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The Surgeon General has newly released a report on smoking cessation.  Since the first report released in 1964, the Surgeon General has published more than 25 reports on the health effects from tobacco, second hand smoke, e-cigarettes, and addiction, but this is only the second report, and the first in 30 years, on a topic of personal interest to the members of the EX community: smoking cessation. 

The major conclusions in the report include 1.) Despite important and dramatic reductions since 1964 in the percentage of people who smoke, tobacco is still the leading cause of preventable death in the United States. 2.) Smoking cessation at any age improves health and enhances quality of life. 3. Most people who smoke attempt to quit each year but the large majority of them do not use methods (like EX) that are proven to improve success.  4.) FDA approved smoking cessation medications and counseling or other behavioral support effectively increases success in quitting.  5.) Coverage for smoking cessation that is barrier free and widely promoted leads to higher rates of successful quitting.

 

 

What the report has to say about web based support may be of particular interest to members of the EX Community.  For any of the Reports, the Surgeon General team review thousands of studies and then determine if the scientific evidence is sufficient to show cause, or infer the effectiveness of an intervention.  This new report finds for the first time, that the evidence is sufficient to determine that web and internet interventions increase success for people trying to quit, especially if the site is interactive. 

 

 

But, I suspect you already knew that.  You see the wonderful success that stems from EX every day. You hear from one another about how the struggle to quit becomes easier over time, how the health benefits happen for people of any age, and how quality of life can improve each day.  You encourage those who are struggling, congratulate those who are succeeding, and welcome those who are unsure. The interactive support you provide for one another is wonderful, and it works!  Thanks and keep up this good work!

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

You probably are aware that ‘Tobacco 21’ was signed into federal law in December, and went into effect as of January 1, 2020.  This is a good thing.  The National Academy of Medicine in a report issued in 2015 estimated that this law would reduce smoking initiation among people ages 15-17 by 25% and among those age 18-21 by 15%; eventually resulting in more than 200,000 saved lives for people born since the year 2000.

 

The purchasing restrictions include all types of tobacco including cigarettes, cigars, pipe tobacco, chewing tobacco, snus and dissolvable nicotine products.  It also restricts sales for anyone under 21 of all types of vapes and e-cigarettes, including e-liquids and components intended for use in an electronic smoking device such as mechanical heating elements, batteries or tanks.

 

A question was raised about how this might affect people between ages of 18 and 21 who might be tobacco addicted and suffer from craving and withdrawal symptoms.  The new regulation does not include medications, like nicotine replacement, Chantix, or Zyban, that can alleviate craving and withdrawal and help people to stop smoking or vaping.  Again, good news from our perspective.

 

Would be interested in hearing any thoughts or experiences people in the community might be having with the new Tobacco 21 regulation.

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

We often hear from people that they are better off not making a tobacco quit attempt because they are depressed, anxious, or too stressed and they fear that these problems will worsen if they stop using tobacco.  These challenges can certainly make it difficult to consider stopping, and often the reinforcement from nicotine is paired with natural and effective coping skills like taking a breath, stepping away from a situation, or taking time to think things through.  The good news is that for many people, stopping tobacco will usually result in improved mood, and lower levels of depression, anxiety and stress.  

 

A number of studies have now found that within 2 weeks of stopping tobacco stress, anxiety, and depression all improve.   And, the total effect from stopping smoking is comparable to the effect shown in studies of people who begin antidepressant treatment for mood and anxiety disorders.  Contrary to what many people believe, stopping smoking may help improve their mental health in addition to being the single best thing they can do to improve their physical health.

 

There is an important caveat.  Depression and anxiety are relatively common nicotine withdrawal symptoms.  So, withdrawal can mask the improvements in mood that happen after stopping tobacco. This is one reason that a nicotine replacement therapy (nrt) can help people quit, it effectively reduces the withdrawal symptoms like irritation, anxiety, depression and stress. 

 

  I would be interested to hear your thoughts and experiences with quitting, anxiety, depression, and stress?

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

NDC.Treatment.Team

Resolution Time

Posted by NDC.Treatment.Team Jan 8, 2020

 

It’s resolution time of the year,...again.  Making a resolution is an admirable New Year tradition but, resolution season can be a time of demoralization and great pressure from self and others.   As a person wanting to make any important change, are you sometimes worried burdened with judgement and expectation from others, or yourself, that your resolution should be completely and perfectly accomplished?  

