As an alarming number of young people take up vaping, and reports of dangerous vaping-related lung illnesses continue to surface, what’s a worried parent to do? Pulmonologist and smoking cessation specialist Humberto Choi, MD, delivers the knowledge you need to talk with your teenager or loved ones about e-cigarettes.

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What We Do and Dont Know About the Dangers of Vaping with Dr. Humberto Choi

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef. E-cigarettes and vaping were initially thought to be a safer alternative to smoking, but now, reports of serious respiratory illnesses, likely tied to vaping, are popping up across the country, including young adults being put on mechanical ventilators to breathe.

The CDC's reporting hundreds of possible cases nationwide, including in Ohio, and there have been several deaths reported potentially linked to vaping. Unfortunately, we've even seen this at Cleveland Clinic. So with us today, we have Dr. Humberto Choi, a pulmonologist here at Cleveland Clinic, and a medical director of the Respiratory Institute Smoking Cessation Program. Dr. Choi is here to talk to you about vaping and taking your questions. Thank you so much for being here today.

Dr. Choi:  Thanks for having me.

Nada Youssef:   Sure thing. During the second half of this broadcast, what we'd like to do is dedicate the second half to you and your questions. So, make sure any questions that you have for Dr. Choi, please put it in the comment section below. We'll get to it as much as possible. Before we begin, please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. All right, so vaping. Let's talk, first of all, what it is, and what do we know about it so far?

Dr. Choi:  So, vaping became almost like this nickname for when someone uses an electronic cigarette, which can have different forms and shapes. All the other terms for that would be pens, electronic cigarette, or a more fancy name, electronic nicotine delivery system. They all mean the same thing, but vaping, I think, became more the popular name. It just refers to using a device that heats up a liquid, that liquid then is cooled, and then releases typically a gas, aerosol, with nicotine or other substances.

Nada Youssef:   Sure. So, t's heating up the oil before it's hitting your lungs?

Dr. Choi:  Correct, correct.

Nada Youssef:   Correct. Okay. Now, so vaping and e-cigarettes are the same thing? It's just a cooler name for it?

Dr. Choi:  Yes. Electronic cigarette is more like the general term, and vaping just became almost like the popular term to refer to an electronic cigarette device.

Nada Youssef:   Sure.

Dr. Choi:  But, vaping is a little misleading because what comes out from the device is not exactly vapor. It is actually an aerosol. The difference is just the fact that a vapor is just, very geeky about it, is just the gas phase of something that is typically liquid or solid, like water. But, aerosol is just that gas phase, but mixed with a particle or something solid, for example. It's not exactly a vapor. It's actually an aerosol. This is something that even the CDC comments about.

Nada Youssef:   Oh, very interesting. That's kind of misleading because you think vape is a vape coming out of it or water than a gas.

Dr. Choi:  Correct. Right, yeah. So, a gas is actually a gas with some particles, and sometimes with other very small solid parts too.

Nada Youssef:   Okay. So the million dollar question, is vaping less harmful than cigarettes?

Dr. Choi:  Very tough question. I'm asked about this all the time. I think all these cases already proving the point that vaping is not safe. We don't know exactly if there's any single agent or substance or liquid that is responsible for all the diseases that we are hearing about, but I always tell that what they have in common is vaping itself. So, I think vaping in general is really not safe, so it's definitely something that we would not recommend.

Now if it's safer than cigarettes, I think this would take some time for us to learn. With cigarettes specifically, there are many short-term effects from that, but we worry more about, typically, about the long-term effects. For example, when someone develops emphysema, heart disease, or cancers from a long-term use of cigarettes. So that information, we don't know yet about the electronic cigarettes or vaping. We are seeing now all the immediate effects in the lungs, which is mostly inflammation. But now if the same use after a long time can also cause emphysema, any chronic lung disease, heart disease, or even if it's connected to cancer, we don't know yet. It might take a few years for us to learn that lesson.

Nada Youssef:   So, we know that short-term, it could be deadly, and long-term, we don't know yet.

Dr. Choi:  Right.

Nada Youssef:   Right. So, would you say that vaping is as addictive as cigarettes?

Dr. Choi:  Yes. Well typically, vaping has an oil, a liquid, that contains nicotine. Not all forms contain nicotine, but it may contain THC, and most of them, nicotine. So yes, vaping can be addictive. Something that concerns me is the fact that most people using are very young, so they're very susceptible to addiction. The fact that sometimes the concentration that someone can find in one cartridge can be higher than you what you find in a full pack of cigarettes. So yes, it can be addictive.

