share an article on how you’re working to knockout pneumonia in your community. • Use social media to share important facts, signs/symptoms of pneumonia. Also share pictures of your staff, leadership, trustees getting their pneumonia vaccination #pneumoniaknockout • Connect with community partners (Dept. on Aging, Health Depts., Walgreens, Walmart, CVS) to host a pneumonia vaccination clinic. Resources Patient Commercial - https://www.youtube. com/watch?v=b1gfs3J_AUE Are you at risk? Take the assessment! https://www.whopneu.com/ Protect yourself from pneumococcal disease….get vaccinated! http://immunize.org/catg.d/p4412.pdf English http://immunize.org/catg.d/p4412-01.pdf Spanish 5 Questions To Ask Your Doctor http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/fivetop-questions-for-dr.html 5 Facts You Should Know About Pneumonia http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/fivefacts-you-should-know.html
Pneumococcal Vaccine Timing for Adults – Pocket Guide http://eziz.org/assets/docs/IMM-1152.pd Immunization Action Coalition http://www.immunize.org
Finally, the campaign has defined the parameters or measures that will be collected in an effort to ascertain whether the major campaign goals are achieved. These strategies for the assessment of mortality and readmissions are included below. Measurement Strategy: Pneumonia Mortality • Reduction in Number of Deaths due to pneumonia (PNE) diagnosis by facility • Improved accuracy of inpatient admissions coded correctly for PNE • Increase number of hospitals that report review and updated Sepsis Protocols • Assess baseline of hospitals that perform blood cultures on suspected sepsis patients prior to first antibiotic dose administrated • Assess pre-and post-FLU and PNE immunization rates for the nine NC counties with the lowest pneumococcal vaccination rates Measurement Strategy: Pneumonia Readmissions • Number of PNE 30-day readmissions for reoccurring condition • Number PNE 30-day NH readmissions • Number of PNE HHA 30-day readmissions • Number of facilities who have a readmission risk assessment scoring tool (Hospital, NH, HHA) • Number of appointments made at discharge from hospital with primary care for follow-up within 7 days post discharge • Number of patients who had a follow up visit with primary care provider within 7 days of discharge (CMS Claims) • Number of readmissions who failed due to poor medication management The first article in these series of updates on this campaign was published in the Summer 2017 edition of North Carolina Pharmacist. 13
Tw o Me e t i n g s - O n e L o c at i o n
March 21 - 23, 2018 Chronic Care Practice Forum Meeting
Health-System Practice Forum Meeting
Great Wolf Lodge, Concord, NC Reserve your room today at https://www.greatwolf.com/concord Offer Code 1803NORT and One Night Deposit is Required
Exhibitors please contact Sandie Holley at 984-439-1646 or sandie@ncpharmacists.org
Two new on-demand CE Webinars Diabetes Pharmacotherapy Update and Antibiotic Stewardship Primer available from NCAP FREE TO MEMBERS ONLY CLICK HERE
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Thank You to all those that attended the NCAP Beer and Wine Socials. We want to Welcome our New Members and to Congratulate the Winners of the Free Membership Raffles!
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NCAP Awards
Ambassador Award Paul W. Bush
Bowl of Hygeia Stephen M. Caiola
Cardinal Health Generation RX Champions Award Cathy H. Huie Accepted By: Stephanie Ferreri 16
NCAP Awards Community Care Pharmacist of the Year Tiffany Graham Barber
Distinguished Young Pharmacist Holly E. Causey
Don Blanton Award Robert J. McLaughlin Accepted By: Christy Hollend 17
NCAP Awards
Excellence in Innovation Robert Carta
Health-System Pharmacist of the Year Debra W. Kemp
President’s Service Award Ouita Davis Gatton
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School Awards
Campbell University College of Pharmacy and Health Sciences Preceptor of the Year Award
Campbell University College of Pharmacy and Health Sciences Preceptor of the Year Award
Dr. Will Criswell
Dr. Jonathan Harward
Wingate University IPPE Preceptor of the Year Award
Wingate University APPE Preceptor of the Year Award
Joy Jaco, PharmD
Amanda Eccleston, PharmD
UNC Paoloni Community Preceptor of the Year Award
UNC Paoloni Health System Preceptor of the Year Award
Mickey League, RPh, MS
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Brian Murray, PharmD, BCPS, BCCP
BCBS Awards
2016
EXCELLENCE IN PHARMACY Award Program TOP PERFORMER AWARD RECIPIENTS + + + + + +
Mountain Street Pharmacy Western Region College Park Pharmacy Charlotte Region Tyro Family Pharmacy Triad Region South Court Drug Company Triangle Region HomeRx Healthcare Eastern Region CVS Chain Pharmacy
Top Performers This award recognizes the independent pharmacies and the chain pharmacy with the highest medication adherence rates on the following measures: + Non-insulin diabetes medications + Hypertension medications(RAS antagonists) + Cholesterol medications (Statins)
TOP ACHIEVER AWARD RECIPIENTS + + + + +
Mountain Street Pharmacy Western Region Price Pharmacy Charlotte Region Marley Drug Triad Region Southside Pharmacy Triangle Region Thomas Drug Store Eastern Region
Top Achievers This award recognizes independent pharmacies with the greatest improvement in adherence across the three measures listed above – compared to their previous year performance.
bcbsnc.com
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other marks are the property of their respective owners. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. U13384, 8/17.