 

Quitting smoking or staying tobacco free is a great resolution, as it can be a singular path to achieving three of the most touted New Year’s resolutions:  health (saving your body from smoking related illnesses), wealth (saving your income from smoking related costs) and peace of mind (saving yourself from anguish about engaging in the harmful habit).  However, one can get discouraged by challenges or the fear of failure in light of the expectations by the second week of January. So, how do we resolve to achieve this goal without caving under its weight?   I have suggestion, just a suggestion: approach quitting tobacco or other resolutions in a gentle, uplifting and “bit by bit” way.

Resolve to:

  1. Go beyond verbalizing a resolution and create a plan for managing stress, cravings and triggers.
  2. Resist the tendency to try to conquer the beast on your own. Let others know your goals and challenges.
  3. Resist the urge to “rush” the process.
  4. Resist the tendency to romanticize the relationship with cigarette or old behaviors.
    • For example, beware of thoughts like “It has or had been the only thing that has been there for me through the highs and lows for 30 years.”
  5. Don’t wait to celebrate your accomplishments along the way to the long-term goal.
  6. Resist all or nothing thinking.

Instead:

  1. Identify a plan that can work for you to make the process easier.
  2. Reach out to your trusted family and friends or participate in the EX community.
  3. Take each day at a time, or one moment at a time if need be.
  4. Recognize and draw from your strengths in overcoming great challenges in the past. And remind yourself why you choose to be healthier.
  5. Honor your efforts daily.
  6. Never, ever give up believing in, going after and yes, even fighting for the best healthy lifestyle for you.

 

Any additional thoughts from EX community members?

 

Jennifer Burden, PhD

NDC Counselor/CTTS

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

 

The holidays can be a challenge for people who are trying to stop smoking or vaping.  Being busy with family commitments, shopping lists, party preparations, and the chaos of the holidays can be quite stressful.  And while on one hand, being busy can take one’s mind off of smoking, there is also a drain that occurs to the ‘willpower’ muscle, so that a quick impulse and opportunity to smoke results in lighting up or puffing.  However, thinking through and deciding on what you’ll do if the opportunity to use arises, is a path to success. 

 

When the urge to smoke or vape happens, the cognitive energy to develop an alternative is somewhat compromised.  Having pre-formed plans of what you will do in a smoking situation makes it much easier to do something different.  It doesn’t have to be much.  Sipping a glass of water, taking a deep breath, thinking of those you love, are all alternatives that will allow the thought of smoking to fade, and assure that you will get onto a smoke/vape free season.

 

Remember also that smoking will not solve worries and it is not an effective way to manage stress.  Find real ways to build your body’s stress immunity: laugh, do something you enjoy, talk with a friend, get active.  There are many ways to build your resilience.  Check out the BecomeAnEX.org website and click the picture at ‘New Tobacco-Free Ways to Relieve Stress’ to see how you might really reduce stress and build your relaxation response.   

 

The holidays can be a good time to help the people you know and love be most supportive. Let those who can be helpful know that you are doing something important.  If you can, limit your time as much as possible with people who smoke and if you cannot, make a plan for slipping away into a smoke-free room or outside environment for those times and places where you know relatives and loved ones will be smoking. 

 

Put some fun time and effort into being good to your-self during the holiday. Happiness relieves stress. Look for recreation throughout your day. Enjoy!  As the song says, ‘Don’t worry. Be happy.’   And may we add – ‘Be healthy!’

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

Next week, here in the northern hemisphere, is winter solstice, the shortest day, the darkest day, of the year.  The solstice however is the beginning of a change. Each day afterwards, the amount of daylight increases.  Each day is brighter and longer through spring and into summer.  I like to think of the solstice as a time of renewal, a time when we can begin to kindle a sure hope of spring.

 

This time of year also reminds me of the struggle, challenge, and eventual achievement people face in becoming tobacco free.  As you all know, the process of stopping smoking can be long and difficult.  It is not uncommon to struggle through feelings of discouragement and hopelessness.  But at some point, maybe at many points in a lifetime, hope that one can succeed  begins to dawn and builds into an intention, a plan, success and increasing confidence in a tobacco free life.