Nada Youssef:   Wow, wow. And the CDC mentioned that 80% of the patients are under 35, which is huge numbers.

Dr. Choi:  Right.

Nada Youssef:   So, what is causing all this vaping illness and deaths that we know of?

Dr. Choi:  Well, my first point is vaping itself is causing this.

Nada Youssef:   Okay.

Dr. Choi:  Now, we still don't know if there's any specific liquid or any specific, even of a brand, or something that is mixed with the liquid that is causing all this. It's very difficult to find that answer because there are so many different devices, different kinds of liquids, and even the liquids are oils that can be obtained from different people, sometimes even off the streets, or they can even be manipulated at home. So, I think people just being very creative in how they use that, so it's hard to find one agent specifically. But, we know that most of the cases that we've heard so far, according to the CDC, had some relation to THC in the oil or in the liquids, but not all of them.

Nada Youssef:   Right.

Dr. Choi:  So, even the devices that only had nicotine, they also cause lung disease.

Nada Youssef:   Now, I've read a lot about some Vitamin E agent that's in there that could cause some kind of-

Dr. Choi:  Yes. So, it's one of the substances that you can find in the liquid, and that's the scary part. There are so many other things that are there that could be causing harm, and we just don't know yet if that is the main reason or a potential reason for harm. There are many things that are in these liquids or the oils that are often used for different things. For example, things that are used to conserve food. Other things, they have different purposes, but we don't know how that affects when you are inhaling death into your lungs.

Nada Youssef:   And heating it in any element.

Dr. Choi:  Correct.

Nada Youssef:   Yeah, yeah. So vaping, is that like a FDA regulated item? Do you know?

Dr. Choi:  So, the regulation is more related to the nicotine device. Different states have different rules about that. The age, at least in Ohio, for anyone to buy a nicotine product is now 21.

Nada Youssef:   Yeah, I heard that.

Dr. Choi:  The governor signed a bill recently, and hopefully is now in effect.

Nada Youssef:   Yeah.

Dr. Choi:  Takes about three months for that going into effect. So in many states, either 18 or 21, but electronic cigarette does not regulate it as a medicine, and how it's manufacturer's also not regulated. So, that's why there are different combinations of how the liquids or the oils are made.

Nada Youssef:   Are administered, sure. So, what are the symptoms and signs of this type of illness?

Dr. Choi:  So, the symptoms can be very nonspecific. Can be coughing, can be a shortness of breath, some people had fevers, even abdominal pain, or just not feeling well, or even just nauseated. For the clinician, it can be difficult to make that direct association that maybe those symptoms are related to vaping unless you asked specifically about that.

What's been helpful about all these cases that are being reported, I think that awareness has really risen over the last few weeks. So now, I think people are really looking for that specific question. If someone, especially young, comes to office or to an emergency room, I think people are asking more about if someone is vaping. It is something that we are even doing now at Cleveland Clinic in our Pulmonary Department. When someone comes, we ask them if they are a vaping or not, just like we would ask if someone is smoking or not.

Nada Youssef:   Sure, sure. It's the same. So, I want to discuss the vaping with young adults and teens, because the National Youth Tobacco Survey found that e-cigarettes have increased in use among teens by more than 20%. So first of all, as a parent, we worry sick that our kids are getting exposed to these kinds of things that can be such a dangerous fad. How do we talk to our kids about vaping and not to do it?

Dr. Choi:  Yeah, good question. This is something that shocks me a little bit because in most states, you have to be at least 18. And now in a lot of states, like in Ohio, you have to be at least 21, but teenagers, even younger than 18, are still obtaining this nicotine products. So, they're finding different ways to get them. This is something that we have to look into because it is a fact, and I think this is the right topic for parents to talk to their kids, but I think it's very important for everyone to have a very open conversation.

I think this fact shows that teenagers are being exposed to that in different ways, and they know how to access that. So if the parents or teachers or anyone who is in contact with teenagers, if they don't have that open conversation with them, they're going to find ways to find it by themselves. So, I think having an open conversation about what is known, what is unknown about the risks that are involved, all the diseases, all the cases of lung disease that we are seeing, even deaths, 19 so far. I think all this should be topics for conversation.