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Featured NCAP 50+ Member Charles “Micky” Whitehead Interview By Lindsay Cooper
Each year NCAP honors and recognizes 50+ members to highlight their dedication to the state association as well as to the profession of pharmacy. As a 4th year pharmacy student, I was given the honor of speaking with Micky Whitehead, a recently retired 50+ member. Little did I know, Micky and I share more than just a love for pharmacy and involvement in our state association. Although he currently lives in Asheboro, NC, he grew up and practiced in Ramseur, NC—the same small town in which my grandmother has lived since she was young. I found out that the two actually knew each other very well and that many of my family members have gone to Micky to receive their prescriptions and for medical advice. Charles “Micky” Whitehead is a lifetime member of NCAP and recently retired after working as a pharmacist for 50 years. He graduated from the University of North Carolina in 1967 after completing one year of pre-pharmacy courses, four years of the pharmacy curriculum, and a one-year internship program. From there, he returned to his hometown of Ramseur to practice with his father, Raymond Whitehead (UNC ’24), who was also a pharmacist and owned Ramseur Pharmacy Inc. Micky grew up helping out at the pharmacy and officially started working at the store at 14 years old. He immediately fell in love with compounding and the patient interaction. He knew that community pharmacy was what he wanted to do. As he moved into the pharmacist role nearly 10 years later, he worked alongside his father and eventually took over ownership of the store. In 1989, he sold Ramseur Pharmacy to Rite Aid. Though Micky retired in June of 2017, the pharmacy currently still stands and operates as a Walgreens. Although he enjoyed his 50 years as a pharmacist, Micky admits that he is enjoying retirement so far and enjoys being able to travel with his wife, Pat, and spending more time with his children and grandchildren. As a strong advocate for the profession and patients, Mr. Whitehead chose to remain highly involved during his career. As a student, he was an active member of the NC Pharmaceutical Association (NCPhA), Student Senate, and Phi Delta Chi pharmacy fraternity. As a pharmacist, he served as an executive committee member for the NCPhA, a member of the Board of Directors for the UNC School of Pharmacy Foundation, NC Mutual Drug, and for the now inactive NC Association of Professions. Micky also enjoyed serving those in his community as Vice Chairman of the Randolph County Mental Health Board and as Chairman of the Randolph County Board of Health. Some of his other positions include Chairman of the Ramseur Public Library, President of the Ramseur Lions Club (on the Board of Directors for the NC Lions Association for the Blind), Corporate Board member of Randolph Hospital, and member of the Pharmacy Education Advisory Board for Glaxo-Smith Kline. In 1973, Micky was recognized with the Don Blanton Award for his work and dedication to the advancement of pharmacy. 22
He says a lot has changed during his time as a pharmacist. One important aspect in the advancement of the profession was the incorporation of computers into pharmacy practice settings. Prior to computer accessibility, Mr. Whitehead had actually copyrighted a “Prescription Drug Information Form” that was a manual of appropriate auxiliary labels and was used at Ramseur Pharmacy to improve workflow. However, he decided not to take this idea further when computers became more and more common in pharmacies. Other than technological advances, he has also observed the advancement of direct patient care provided by pharmacists. Throughout much of his career, pharmacists were only expected to dispense medications and recommend OTC products. Generally, all other questions were directed to the patient’s doctor. Now, pharmacists can perform Medication Therapy Management, Comprehensive Medication Reviews, immunizations, blood pressure and blood glucose screenings, detailed patient education, and much more. He also noted significant development of the pharmacist-doctor relationship, resulting in improved patient care. He found this to be particularly exciting progression and did not experience any push back from doctors in Ramseur. Mr. Whitehead has also been impressed with advancing practitioner knowledge and better education of health professionals overall including pharmacists, doctors, nurses, etc. However, he did say that the one thing that has not changed during his career and that will not change over time is that patients still deserve our quality time to consult with them about their health needs. Regarding the future of the profession of pharmacy, Mr. Whitehead is most excited about the prospect of pharmacists being paid for full services offered, provider status, enhanced collaborative practice, and proving pharmacist value to patient care. As a lifetime NCAP member, Micky has contributed much to the organization. He values the annual convention and continuing education opportunities supplied by NCAP, but most of all, he is grateful for the networking and connections he has gained through the association. One of his most rewarding opportunities has been to serve as a preceptor for both UNC and Campbell pharmacy students and to assist with their learning over the last 15 years. He has enjoyed passing on his knowledge and insight to the next generation of pharmacists. Micky’s advice to new pharmacy graduates would be to 1) be people-oriented and patient-focused, 2) collaborate well with coworkers and other health professionals, 3) try to affect change, and 4) view people’s health as a priority and purpose for practice. As a 4th year pharmacy student interested in pursuing a career in community-based pharmacy practice, I am inspired by Micky’s advice. Pharmacy has changed tremendously over the years and will continue to progress thanks to innovators and advocates such as Micky. Interview by Lindsay Cooper. She is a PharmD student at the UNC Eshelman School of Pharmacy. This interview was conducted on September 25, 2017. 23
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Convention Fund-Raising The Silent Auction raised $2,325 for the Advo- Team Penske and Joe Gibbs Racing cacy Fund. Auction items were generously donated by Board members, Practice Forum Ex- Kim Nealy ecutive Committees and others. Dave Phillips / Blue Ridge Pharmacy Campbell NCAP Chapter - SPN UNC NCAP Ralph Raasch Chapter - SPN WU NCAP Chapter - SPN Jamie Brown
Penny Shelton
Jennifer Burch
Sona Pharmacy + Clinic
Carolina Hurricanes
Jenn Wilson
Carolina Panthers
Winston-Salem Convention and Visitors Bureau
Chronic Care Executive Committee Community Care Executive Committee
The following made contributions totaling $310 to the Advocacy Fund and received a free power bank.