 

I wish all of you a warm, hopeful and tobacco-free holiday season.  If you have been tobacco free for a while, spend a moment to remember how far you’ve come.  If you’re still struggling to quit, take heart and kindle that hope.  Spring is sure to come.

 

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

I have been doing a great deal of thinking about shame and the power it has on influencing our thoughts and how it can sabotage us, when we are trying to make changes.  I once heard shame described as “one of the most corrosive human emotions.” When shame gets in our head our self-talk turns to, “I am a failure,” “I am flawed,” “I am unlovable,” and “what were you thinking?”  Shame is a powerful feeling but it is also a common one that we have all experienced one time or another.  Maybe you are experiencing this feeling now because of unsuccessful quit attempts. Whatever the reason, it is important to find ways to manage the shame so that is doesn’t lead you down the path of self-destruction and sabotage your quit. 

 

Here are a few tips to try:

  • Talk about it – Acknowledge it and talk about it with those trusted people that you have in your life, because the more you talk about shame, the less power it has in your life. The empathy from others will help you keep your self-talk in perspective and assist you in coming up with coping strategies to manage it. By acknowledging shame, you refuse to let it define who you are as a person.  Author Dr. Brenae Brown writes, “When we bury the story, we forever stay the subject of the story.  If we own the story, we get to narrate the ending.”
  • Name your feeling – Are you really feeling shame or is it something else? Often times when we stop and reflect on our emotions, we discover that we are feeling something totally different, such as guilt or embarrassment. Neither of these feelings are comfortable but they are not targeting your self-worth.
  • Disconnect what you do from who you are as a person – If your quit attempt does not go the way you had hoped, it does not mean you are a bad person, it just means you need a new plan. Forgive yourself and try again.
  • Seek Support – Shame at its core is a fear of disconnection. By reaching out to family, friends, and communities (EX Community is a great place), we make connections that allow us to accept ourselves and others.

 

Heather Kraling-Coons, MA

NDC Counselor/CTTS

Your bones – your skeleton –what gives the body form to function is very important.  And it is not something you think about when you consider the many medical consequences of smoking.

 

But I don’t need to worry about this osteoporosis thing until I’m in my 60’s right?  

 

Wrong. Many people begin smoking while in high school, and although they know about many of the more widely known concerns with smoking like lung cancer, one thing they may not realize is that their bones will continue to grow and develop until about age 30.  And so, if you are smoking as a teenager, you risk not reaching the most bone mass you could; and hence, the best bone strength and health you could have for life. 

 

But what exactly is happening to the bones in smokers?

“Free radicals” – compounds that are found in cigarette smoke - are harmful to the body as they engage in the breakdown of our body’s natural defense systems.  While these free radicals attack the   osteoblasts which are the building blocks of bone, they also upset the balance of hormones in the body –particularly estrogen- which is so important in building bone and maintenance of the body’s framework in both women and men.  For women entering menopause, the natural loss of estrogen compounds the problem for women who smoke.  These free radicals also lead to an increase in the hormone cortisol and the hindrance of the production of calcitonin – both of which tend to deter bone growth.  And, again the concern about smoking’s effect on the body’s vascular system cannot be overlooked here.  Bones need to have a steady supply of blood; and smoking affects the blood vessels, which in turn, leading to nerve damage, and consequently, falls and fractures.  In fact, smokers increase their risk of fractures by a factor of 2; and the heavier you smoke, the risk just goes up from there.  Smokers over age 65, have a 30-40% chance of hip fracture, and those who suffer such a fracture have a 25-30 % chance of dying within the first year.

 

You’ve heard it before, like so many medical concerns, quitting smoking is the NUMBER ONE thing you can do to protect so many aspects of your health, and your bones are no exception.

 

What happens if I quit?

There is some research to suggest that your bone density may improve upon stopping smoking.  Certainly the damage being caused by active smoking stops.  Overall health and circulation supporting good overall functioning improves.  Your ability to be physically active and build strength and improve skeletal support all improve.  If you have quit already, take a moment to appreciate all the good things that are happening. 

 

However, the ultimate question when considering the consequences of smoking is not so much what happens when I do quit – but rather, what happens if I don’t?