Nada Youssef:   Sure. Now, are there things to look for as a parent if your child does not come to you and tell you that they're vaping? Is there anything that would make you suspect that they're vaping? Is there anything to look out for as a parent?

Dr. Choi:  Well, I think that's a tough one to answer.

Nada Youssef:   Because small cigarettes are vaping on your kids, right?

Dr. Choi:  A lot of the devices do have a flavoring, so there's definitely maybe like a scent that can come with it.

Nada Youssef:   Okay.

Dr. Choi:  But, I think behaviors of possible addiction would be when someone is maybe not concentrating as they were, maybe not performing as well as they were before, or leaving a room all the time because they need to vape. For example, I hear that sometimes the bathrooms are the new vaping rooms, which used to be, back in the day, the smoke room in schools, but now they're vaping room. Now, when someone needs to be excused frequently, I think those are signs that someone could be vaping.

Nada Youssef:   Sure. Back to that sweet smell that you were talking about, the fruity smell. So, the government is working on banning of vapes that have that fruity or kind of something that's attention grabbing to children. I want to ask, is it being banned because we don't want to advertise to little kids about a deadly device, or are we doing it because there's bigger health factors with the fruity flavors? Why are we banning only the fruity ones?

Dr. Choi:  So, we actually don't have a lot of information whether the flavoring itself can cause lung problems or other problems, but we know that flavoring is something that attract teenagers and young adults to vaping. Nicotine itself actually has a very bad taste, and that's not something that attracts, especially, teenagers.

But when they know that it will taste or smell like a mango or strawberry or have different flavors, that might be something that will attract to that, and it is something I think they are focused on in how people start to use a vaping device. I think overall, we support any measure that to help curb the use of vaping, but this is not enough to decrease significantly the number of people using these devices, but hopefully helps deter some young people to start using the vaping.

Nada Youssef:   Right. So, I've been seeing maybe a lot of people that maybe are angry that they quit cigarettes by starting to vape. So, what is the best way to quit vaping?

Dr. Choi:  So, one is counseling. I think we should all as healthcare professionals always have this conversation, that we are seeing so many cases of lung disease, lung injury from vaping is definitely not safe. This was never an approved method to quit smoking anyway. Although, it was advertise like that in the past. So, we definitely were never supported that, and we still don't know what would be the best method.

The addiction itself, the dependence is to nicotine, the same nicotine that is present in cigarettes, but there are some differences in how people use a nicotine. So, I think we may need to adapt the same tools that we use for cigarettes for vaping, exactly. One of the differences that when someone is smoking, you have to go somewhere, you have to get your cigarette, light it up, and finish that cigarette. But with vaping, you are constantly inhaling that.

So, how you are exposed to the nicotine, how you use that is a little different, and a concentration of nicotine in those devices can be higher. So, definitely the way we will approach these patients will be maybe similar to how we approach a cigarette, but with some adaptation to adjustments to the habits.

Nada Youssef:   Adjustments, yeah. It sounds like it would be more difficult just because I see a lot of people vaping indoors. So just like you said, you don't have to go outside for it.

Dr. Choi:  Right.

Nada Youssef:   If you want to quit cigarettes, vape, and that was the message that we've heard for a long time.

Dr. Choi:  Yes.

Nada Youssef:   So with cigarettes, we know that our bodies heal themselves. You quit smoking cigarettes, your body will start getting more oxygen, and so on the more the time goes. Is that the same thing for vaping?

Dr. Choi:  So, I think there was a broader spectrum of lung diseases that can be associated with vaping. The one have been reported are the more severe forms of people who get very sick, who need oxygen, sometimes even need a life support because they are so sick. But on the other side, there's probably those mild cases, people with just coughing, or just very mild symptoms, or maybe some just some mild changes in the x-ray or CT scan. For some of these cases, just avoiding vaping, just when you stop that, things do get better.

Nada Youssef:   Sure.

Dr. Choi:  And sometimes, they don't even need additional treatment other than just don't vape anymore. So, I think there's definitely a component that inflammation that vaping can cause can subside on its own once you stop the exposure. So yes, so there is probably some repair mechanism that is inherent to the lungs that they'll help fix that. But sometimes, the inflammation can be so overwhelming, and then we need to talk about treatments like steroids, or providing life support, or providing oxygen to someone.