Tom D’Andrea
Ouita Gatton
Ashley Branham Lisa Dinkins Durham Bulls Stephen Eckel Stefanie Ferreri Ouita Gatton Linda Goswick Health-System Executive Committee NASCAR Hall of Fame
Jonathan Graham Liza Hoomana Jennifer Kim Brianna Luft Macary Marciniak Holly Nunn Al Rachide Becky Szymanski The 50/50 Raffle raised $270 for the Advocacy Fund. Cathy Richwine won the raffle. She donated her winnings of $135 back to the NCAP Advocacy Fund.
Thank You! 25
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From the New Practitioner Network
Member Spotlight!
Desiree Gaines, PharmD Clinical Pharmacist - Community Pharmacy and Ambulatory Care Rx Clinic Pharmacy and Carolina Family Healthcare
Desiree Gaines started her career in pharmacy as a technician at the age of 18.
From there, she knew that a career in pharmacy was her dream. With many great mentors along the way, she later graduated with her degree from Wingate University School of Pharmacy in 2015. After graduating, she went on to complete a community pharmacy residency through the UNC Eshelman School of Pharmacy at Moose Pharmacy in Concord, NC. During her residency, she completed a project focusing on medication safety and take-back events, and she had the unique opportunity to learn new ways to provide excellent patient care through innovative services. Desiree currently has a unique clinical pharmacist role working with Rx Clinic Pharmacy, Moose Pharmacy, and an independent family practice medicine clinic, Carolina Family Healthcare. At Rx Clinic Pharmacy, Desiree works to provide Chronic Care Management, e-Care Plans, immunizations, Medication Therapy Management services, precepting, diabetic shoe fitting, and staffing. At Moose Pharmacy, Desiree works with CCNC to provide medication management for foster children and Transitions of Care services. At Carolina Family Healthcare, Desiree serves as the clinical pharmacist providing Annual Wellness Visits, Chronic Care Management, travel health consultations, diabetes education and Transitions of Care. Desiree says, “It’s challenging, but I love what I do! I wouldn’t have had these amazing opportunities without wonderful mentors in my life, while in school and during my residency.” Desiree enjoys precepting most of all. “Because I had some phenomenal preceptors and mentors, I feel that it’s now my responsibility to provide students with a unique rotation that will allow them the opportunity to experience a variety of clinical services.” Desiree serves on the Community Care Practice Forum. She says that she enjoys the NCAP annual convention because she has the opportunity to network with the amazing pharmacists in North Carolina and surrounding areas. 29
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Mentoring Student Pharmacists:
Suggestions for New Practitioners
Megan Coleman Cortney Mospan
Introduction Thinking through your professional development, more than likely, there were mentors who played a role in molding you and defining your professional path. As new practitioners gain experience, mentoring student pharmacists is a great way to give back to the profession and pay-it-forward! Many opportunities for mentoring exist, each with unique skills development and learning opportunities.
Student Organizations
Too often, student pharmacists do not fully grasp the immense development opportunities that student organizations offer. It is important to encourage students to attend professional meetings, especially state and local meetings, stressing the professional networks that these meetings facilitate.
If you serve in a formal mentorship or advisor role to student organizations, there are additional opportunities. Patient outreach activities and inviting practitioners to share their experiences at chapter meetings can provide opportunities to work with students on their planning skills. Outreach events take much coordination between the site, finding a preceptor, and getting necessary supplies. You can work with students to create realistic time lines to ensure event success, review compliance with necessary laws and regulations (CLIA waivers, legal intern activities, etc.), and help them acquire necessary supplies in advance. Naturally, conflict will arise between team members. Working with executive committees 31
of student organizations, you can proactively create leadership development seminars by utilizing StrengthsFinders1, the Conflict Management Scale for Pharmacy 2, and other resources. You can also individually coach students in areas they self-identify as opportunities for improvement.
Student Research
Engaging students in research efforts can be another avenue to mentor students in their professional growth, particularly those who are interested in residency training. By involving students in your research efforts, they can provide support in data collection, IRB submission, and writing the manuscript while gaining valuable skills along the way. Engaging students with practice areas similar to your own early
in the research project allows for students to see the process of development of a research idea from the generation of the hypothesis to conducting the background search, to running the project and working towards publication. Mentoring students through this process better prepares them for research as residents and helps to develop their writing and critical thinking skills prior to graduation, potentially enabling them to feel more comfortable with generating their research project idea as a resident.
tunity to assist students with career discovery. One tool that may be helpful for this particular discussion is the APhA Career Pathway Evaluation Program for Pharmacy Professionals 3. Once students have identified an area of practice interest, working with them to foster this interest and develop career goals can be very rewarding.
During practice experiences, demonstrating appropriate time management of both practice and professional responsibilities, while maintaining patient care as the highest priority, is necessary to the professional development of students. As a mentor, opportunities may arise for you to work with a student on their time management skills to better balance and prioritize the demands of the profession. Additionally, modeling professionalism is essential as students often emulate behavior observed during practice experiences.