 

Barb Dallavalle, MA, LP

NDC Counselor/CTTS

Sleep can be incredibly important for health. Good sleep improves concentration, productivity, mood, and weight metabolism.  Poor sleep is a factor in heart disease, stroke, systemic inflammation, and mental health.  However, developing good sleep patterns can be a challenge, and good sleep is complicated by smoking.

 

Sleep quality is measured in a couple of ways. ‘Sleep continuity’ is basically the amount of time a person spends in bed, as a ratio of time sleeping; for example, factors measured to assess sleep continuity include sleep latency or time getting to sleep, total sleep time, and frequency of waking at night.  Sleep architecture is another measure of sleep quality.  Sleep architecture is usually evaluated with overnight sleep studies.  Good sleepers spend more time in deeper sleep, both dreaming (REM or rapid eye movement) and  in non-REM sleep. 

 

Most studies find that non-smokers have better sleep continuity and sleep architecture than non-smokers.  Smokers on average sleep less, take longer to get to sleep, and wake more often than non-smokers.  Waking more often at night is directly correlated with the higher addiction.   Smokers also spend less time in deep sleep states, both REM and Non-REM.  People who smoke also subjectively report poorer sleep, and are in general more drowsy and sleepy during the day.

 

Unfortunately this seems to worsen in the short term when people are stopping smoking.  During the first few weeks of smoking cessation, people who stopped smoking had worse sleep continuity, more waking at night and poorer self-reported sleep compared with those who did not stop.  Those who measured more addicted to tobacco did worse than those measuring less addicted.  This makes sense, because poor sleep and insomnia are withdrawal symptoms; however use of nicotine patch, or varenicline did not reduce sleep disturbance and tended to increase them. 

 

Sleep disturbances do get better over time when people stop smoking. Studies have found that post cessation sleep disturbances peak during the first week stopping.   Four to twelve weeks after stopping, sleep quality returns to at least pre-cessation baseline, and for many sleep is better than before they stopped.

 

The bottom line is that it may be important to take steps to improve your sleep as you stop smoking.  Good habits do work to improve sleep.  Check out our six tips to improve sleep which we hope you find helpful. 

 

Kathy Zarling, MS, APRN

NDC CTTS

Gratitude is a powerful emotion!  Gratitude activates the parasympathetic (rest-and-digest), relaxing part of the nervous system, which results in many positive effects, such as decreases in our body’s cortisol levels, lowering of blood pressure, strengthening of our immune system, and so much more can occur when we feel and express positive emotions! 

 

Research shows that positive emotions, such as gratitude, thankfulness, and happiness have further significant effects on our lives.  Positive emotions improve relationships and enhance resiliency and stamina, which are important aspects of successful tobacco abstinence!

 

Your EX community is such a great resource for sharing ideas about successes and support for ongoing abstinence.  What are you grateful for in your tobacco-free journey?  What individuals have made a difference in your life and supported you?  What advice would you share with this community about what has impacted you, that has really made a difference for you?

One exercise many stress researchers suggest to build resilience is to wake up each day, and before getting out of bed, think about 3 things you are grateful for in your life.  Make them different each day.  Beginning your day with positive thoughts and emotions can start you off on the right track. 

 

During this month of Thanksgiving, what would you share with our Become an Ex community about what YOU are grateful for? 

“Being thankful is a feeling; being grateful is an action” 

         Tessa Masula, Waynesburg University

Michael V. Burke, Ed.D

Program Director and NDC Counselor/ CTTS

We are met daily with irritating and frustrating experiences that heighten our sense of feeling stressed.   We have our “go to” actions we do to feel better, calm our tempers, soothe our emotions, and clear our heads.  These actions can give us a moment to escape the stressful situation or process our thoughts so that we can think through how to best respond to ensure our well-being (so that we keep our jobs, relationships and stay out of jail).  It is easy to get into the “rut” of smoking being the only way we use to respond to stress in the moment. After years of smoking, it may be the only or primary stress response behavior you have practiced.  Thus, smoking may feel like the only tool you have at your disposal to relieve stress in the moment.  You may be in a mental rut when trying to identify alternative and healthy ways to calm yourself when stress creeps up on you and you only have a few moments to react.  To help you get started, here are a few quick and healthy stress relievers ex-smokers have shared that they find works to take the place of smoking to deal with stress in the moment. :

  • Deep breathing
  • Meditating, praying
  • Playing phone games
  • Laughing (Watching comedy - even short YouTube videos on your phone)
  • Listening to music, singing or whistling
  • Taking a short walk
  • Looking at pictures (on the phone) of loved ones

What are some ways you can deal with stress in the moment instead of smoking/vaping/chewing? You are most likely to use the ideas you come up with on your own, but it helps to have suggestions to get you started with ideas of your own.  This EX community is a great resource for getting ideas that work.