Nada Youssef:   Sure, sure. Now, I mean, our lungs, we're not supposed to be really inhaling anything, right?

Dr. Choi:  Right.

Nada Youssef:   Can you talk about what actually is happening as we're inhaling the vape or the smoke into our lungs?

Dr. Choi:  Yeah. So, I think we always say that the lungs were made to breathe clean air, and that's what we should be doing. There are medicines that we can also inhale, but if it's not clean air or specific medicine prescribed, we should not be inhaling into your lungs. So because what is coming out from this device is actually aerosol, what it's doing, that aerosol is going into the lungs, and then that's triggering an inflammatory response from the cells in the lung.

They are seeing that something that doesn't belong there, and then our lungs will fight it. If the exposure is mild enough, and your defense system strong enough, maybe that won't cause any problems. But some cases, it's overwhelming, and it can lead to a severe form of inflammation in the lungs, and lead someone to need to come to the hospital.

Nada Youssef:   Sure, sure. Great. Again to our audience, if you have any questions to Dr. Choi regarding vaping, please put them in the comments section below, and we'll get to those questions here shortly. I have one more question for you here. Now, when a patient comes to see you, and they have these symptoms and a history of vaping, what is the next thing that you do? What kind of tests do you run? What do we expect out of that kind of visit?

Dr. Choi:  So, the same symptoms we can see with different things, it can be something just like a bronchitis that is common or a pneumonia. So when someone comes with symptoms, one part of the evaluation is looking to see if there's any infectious cause, and that might include like a chest x-ray or even a CT scan, or doing some other tests, like even cultures or swabs looking for viruses. Other tests like blood tests, looking for specific things that can be associated with certain types of inflammation. So, that would be, more or less, the general evaluation, having some blood tests and having some kind of imaging test for the lungs, like an x-ray or a CT scan.

Nada Youssef:   So, would those imaging tests, if you look at, let's say an x-ray of a lung or a chest of someone that's smoked cigarettes for years and someone that's been vaping for a year, do you see similarities? Are they different, the kind of damage that happens to the lungs?

Dr. Choi:  They can be very similar. One of the things can really mimic those, or say pass as those shadows that we see in the lungs, can be associated with infections or exposure to different things.

Nada Youssef:   Sure.

Dr. Choi:  So, part of the criteria for us to diagnose a suspected or a confirm case is the exclusion of these other things, like excluding infections mainly. And then, having that history of vaping use and having a specific pattern in a x-ray, CT scan, that's how we will make the diagnosis. The x-ray or CT scan, or even biopsy, there is no specific signature that say, "Okay, this is from vaping and nothing else." It's just putting all the information together and excluding other causes.

Nada Youssef:   Okay. Then, you hear a lot on the news about popcorn lungs. Is that same thing as scar tissue? I don't even know what popcorn lungs are.

Dr. Choi:  Yeah. So, that comes for their concern that the liquids that are a lot in this device are actually oils. Some of the cases had evidence of oil particles in the cells that were collected from bronchoscopy. For example, when we got a liquid directly from the lungs that was tested, and there were signs of oil in those cells, which is not clear if those oils was just really part of the inflammatory response that happen in the lung, or if it was just some marker because they were using from the vaping itself.

Nada Youssef:   Coming from the vaping, sure.

Dr. Choi:  It's not clear, but there are some forms of pneumonia, of inflammation in the lungs, that are associated with oils that are inhaled. So, that's what a concern of the popcorn lung or the lipoid pneumonia came from.

Nada Youssef:   Sure. Now as these patients come to you, and you were finding all these lung issues from vaping, are you reporting this somewhere for research? What are you doing?

Dr. Choi:  Not only for research, but it is for public health concerns. The CDC has recommended for everyone to report suspected cases of vaping associated lung disease. Here in Ohio, the Ohio Department of Health has requested for these cases to report it. They even sent a notice just in the last few days asking for physicians or any caregiver to report cases within 24 hours when they see a suspected case, because they're really taking this epidemic seriously. They're really investigating a case by case to see if it's a confirmed case or not. Because, we need to get all these cases together, and see what we can learn from from them, and see if there's anything we can learn about what is causing all that, other than the fact that it's related to vaping.

Nada Youssef:   Right, right. Just as a mom to make sure that I'm always up-to-date on vaping and what's causing it and all that, would you say the CDC would be the best website to check on the latest news for vaping?