Cortney Mospan, PharmD, BCACP, BCGP, is an NPN Liaison to the Community Care Practice Forum and Assistant Professor of Pharmacy, Wingate
Practice Experiences
You may also have the oppor-
Megan Coleman, PharmD, BCPS, CPP, is an NPN Executive Committee Member-atLarge and Assistant Professor of Pharmacy, Wingate University School of Pharmacy, m.coleman@wingate.edu
32
University School of Pharmacy, c.mospan@wingate.edu
Drs. Coleman and Mospan have no potential or actual conflicts of interest in relation to this article. References 1. Rath, Tom. Strengths Finder 2.0. New York: Gallup Press, 2007. Print. 2. Austin Z, Gregory PA, Martin C. A conflict management scale for pharmacy. Am J Pharm Educ 2009;73(7): Article 122. 3. “APhA Career Pathway Evaluation Program for Pharmacy Professionals.� American Pharmacists Association. Available at: www.pharmacist.com/pathway_survey. Accessed September 25, 2017.
33
The Potential Harmful Effects of E-cigarettes in Youth: It’s Not Just Vapor Carolyn Ford Dominique L. McClain Trana Rashid Introduction “It’s not harmful, it’s just water vapor” is a common misconception about electronic cigarettes (EC) held by many American youth today.1 Because of this widespread belief, targeted marketing tactics, and other psychosocial factors, the use of EC has skyrocketed among adolescents and young adults.2 According to the 2016 National Youth Tobacco Surveys (NYTS) data analyzed by the Centers for Disease Control and Prevention (CDC), 4.3% of middle school students reported using EC over the past 30 days in 2016 compared to 0.6% in 2011.3 Similarly, 11.3% of high school students reported using EC over the past 30 days in 2016 compared to 1.5% in 2011. This sharp increase, rampant use in teens and young adults, and potentially harmful effects have prompted the U.S. Surgeon General to declare EC use a major public health concern.2 Accordingly, it is important that health professionals, especially pharmacists, become familiar with all aspects of EC use in this population. Prevalence of E-Cigarettes in Adolescents
EC use has sharply increased from 1.5% to 16% among high school students and 0.6% to 5.3% Electronic cigarettes are among middle school students the most common form of tobac- from 2011 to 2015.4 For the first co used by youth in the United time in 5 years, EC use dropped States.2 According to the 2016 from 16.8% to 11.3% among high NYTS CDC surveys, e-cigarette school students and 5.3% to 4.3% use among high and middle among middle school students beschool students, respectively, was tween 2015 and 2016.3 However, 11.3% (1.68 million users) and it is important to note that over 2 4.3% (500,000 users) in com- million youth are EC users and parison to traditional cigarettes, that this rate exceeds the use of which was 8.0% (1.18 million us- cigarettes and other tobacco proders) and 2.2% (260,000 users).3 ucts. Also, the same survey found 34
that current use of any tobacco product in high school students was 20.2% (1 in 5) and 7.2% (1 in 14) in middle school students for a total of 3.9 million tobacco users. Moreover, the use of multiple tobacco products is also prevalent in youth. Nearly 10% of high school students (47.2% reporting the use of any tobacco product) and 3.1% of middle school students (42.4% reporting use of any tobacco product) reported use of two or more tobacco products in the past 30 days.
Prevalence of E-Cigarettes in North Carolina North Carolina leads the nation in tobacco product growth and ranks #45 in state spending on tobacco prevention (equivalent to 1.2% of CDC recommended spending).5 Therefore, it is not surprising that NC youth have a higher tobacco use rate (including EC) than the national average.6 According to the North Carolina Youth Tobacco Survey, there was an 888% increase in EC use among high school students between 2011 and 2015.7 During the same time period, EC use increased 600% in middle school students. In comparison, the national EC use rate was 16% vs.16.8% among high school students and 5.3% vs. 6.99% among middle school students in 2015. Also, nearly 28% of NC high school students reported that they were considering using EC in 2016.7 The NC EC use data for 2016 is currently unavailable. Moreover, it is not possible to determine if NC witnessed a similar, significant decline in EC use among middle and high school students consistent with the national rates. Descriptions of E-Cigarettes E-cigarettes, also referred to as e-cigs, vapes, vaporizers, vape pens, e-hookah, hookah pens, tank systems, mods, and epipes, are a group of devices collectively known as electronic nicotine delivery systems (ENDS).8 These battery-powered devices produce an aerosol or vapor that usually contains nicotine. Inhala-
tion of this aerosol is known as “vaping” and mirrors the smoking of a traditional cigarette. Despite the wide variability in design and appearance, EC typically have three primary components: 1) battery, 2) electronic heating element (atomizer, cartomizer, or clearomizer), and 3) fluid cartridge (Figure 1). The battery is the power source for the electronic heating element that heats the liquid in the cartridge and produces the aerosol or vapor for inhalation. EC devices can be activated automatically where a flow sensor detects the air current created by the user puffing on the device or manually where the user presses a button. The cartridge or reservoir holds a liquid solution, commonly referred to as e-liquid or e-juice, which typically contains nicotine, humectants (such as propylene glycol and vegetable glycerin), flavorings, and other potentially harmful chemicals.9,10 The nicotine concentration in the e-liquid can range from 0 to 36 mg/ml in comparison to the 0.7-2.39 mg found in traditional cigarettes.11 The humectants serve as carrier solvents to generate the smokelike appearance of aerosol. Considering that most e-liquids are flavored, it’s estimated that approximately 8100 unique flavors exist with sweet and fruity flavors like candy and bubble gum being the most common and attractive to adolescents. There are approximately 500 brands of EC that can be divided into four major types or generations (Table 1)12. The first generation, referred to as “ciga-likes,” is relatively small and resembles a traditional cigarette in size and 35