 

Jennifer Burden, PhD

NDC Counselor/CTTS

Most spouses or partners of smokers would like it if there loved one would quit. However they may be unsure of the best way to help their loved one. When looking to be supportive - Here is some information that may be helpful for your quitting spouse.

 

Despite the difficulties in quitting, 40% of those who are successful attribute their success to having appropriate support. So partners can play a greater role at successfully quitting than they might realize.

 

  • Express concern without lecturing- Most smokers already know the health risk associated with their addiction. Having a judgement-free conversation and expressing concern about wanting to live a healthy long life together may be beneficial.
  • Help manage withdrawal symptoms- Being patient with your spouse during the period of withdrawal and longer (quitting is a process and often a major change). Encourage the use of NRT (nicotine replacement therapy) or other smoking cessation medications, if your partner is using them.
  • Together come up with distractions- Distractions can be very helpful in battling withdrawal and cravings. Together establish a few fun activities such as; exploring nature, watching a new movie, cooking meal together…etc.
  • Find the appropriate level of encouragement- Having unrealistic expectations for your partner can really have negative effects. If your partner feels that you are “nagging” constantly this may shut down open communications- Ask them what they would like encouragement to look like. If they are seeing outside help for smoking cessation, ask them if you would be able to join.
  • Be supportive during the “hard times”- Often people working towards quitting are not successful on their first try, quitting can take multiple attempts. Your understanding and ongoing support will make it more likely that your spouse will keep trying and ultimately succeed.
 “Addiction is a family disease, one person may use but the whole family suffers”
– Shelly Lewis

Laura McConahey

NDC Counselor/CTTS

The older I get, the more concerned I become about taking care of myself.  I am realizing that the body I have been given is what I am living in day in and day out! And a large part of the protection of that body is the wrapping – i.e., YOUR SKIN!  The skin is the body’s largest organ – making up 16% of its total weight!   Our skin performs many invaluable functions including protecting us from extremes of temperature, UV rays, and chemicals in the air. 

 

And so it goes that quitting smoking is paramount to protecting that body of yours, and the relics of smoking are no more obvious than on your skin. 

 

Wrinkles are the first thing people notice – especially on your face.  Again, those toxins in cigarette smoke damage the collagen and elastin in the skin which can lead to wrinkles.  Carbon monoxide in cigarette smoke inhibits blood and oxygen flow to the skin cells, leading to this premature aging of the skin.   Vertical wrinkles around the mouth, sometimes called “Smoker’s Lines”, are due to years of pursing the lips to smoke.   The lack of oxygen also plays a role in the greyish skin tone of someone who smokes. 

 

And if your appearance is not enough to say on this topic – skin cancer just might be.  Among the most common of skin cancers, squamous cell carcinoma, is over 50% more likely to develop if you smoke.

 

While stress is a culprit for developing psoriasis; people who smoke, on average, double their chances of getting this condition characterized by red, itchy, scaly patches on the skin.  Therefore there is some thought that those who smoke as a stress management strategy may increase their risk of developing psoriasis.

 

Your risk of developing acne inversa (boil-like nodules caused by skin rubbing against skin), is increased with smoking.  Another condition is vasculitis, one form of which is Buerger’s disease, in which skin ulcers develop; and in extreme cases, can cause one to even lose fingers or toes!   

 

While this is in no means an exhaustive list – it is enough to cause one to consider the risks with smoking to your skin and overall health.  Surprisingly, many do notice the appearance of their skin improving within just days of quitting; and it is very exciting and encouraging to see such improvement so quickly after quitting smoking.  So give quitting a try – and watch that healthy glow return to your skin!

