Selected Podcast
Addressing Vaping Concerns
Vaping is regularly a concern in the media. Dr. Pebbles Fagan, Director of the Center for the Study of Tobacco at the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences, discusses vaping.
Featured Speaker:
Fagan has more than 20 years of experience in conducting research into tobacco prevention and control and cancer prevention and control. She has an extensive background in research that aims to reduce health disparities.
She has a doctorate in health education from Texas A&M University; a Master of Public Health in health education/communication from Tulane University School of Public Health & Tropical Medicine; and a bachelor’s degree in rhetoric and communications and Afro-American studies from the University of Virginia.
Before coming to UAMS, Fagan conducted research as an associate professor in the Cancer Prevention and Control Program at the University of Hawai’i Cancer Center, University of Hawai’i at Mānoa in Honolulu. She also served for 10 years as a health scientist at the National Cancer Institute in Bethesda, Maryland; and a postdoctoral fellow at Dana-Farber Cancer Institute and the Harvard School of Public Health in Boston.
Fagan has published more than 60 peer-reviewed papers, has a track record of leading and collaborating on National Institutes of Health and foundation-funded grants, and is the project director/principle investigator on part of a grant funded by the National Institute on Drug Abuse and the Food and Drug Administration. Fagan provides leadership to a team of researchers who conduct studies that use mixed-methods to understand electronic cigarette use and the unorthodox use of electronic cigarettes.
Pebbles Fagan, PhD, MPH
Pebbles Fagan, Ph.D., M.P.H., is director of the Center for the Study of Tobacco at the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences (UAMS). She is also a professor in the Department of Health Behavior and Health Education in the College of Public Health.Fagan has more than 20 years of experience in conducting research into tobacco prevention and control and cancer prevention and control. She has an extensive background in research that aims to reduce health disparities.
She has a doctorate in health education from Texas A&M University; a Master of Public Health in health education/communication from Tulane University School of Public Health & Tropical Medicine; and a bachelor’s degree in rhetoric and communications and Afro-American studies from the University of Virginia.
Before coming to UAMS, Fagan conducted research as an associate professor in the Cancer Prevention and Control Program at the University of Hawai’i Cancer Center, University of Hawai’i at Mānoa in Honolulu. She also served for 10 years as a health scientist at the National Cancer Institute in Bethesda, Maryland; and a postdoctoral fellow at Dana-Farber Cancer Institute and the Harvard School of Public Health in Boston.
Fagan has published more than 60 peer-reviewed papers, has a track record of leading and collaborating on National Institutes of Health and foundation-funded grants, and is the project director/principle investigator on part of a grant funded by the National Institute on Drug Abuse and the Food and Drug Administration. Fagan provides leadership to a team of researchers who conduct studies that use mixed-methods to understand electronic cigarette use and the unorthodox use of electronic cigarettes.
Transcription:
Addressing Vaping Concerns
Scott Webb (Host): It seems that vaping and it’s effects are in the news on a daily basis. My 16-year-old son tells me that vaping is out of control at his high school. It’s really frightening. My guest today is Dr. Pebbles Fagan. She’s the Director of the Center for Study of Tobacco with the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences. She’s also a professor in the Department of Health Behavior and Health Education in the College of Public Health. Let’s talk to Dr. Fagan about the vaping concerns and questions that many of us have.
This is UAMS Health Talk from the University of Arkansas for Medical Sciences. I’m Scott Webb. Dr. Fagan, thanks for joining me. I have so many questions for you, but let’s start here. What is vaping and how and why did it become so popular, so fast?
Pebbles Fagan, PhD, MPH (Guest): Vaping devices or E-cigarettes, they are the same thing, are battery powered devices that release an aerosol when heated. They contain things such as nicotine, flavorings, propylene glycol, vegetable glycerin, formaldehyde, acid aldehyde, acrolein and some other harmful chemicals that are released when heated through a battery. They come in all shapes and sizes. Sometimes we call cigarette looking ones cigalikes, those were the first generation of e-cigarettes to hit the market and then after that, we saw a number of other types of devices being released on the market such as the vape pens which are long and thin, the e-pipes, e-cigars, the large tanks, Sub-Ohm tanks and devices that contain pods such as JUUL and SOURIN. But all of these devices are battery operated. They heat the liquid that release an aerosol.