shape. Some may also have an LED light on the end that lights up to simulate smoking. Other versions of ciga-likes resemble a cigar or pipe. The disposable version is unusable after the battery dies. The non-disposable version has a rechargeable battery and a replaceable cartridge (cartomizer) that is pre-filled or refillable. The second-generation devices, typically shaped like pens or laser pointers, are referred to as vape pens. They are also called tank systems because of their transparent, cylindrical reservoir that holds much larger quantities of e-liquid than the first-generation models. These systems are reusable, allow any type of fluid, and have variable voltages. Some second generation devices called “mods” can be modified according to user preferences. Third and fourth generation devices--sometimes referred to as advanced personal vaporizers (APVs) or “mods”--vary significantly in shape and size and have very little resemblance to a traditional cigarette. They are customizable and vary in battery size, voltage and wattage. The fourth generation devices have added capacity to regulate temperature. Harmful Effects of E-Cigarettes The use of EC in youth has been declared a major health concern due to widespread use and the likelihood of harmful health effects attributable to aerosolized nicotine, flavorings, solvents, chemicals, and toxicants.2 This concern is further exacerbated by the current lack of FDA regulations that allow a wide variability of e-liquid constituents from prod-
uct to product and EC devices marijuana, cocaine, and metham- sea, abdominal pain, vomiting and 2 (regulation scheduled in 2018).13 phetamines. It has also been de- diarrhea, tachycardia, and elevatTherefore, a review of how e-liq- termined that the younger the age ed blood pressure) secondary to uid constituents potentially lead of nicotine initiation, the stronger nicotine absorption through the to harmful health effects is war- and faster the rate of addiction. skin have been reported. Additionally, nicotine use in adoranted. lescents may serve as a gateway Solvents to smoking traditional cigarettes Nicotine which are significantly more toxic Propylene glycol and veg17 than EC. Research has shown etable glycerin are solvents used The negative consequences of nicotine (secondary to to- that youth who use EC are more in EC. Per the Agency for Toxic bacco use) are well established. It likely to start using other tobacco Substances and Disease Registry (ASTDR), propylene glycol is an is also known that young individu- products like cigarettes. Another major concern is additive found in foods, medicaals are more susceptible to the 19 adverse effects of nicotine than acute nicotine toxicity or poison- tions, and cosmetics. It is safe adults.14 As most EC contain ing that can result from inges- for ingestion, injection, and topical 2 nicotine and deliver concentra- tion of e-liquids. Commercially administration. However, it has tions equivalent to or higher than available e-liquid refill cartridges not been addressed whether it is traditional cigarettes, similar ad- contain up to 36 mg of nicotine safe for inhalation. Other names verse health effects are expected whereas cartridges purchased for propylene glycol are 1,2-prowith these agents. This increased wholesale from the internet can panediol, 1,2-dihydroxypropane, sensitivity to nicotine in youth cor- contain up to 100 mg of nicotine. methyl glycol, and trimethyl glycol. relates to its ability to impair brain A lethal poisoning can occur, es- Aerosolized propylene glycol has development.15 During the period pecially in children, if the contents been used during military exercisof adolescence up to age 25, the of one nicotine refill cartridges is es and fire simulations because brain is undergoing major struc- consumed, considering that the of its ability to produce a dense tural remodeling and rapid growth lethal dose in adults is 0.5-1.0 mg/ smoke without open flames. The in circuitry that controls executive kg and 0.1-0.2 mg/kg in children, ASTDR reports that people who functioning (e.g. decision-making, respectively. Young children un- receive a rapid intravenous infuself-discipline, impulse control, at- der 6 years of age are the most sion of the substance or have intention, learning, memory, reason- vulnerable to poisonings, and the creased contact time with the subing, reward processing, and emo- incidence of poisonings has in- stance are at the highest risk for tional maturation).16 Disruption of creased significantly secondary to toxic exposure to propylene glythis neurobiological maturation by widespread EC use. According to col. Propylene glycol has a similar nicotine can result in long-lasting National Poison Center calls, an chemical structure to ethylene glycognitive and behavioral impair- average of one call per month for col. While these two compounds ments such as reduced impulse nicotine poisoning was reported in have similar structure, ethylene control, disruptive behaviors, de- 2010 compared to an average of glycol exposure is more hazard18 ous to the body. creased ability to learn and pay at- 215 per month reported in 2015. Vegetable glycerin is a tention, reduced working memory, As of July 2016, the Child Nicotine Poisoning Prevention Law food additive that is also referred and increased mood disorders. Nicotine also impacts the requires e-liquid refill containers to as glycerol, glycerin, 1,2,3-probrain reward processing center be sold in child-resistant contain- panetriol, and 1,2,3-trihydroxypro20 during this sensitive maturation ers. Nicotine toxicity secondary to pane. There are currently no sufperiod which can lead to drug- eye, skin, or mucous membranes ficient data on health hazards that seeking behaviors that result in exposure is usually limited to local can result from direct inhalation of 20 a higher risk of addiction to nico- irritation. A few cases of systemic vegetable glycerin. tine and other drugs like alcohol, toxicity (increased salivation, nau36
Flavorings