 

Barb Dallavalle, MA, LP

NDC Counselor/CTTS

 

References:

How Much Does Your Skin Weigh? | Live Science 

Structure And Function Of The Skin | Wound Care Education | CliniMed 

9 Ways Smoking Effects Your Skin 

Your brain has a built in reward based learning system that is geared towards immediate gratification.  Since nicotine is fast acting, individuals that use tobacco get stuck in a habit loop that is difficult to interrupt. As most of us know too well, the immediate reward from the tobacco trumps the knowledge of the long term consequences of smoking.

 

A tool that I use to help patients break the habit of using tobacco is mindfulness. Mindfulness works because it teaches you to be more accepting of unwanted thoughts and behaviors.

 

The first step of mindfulness begins with starting to pay attention to your smoking.  What do you notice when you smoke?  For example, some of my patients describe the burning sensation of the smoke down their throat and into the lungs; some will notice the taste.  Paying attention and being present in your experience instead of unconsciously smoking while talking on the phone or driving helps you learn skills to help manage your cravings.

 

Avoiding a craving without mindfulness will make it much more difficult to break free from tobacco.  Instead be aware, acknowledge and accept the craving to smoke and allow the thoughts and feelings to come and go. Each time you ride out a craving it gets weaker. Think about the things that you value about not smoking and use that to motivate your decision to quit and to help get through the cravings. Mindfulness could be the key you need to break the loop between habit and behavior.

 

Heather Kraling-Coons, MA

NDC Counselor/CTTS

The recent and growing epidemic of serious lung injury apparently related to electronic nicotine delivery devices, AKA electronic cigarettes or e-cigarettes, has caused us to rethink a lot of our assumptions in the tobacco control community. 

For example, we assumed e-cigarettes were considerably safer than the standard combustible tobacco cigarettes.  This assumption was based on reasonable science.  Public Health England made the assertion in 2017 that e-cigarettes were “95% safer” compared with tobacco cigarettes. (1)  This statement was based on the fact that the level of many toxic chemicals that are known to be disease causing and found in tobacco smoke were orders of magnitude lower in concentration in the e-cigarette aerosols tested.  What we did not know at that time with how rapidly e-cigarette technology would advance and how widely e-cigarettes would diffuse in the population, particularly among youth.  New devices and new electronic cigarette solutions used in those devices have come on the market in great numbers with uptake of these devices among our teenagers and young adults in astounding numbers. 

 

We also assumed that e-cigarettes would provide a means for adult tobacco cigarette users to quit smoking tobacco in a way that was much more acceptable than the pharmacological treatments that are available.  In fact, some early data suggests this might be possible. (3)  But in this largely unregulated industry we have also seen products marketed to youth using attractive flavors and advertisements to entice young people to use them.  The four-fold rise in the prevalence of current e-cigarette use among high school students in the United States from 2017 to 2018 (4), coupled with the report from the National Academy of Science, Engineering and Medicine showing that young people who use e-cigarettes are more likely to use tobacco cigarettes (5), has made us wonder whether we can “thread the needle” -- make e-cigarettes widely available to adults as an aid to smoking cessation, while keeping them out of the hands of teenagers.

 

I have abandoned most of my assumptions about e-cigarettes and the role they may play in ending the scourge of tobacco caused death and disease.  My hope is that the current news grabbing had lines about the dangers of e-cigarettes will spur execution on effective regulation and awaken healthcare community to the role they should play in advising their patients about the dangers of e-cigarettes and in helping them to quit.

 

Dr. Hays

 

  1. McNeill A, Brose LS, Calder R, Bauld L & Robson D (2018). Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. London: Public Health England.
  2. Centers for Disease Control and Prevention. Outbreak of severe pulmonary disease associated with using e-cigarette products: investigation notice. August 30, 2019 (link).
  3. Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med 2019; 380:629-637. DOI: 10.1056/NEJMoa1808779.
  4. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR November 16, 2018 / 67(45);1276–1277.
  5. National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. DOI: Public Health Consequences of E-Cigarettes | The National Academies Press .
  6. AMERICAN ACADEMY OF PEDIATRICS, et al. v. FOOD AND DRUG ADMINISTRATION, et al. Case 8:18-cv-00883-PWG Document 73 Filed 05/15/19 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND. [PDF] Accessed 11SEP2019.

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