Dr. Choi:  Yes. The CDC has been doing a great job. I think they're really honing this topic, and they have been sending updates very frequently. So, it seems to be a very good source to look for updated information.

Nada Youssef:   Okay, great, and that's cdc.gov, just to keep up with all this information. So, I'm going to go to some live questions. First, I have Lee, "Is there any difference between a hookah and vaping?"

Dr. Choi:  Yeah. So actually, there was even called e-hookah, the electronic hookah-

Nada Youssef:   Maybe we could talk about what hookah is first maybe for the people that don't know.

Dr. Choi:  Yeah. So, the hookah comes just also as a similar way to inhale some-

Nada Youssef:   Flavored tobacco. Yeah.

Dr. Choi:  A flavor tobacco, usually have different devices. It's not only the small ones. These are very popular. You can even have coffee shops with hookah. Now, if they are causing the same injury as the electronic devices, I think that's not clear. There is such a thing as electronic hookah as well, mostly because of the flavorings.

Nada Youssef:   Sure.

Dr. Choi:  But probably the way that the liquid is heated up is a little different because the devices are a little bigger and the liquids are a little bigger. But still, if you ask me if it's one safe than the other, I'll say, "None."

Nada Youssef:   Yeah, yeah. That's good to know.

Dr. Choi:  Nobody should be using any of that.

Nada Youssef:   So if I ask you if cigarettes are safer or vaping, what would your answer be?

Dr. Choi:  I'll say don't use anything.

Nada Youssef:   Neither. Okay. So, don't go for it. All right, good to know. I have Bonnie and Dusty, "Do you have information on secondhand vaping for children with health issues?"

Dr. Choi:  Good question. I think this is something that we don't know yet. I'll say that there are maybe indirect ways that someone that vaping can affect, especially children. Because some children, especially children with asthma for example, they can be very sensitive to scents that are in the air, or anything that is in the air that could be inhaling.

So, maybe not a direct effect from the nicotine, but maybe from the scent and from the smell that is in the air. It could affect children, and even cause a bronchospasm, like an asthma attack, when someone is very sensitive to that. I think maybe when someone is vaping, they may think that people around them are not aware that there is that scent in the air, but there is.

Nada Youssef:   Yeah.

Dr. Choi:  Children, especially with asthma or auto chronic lung diseases, can be very sensitive to that, and that can can, again, affect them. So, maybe that'll be one way that they could be exposed to that, and it could harm them like as a secondhand exposure.

Nada Youssef:   Sure. Now with cigarettes, we know there's even thirdhand smoking, which is when it's stuck to your couches, and your car seats, and pillows.

Dr. Choi:  Right.

Nada Youssef:   Do you know anything about vaping if it has that same effect on furniture and things at home?

Dr. Choi:  No.

Nada Youssef:   We don't know that, right?

Dr. Choi:  Yeah, I think as far as I know, we don't have any data about that thirdhand vaping yet.

Nada Youssef:   Yeah, thirdhand vaping. You never know. It's coming out of each corner. All right. So Tracy, "Can you explain the difference between," I'm going to say this wrong, "vegetable glycerin instead of propylene-"

Dr. Choi:  Propylene glycol.

Nada Youssef:   ... "glycol?"

Dr. Choi:  Yeah.

Nada Youssef:   We don't know what those are, so if you could [crosstalk 00:27:45].

Dr. Choi:  I traced it. So, these are the different things, the different substances that can be in the liquid that are mixed with nicotine. These are common substances that are used for other purposes, like in the food industry, for example. Now, how harmful they are in the lungs when they're inhale like this, it's not clear yet, but this is just an example that what is in the liquid or in the oil is not just a nicotine or flavoring.

There are other things that can be something like glycerin or propylene glycol that you are inhaling into your lungs. It can be even formaldehyde, can be even heavy metals. Like a lab for example, that could be there, and you just don't know. So, although it's not clear how harmful they are in the way that it is being used, but it's just an example that there's two things, and a bunch of other things that you can find in these liquids that can be potentially harmful. It's not just water, it's not a clean water.

Nada Youssef:   Right. It's not vape.

Dr. Choi:  Nope, no. It's not a vapor, so it's definitely something that could be harmful.

Nada Youssef:   Okay. So, is that coming from non-reputable sources that are selling these things? I mean, because anything could be in it you're saying, right?