their flavored smokeless tobacco product users to move onto unflaFlavorings were originally vored products that deliver more created to mask the tobacco fla- nicotine.23 vor and increase the appeal to Lastly, there is apprehenyounger users. When youth are sion regarding the safety of inhalasked why they started using e- ing flavorings without sufficient cigarettes, curiosity, flavoring and data on their long-term health efperceived low harm compared to fects.24 E-liquid manufacturers other tobacco products top the list. have claimed that the flavoring inIn a study performed by Popula- gredients are recognized as safe tion Assessment of Tobacco and when labeled “food grade”, but the Health (PATH), 13,651 youth Flavor Extracts Manufacturers Aswere surveyed on their use of fla- sociation has declared that safety vored tobacco products. 81.5% of warning only applies for ingestion, the e-cigarette users in this study not inhalation.25 stated that they use e-cigarettes because of the flavoring options Adulterants as they selected “because they come in flavors I like” as one of Researchers have found the eleven options available on adulterants in EC that can result the survey.21 The study ultimately in unhealthy consequences. Nicoconfirms flavorings as a reason tine, nornicotine, anabasine, and for e-cigarette usage in the youth. anatabine are all alkaloids found The 2009 Family Smoking Pre- in a cured tobacco leaf.26 Nicovention and Tobacco Control Act tine makes up the majority of all prohibits flavorings other than the alkaloids. The other alkaloids menthol in cigarettes.22 The US. will eventually become tobacco Food and Drug Administration is specific N-nitrosamines (TSNAs) currently attempting to regulate during the curing process after e-cigarettes, but new legislation undergoing nitrosation. TSNAs has been introduced to weaken include 4-(methylnitrosamino)FDA oversight despite strong evi- 1-(3-pyridyl)-1-butanone (NNK), dence of the link between flavored N’-nitrosonornicotine (NNN), N’tobacco products and e-cigarette nitrosoanabasine (NAB), and Nuse among the youth. nitrosoanatabine (NAT). The InterThe popularity of flavored national Agency for Research on e-cigarettes is very concerning Cancer (IARC) deemed that both as usage increases among youth NNK and NNN are human carand facilitates addiction. This ad- cinogens. TSNAs like NNN and diction can lead to the use of other NNK are found in tobacco cigatobacco products causing ad- rettes sold in the United States.27 ditional harm. It has been docu- Consumers often assume that bemented that tobacco companies cause they are not actually smokmarketed flavored mini-cigars ing tobacco while using EC they (and cigarillos) to intentionally fa- are avoiding these TSNAs; howcilitate youth uptake of cigarettes. ever, that is incorrect. A study was Companies have also intended for done to determine the concentra37
tion of TSNAs in EC produced by four different U.S. companies.28 Researchers used Cambridge filter pads to collect the aerosol released by the EC. Contents of the pads were then extracted with methanol so they could be analyzed using liquid chromatography and mass spectrometry. The study found traces of the TSNAs that were below the limit of quantification designated to be 90 ng/g by researchers. This evidence does suggest that TSNAs are present in the EC; however, the quantities found are lower than what would be discovered in actual tobacco-containing products. Another study was done to determine how much of the alkaloids were present in EC.29 In this study, researchers purchased several nicotine-containing EC online. The cartridges were removed from the smoking devices and mixed in methanol for extraction. High performance liquid chromatography was used to analyze the extractions. One brand in particular had concentrations of anatabine well above the set quantification limit. This is concerning because the alkaloids in EC can potentially undergo nitrosation while being manufactured or if the product is stored incorrectly (which would result in TSNAs being formed).2 Toxins The potential hazards associated with e-cigarette inhalation are complicated due to multiple factors: battery voltage, temperature, nicotine concentration, flavoring chemicals and other e-liquid contents.30 These factors vary widely and produce aerosol-
ized components at different temperatures. E-liquids are normally labeled with nicotine content and a propylene glycol/vegetable glycerin ratio. However, the list of toxic chemicals produced during the atomizer heating process is not directly labeled.31 A study was performed to identify different chemicals in 30 different e-cigarette fluids. A significant number of the chemicals used for flavorings were irritants like aldehydes which can cause damage to the respiratory tract.25 Another study detected the presence of pharmaceutical ingredients amino-tadalafil and rimonabant in e-liquids; some users of the pharmaceutical drug rimonabant reported instances of psychiatric adverse events and neurologic symptoms and seizures. The presence of such chemicals can pose a threat to e-cigarette users due to their unknown effects.32 E-liquids were also found to have diethyl phthalate and diethylhexyl phthalate which both have estrogenic and antiandrogenic effects. Diethylhexyl phthalate is also classified as a suspected carcinogen in humans. The liquids used for e-cigarette refills were also found to have chemical compounds diacetyl and acetyl propionyl (adds a buttery flavor to the product). The National Institute for Occupational Safety and Health declared these compounds safe for ingestion for flavoring but has not declared them safe for inhalation. A study was performed testing 159 samples from 36 different manufacturers and both compounds were found in 74% of the samples tested. Out