Dr. Choi:  Yes. But even those devices that come with a more popular brand from a factory do contain the substances.

Nada Youssef:   Okay. That's good to know.

Dr. Choi:  Yeah. So, it's not something that you get off the street. It's just part of the mix of substance of that that the liquid may contain these things.

Nada Youssef:   Okay. That's very good to know. Shawn's asking, "Will vaping cause emphysema?"

Dr. Choi:  Shawn, this is a question that I think it will take a while for us to to answer. So far, there have been some studies looking to this question. It may take a few years because vaping is still something new for us to see if there was a direct correlation, association between vaping and emphysema.

However, I saw a study recently that made some connection. This study look into getting some samples from directly from the lungs in people who are vaping, and what they found that there were like a pattern of inflammation in those cells collected from the lungs that was very similar to what happens when someone smokes and has an emphysema.

So, we don't have any study making that direct connection, that vaping cause emphysema, but so far, these preliminary studies are showing that vaping has a potential to cause that by having that inflammatory cells in a similar pattern that we see when someone smokes cigarettes.

Nada Youssef:   So, similar symptoms as well, shortening of breath and all that lung stuff?

Dr. Choi:  Well, the emphysema, what happens with the long-term use, it does cause inflammation in the lungs, and it causes the destruction of the lung tissue by these inflammatory cells and other enzymes. What they saw in study is that similar cells and enzymes are related to emphysema was also activated when someone was vaping.

Nada Youssef:   I see.

Dr. Choi:  It's not evidence of direct association, but it's an association, an evidence that vaping has the potential to cause that.

Nada Youssef:   I see, I see. Okay, that's very good information. Patty's asking, "Does smoking or vaping hurt children?"

Dr. Choi:  I'll say both hurt children. I don't know how I can answer this. None of them should be ever used-

Nada Youssef:   Smoking anything.

Dr. Choi:  ... anything. From secondhand exposure, I'll say probably smoking, we know that is more harm to children, but children can be affected in so many different ways by the smoke, by the vape, or to the aerosol from the strong scents. There was one way that children can be affected that I don't think we talk about enough is the fact that a lot of these devices are very colorful and-

Nada Youssef:   Colorful?

Dr. Choi:  Colorful, and very attractive to young people and children. If you Google some information, you see that there are a lot of cases of accidental intoxication by nicotine when children were able to reach those devices and the liquids. So, they're basically drinking them, had contact with them, and they were very ill from the nicotine that was present, or the other liquids, at that were present there.

Nada Youssef:   Then, they put sometimes could leak. I've read that these devices have exploded in people's faces. That's terrifying.

Dr. Choi:  Yes. Yeah. So, I think there are many different ways that this can hurt children directly from how it's used or all these indirect ways, like intoxications and accidents. So, there are many different ways that children can be affected.

Nada Youssef:   Right. Okay. So, Marielle is asking if vaping is connected with COPD.

Dr. Choi:  Yeah. So, just like how Shawn asked, so Marielle, we don't have that data yet. We don't have a good answer, so we don't have a direct connection of vaping with COPD, but we have indirect data showing that vaping can trigger a similar inflammatory response that happens when someone develops emphysema or COPD from smoking. So, there's definitely potential to do that, and would take a few years for us to see if that will happen with vaping or not.

Nada Youssef:   Great. Well, Dr. Choi, our time is up. Is there anything that you wanted to close with, or did we touch on everything?

Dr. Choi:  No, I think we touched lots of several things, and I think my message is always that vaping is not safe as people thought it would be. I'll say that vaping's probably not safe at all.

Nada Youssef:   Sure.

Dr. Choi:  It's not a method to help people quit smoking, so I wouldn't go to that. If someone needs help to quit using cigarettes, there are known effective ways to help someone quit smoking, and we should look up to those options first before going to to vaping.

Nada Youssef:   Sure. Thank you so much for your time today, Dr. Choi.

Dr. Choi:  Thank you for having me.

Nada Youssef:   Thank you all for all your great questions and for tuning in. If you or a loved one are thinking about quitting smoking cigarettes or vaping, please go to ccf.org/stopsmoking. That's our Smoking Cessation Program. Then for all the up to the information, I would go to cdc.gov. For more health news and information from Cleveland Clinic, make sure you're following us on Facebook, Twitter, and Instagram at ClevelandClinic, Just one word. Thank you. We'll see you again next time.

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