of the 74%, approximately half of the samples exposed consumers to levels higher than approved safety limits.33 E-liquid aerosols were also found to have traces of heavy metals such as tin, silver, iron, nickel, cadmium, aluminum and silicate. Concentrations of these heavy metals were found to be higher than or equal to concentrations in original cigarette smoke. Lead and cadmium are specifically linked to respiratory disease.34 The battery voltage is also a component that affects the toxicity of inhalants. Carbonyls like formaldehyde, acetaldehyde and acrolein are found in e-cigarettes with increased voltage.35 These carbonyls are the outcomes from the oxidation of propylene glycol and vegetable glycerin due to high temperatures. Formaldehyde is classified as carcinogenic to humans according to the U.S. Environmental Protection Agency with the maximum allowable daily intake of 0.2 mg/kg.36 Acrolein is toxic in all forms and has been a common factor in several pulmonary diseases like lung cancer, asthma, and chronic obstructive pulmonary disease.37 Increased chances of generating these carbonyls were found at voltages at or above 5 volts. 38 E-cigarette aerosol is misconceived as harmless water vapor to many users. However, e-cigarette users are exposed to several compounds like carbonyl compounds or organic compounds that can cause adverse effects. The effects are still unknown for some of the chemical compounds and will continue to be difficult to research as more di38
verse products become available. Device Malfunction Bodily injury and property damage are common results of EC device explosions and fires. According to the U.S. Fire Administration, 195 separate cases of EC-related explosions and fires were reported between 2009 and 2016.39 Of these incidents, 68% caused bodily injuries and 66% ignited a fire in bedding, clothing, drapes and vehicle seats. 29% of these individuals suffered potentially life-threatening injuries like severe chemical burns, fractured neck vertebrae, finger loss, and nicotine overdose. The U.S.Fire Administration has also determined that the root cause of EC device malfunction is lithium ion battery thermal runaway which causes the battery (or container) to behave like a “flaming rocket.” While the device’s battery is being charged, thermal runaway occurs when the internal battery temperature overheats to explosive levels. The overcharging of the lithium ion battery stems from user error, confusing charging instructions, manufacturing flaws or defects secondary to lack of regulation, poor design, faulty charging units, and counterfeit batteries. In addition to properly charging the battery in accordance with the manufacturer’s instruction, using devices that protect from overcharging, regulate thermal power, and relieve internal overpressure can help prevent thermal runaway.
Second-hand Exposure EC devices produce an aerosol that is exhaled by the user into the environment. This aerosol contains harmful (and potentially harmful substances) like nicotine, heavy metals, TSNAs, VOCs and glycols that can be inhaled, ingested, and absorbed through direct dermal contact by bystanders in a similar manner to traditional cigarette smoke (second-hand exposure). Third-hand exposure can occur when bystanders come in contact with EC aerosol constituents deposited on surfaces. The aerosol produced by EC contains ultra-fine particles that are similar in size and present in higher concentrations than particles found in traditional cigarette smoke. Due to this small size, these nanoparticles can penetrate deeply into the lungs and cross into the systemic circulation of users and bystanders resulting in potentially harmful effects. The FDA has determined that even though the concentration of most harmful substances is lower in EC than traditional cigarette smoke, they can accumulate inside indoor environments. The amount of EC aerosol inhaled by bystanders is unknown and currently under investigation. The concentration of EC aerosol released into the environment is dependent on many factors that include the type of device, e-liquid concentration, number of puffs, depth of inhalation, and the number of users in the room. There is evidence that passive exposure to EC aerosol can result
in increased serum nicotine levels (measured as the metabolite cotinine) that are similar from passive exposure to traditional cigarette smoke which can adversely impact long-term lung function. Passive EC aerosol may also produce allergic reactions in bystanders due to exposure to allergens like propylene glycol and nuts used in some flavorants. This potential risk for allergic reactions and other health concerns (secondary to EC aerosol) should be further investigated based on underlying factors like the high incidence of food allergies in the U.S. Until the long-term health effects are determined, the use of EC in indoor environments should be included in smoke-free regulations.40 Conclusions EC are the most commonly used form of tobacco among youth today. Consequently, youth usage has become so widespread that the U.S. Surgeon General has declared it a major public health concern. Other reasons for this alarming trend are increased nicotine sensitivity (and a greater risk for addiction), delayed brain development, gateway use to other tobacco products like traditional cigarettes, increased unintentional nicotine poisonings, and harmful effects due to inhaling or ingesting aerosol toxicants.41 This problem is further complicated by unregulated aggressive marketing on mainstream media channels that specifically target youth. In an effort to improve EC 39
safety and limit the use in youth, the FDA has approved regulations similar to other forms of tobacco. It is important to note that many EC regulations have not been implemented due to judicial delays. Until such time when regulations are fully implemented to include smoke-free policies, a major public health effort that includes education, prevention, and youth advocacy is warranted to protect vulnerable populations from potential harm.
Carolyn Ford, PharmD. (Corresponding Author) is Professor and Director of Community Healthcare Outreach, Wingate University School of Pharmacy. cford@wingate.edu Dominique L. McClain and Trana Rachid are PharmD Students, Wingate University School of Pharmacy. None of the authors have a conflict of interest.
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electronic cigarette fluids. Tobacco Control 2016;25(e1):e10–e15.
14. Schraufnagel, Dean E. “Electronic Cigarettes: Vulnerability of Youth.” Pediatric Allergy, Immunology, and Pulmonology 28.1 (2015): 2–6. PMC. Web. 2 Oct. 2017.
27. Stepanov I, et al. Carcinogenic tobacco-specific N-nitrosamines in US cigarettes-three decades of remarkable neglect by the tobacco industry. 2012 Jan. Tob Control. 21(1): 44-48.
15. Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. J Physiol. 2015;593:3397-3412. 16. England, Lucinda J. et al. Nicotine and the Developing Human. Am J Prev Med. 2015 Aug; 49(2): 286–293. 17. Barrington-Trimis JL, Berhane K, Unger JB, et al. The e-cigarette social environment, e-cigarette use, and susceptibility to cigarette smoking. J Adolesc Health. 2016;59:75-80. 18. American Association of Poison Control Centers. January 31, 2016. Electronic Cigarettes and Liquid Nicotine Data. 19. Agency for Toxic Substances and Disease Registry .“Ethylene Glycol and Propylene Glycol Toxicity”. U.S. Department of Health and Human Services. 2007. 20. National Institute for Occupation Safety and Health (NIOSH) “Glycerol” . Centers for Disease Control. 2014 July. 21. Ambrose BK, Day HR, Rostron B, Conway KP, Borek N, Hyland A, Villanti AC. Flavored tobacco product use among U.S. youth aged 12–17 years, 2013–2014. JAMA: the Journal of the American Medical Association2015;314(17):1871–3. 22. Family Smoking Prevention and Tobacco Control Act, Pub L No. 111-31, 123 Stat 1776 (2009). [cited 2017 Sept 10] Available from: https://www.gpo.gov/fdsys/pkg/ PLAW-111publ31/pdf/PLAW-111publ31.pdf 23. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 24. Centers for Disease Control and Prevention. Flavored tobacco product use among middle and high school students— United States, 2014. Morbidity and Mortality Weekly Report 2015a;64(38):1066–70. 25. Tierney PA, Karpinski CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in
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28. Flora JW, et al. Characterization of potential impurities and degradation products in electronic cigarette formulations and aerosols. 2016. Regul Toxicol Pharmacol., 74 (1-11). 29. Trehy ML, et al. Analysis of electronic cigarette cartridges, refill solutions, and smoke for nicotine and nicotine related impurities. 2011. J Liq Chromatogr Relat Technol. 34;1442-58. 30. Seidenberg AB, Jo CL, Ribisl KM. Differences in the design and sale of e-cigarettes by cigarette manufacturers and non-cigarette manufacturers in the USA. Tobacco Control 2016;25(e1):e3–e5. 31. Talih S, Balhas Z, Eissenberg T, Salman R, Karaoghlanian N, El Hellani A, Baalbaki R, Saliba N, Shihadeh A. Effects of user puff topography, device voltage, and liquid nicotine concentration on electronic cigarette nicotine yield: measurements and model predictions. Nicotine & Tobacco Research 2015;17(2):150–7. 32. Hadwiger ME, Trehy ML, Ye W, Moore T, Allgire J, Westenberger B. Identification of amino-tadalafil and rimonabant in electronic cigarette products using high pressure liquid chromatography with diode array and tandem mass spectrometric detection. Journal of Chromatography A 2010;1217(48):7547–55. 33. Farsalinos KE, Kistler KA, Gillman G, Voudris V. Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine & Tobacco Research 2014a;17(2):168–74. 34. Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PloS One 2013;8(3):e57987 35. Kosmider L, Sobczak A, Fik M, Knysak J, Zaciera M, Kurek J, Goniewicz ML. Carbonyl compounds in elec-tronic cigarette vapors: effects of nicotine solvent and battery output voltage. Nicotine & Tobacco Research2014;16(10):1319–26. 36. International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: A Review of Human Carcinogens.
Part F: Chemical agents and related occupations. Vol. 100F. Lyon (France): International Agency for Research on Cancer, 2009. 37. Bein K, Leikauf GD. Acrolein—a pulmonary hazard. Molecular Nutrition & Food Research2011;55(9):1342–60. 38. Geiss O, Bianchi I, Barrero-Moreno J. Correlation of volatile carbonyl yields emitted by e-cigarettes with the temperature of the heating coil and the perceived sensorial quality of the generated vapours. Int J Hyg Environ Health. 2016 May; 219(3): 268–277. 39. McKenna, LA Research Group. Electronic Cigarette Fires and Explosions in the United States, 2009-2016. https://www. usfa.fema.gov/downloads/pdf/publications/ electronic_cigarettes.pdf 40. April 2015 CDC Letter of Evidence on Electronic Nicotine Delivery Devices. http://quitlinenc.com/. 41. Know the Risks: E-cigarettes & Young People. 2016 U.S. Surgeon General Report. https://e-cigarettes.surgeongeneral. gov/.
Figure 1: Variety of E-Cigarettes Shapes and Sizes Photo Reproduced from CDC: Mandie Mills.
DIFFERENT TYPES OF E-CIGARETTES 1st Generation
Ciga-like
3rd Generation
4th Generation
Mods*
Mods or APV
Mods or APV
Variable size & shape
Variable size & shape
Variable size & shape
customizable
customizable
customizable
Clear fluid cartridge, cylindrical in shape
Unregulated battery power
Variable voltage and power
Variable voltage, power, and temperature
Pre-filled and refillable
Refillable
Refillable
Refillable
Refillable
Tank-based
Tank-based
Tank-based
Tank-based
Rechargeable
Rechargeable Separate battery and tank
Rechargeable Separate battery and
Rechargeable Separate battery and
Rechargeable Separate battery and
Ciga-like
2nd Generation
Vape pens
Common Names General Description
Looks & feels like a traditional cigarette
Refillable
Pre-filled
Cartridge-type
Rechargeable
Disposable Single unit
Can look like pipe or cigar
Size, shape, & color varies widely
Table 1. Physical features of the different types of E-cigarettes. 12 41
42
• From the CDC, Influenza Vaccination Update. Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. For the full report, https://www. cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm • Update on CMM Grant at UNC, as published in Septeber 2017 ACCP Report. https://www.accp.com/report/index. aspx?iss=0917&art=6
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