How did they become so popular? Well most of them contain nicotine and like cigarettes, nicotine is in cigarettes, nicotine is in e-cigarettes, nicotine is in smokeless tobacco. It is in all tobacco products which means that all of these products have the potential to be addictive. Nicotine is one of the most addictive substances on earth in fact. And as addictive as cocaine and heroin. And so when you talk about why did this product and these products that are on the market become so popular particularly among young people, it’s because they are highly addictive and they contain flavorants such as gummy bear flavor, cotton candy flavor, cheesecake flavor, blueberry flavor that appeal to young people.
Host: So, Dr. Fagan, you mentioned the flavors and I think that that’s probably what appeals so much to children. What can parents and teachers do to stop children from vaping? Because really, quite frankly, it’s becoming an epidemic.
Dr. Fagan: Well I think what’s most important is that they first have an awareness that many teens are using these products that go unnoticed. When you think about products like JUUL and SOURIN which are the pod type devices that look like a jump drive that you put on the computer; they can be hidden very easily. So, I still think it’s important for parents to be aware of what these products look like, to talk to their children about the harms of tobacco products because e-cigarettes, vaping devices are tobacco products because they contain nicotine. They should communicate to their children that even though some people perceive that these products are less harmful than cigarettes, they are still harmful. And so, we know from the many deaths that have been happening over the last two months that these products can cause harm but it’s important for parents to communicate to their children that less harmful does not mean harmless and they can use these case examples of what’s happening across the nation with these e-cigarette deaths and these hospitalizations to demonstrate to their children that these products do contain some harm.
Host: And doctor, correct me if I’m wrong, but people aren’t just vaping tobacco alternatives, they are also vaping THC, correct?
Dr. Fagan: Yeah, that’s correct. And I think this is an important message for teens, for parents and for teachers. First of all, we already know that in these products, there are chemicals such as formaldehyde, acetaldehyde, and acrolein which are lung irritants and cancer causing agents. And so, in the news, you hear a lot about THC and children may be using THC based products, they may be using nicotine based products, or they may be using the combination of the two. What we know is that the harmful constituents that FDA has already deemed as harmful, include formaldehyde, include acetaldehyde and acrolein which is a lung irritant and so, I think we don’t want to confuse parents by just making them think that the THC in these products is the constituent that is causing harm.
The CDC and the FDA has not actually identified what chemicals in these products are causing the lung irritants. What they have identified is the fact that the children are using THC and nicotine based products. But we do know the harmful chemicals that exist in there. There are over 80 chemicals in e-cigarettes. And formaldehyde, acrolein and acetaldehyde are some of the chemicals that we should paying attention to.
Host: So doctor, I’m sitting here, I’m listening to you and I’m thinking to myself, we could be ingesting up to 80 things into our bodies that aren’t meant to be in our bodies? I’m trying to figure out how the industry convinced people that vaping and e-cigarettes was somehow safer than cigarettes.
Dr. Fagan: Well, there’s a difference between thing such as does the product contain less harmful chemicals without it being smoked versus when you actually heat it up, what then happens? There’s a chemical process that occurs that releases and converts some of these harmful chemicals into more harmful chemicals. So, a lot of times, the manufacturers are saying our products contain less carcinogens and other harmful chemicals but that’s in a state when it’s not been heated. When you heat these products, other harmful chemicals are released.
The second thing is that the manufacturers are distinguishing between combusted products and non-combusted products. So, combusted products like cigarettes burn when heated because they reach a particular temperature over 400 degrees. And so, these e-cigarette battery operated devices are being marketed as devices that are not combusted. We know when you burn things, you get more harmful chemicals that are released. And what the manufacturers are saying because it’s not combusted, like cigarettes are; then it’s releasing less harmful chemicals.
However, we know that the power in a lot of these batteries can reach combustion just like cigarettes and that the toxicity yields of these products depend upon not only the heat, but the amount of various constituents that are in these products and the type of device and the flavorants that are added. None of these products are regulated by the FDA. That’s a fallacy and there are no product standards related to any of these devices that are currently on the market. There’s no regulation of how much nicotine, how much propylene glycol, how much THC, how much vegetable glycerin, how much of a flavorant or how much of a salt is added to these devices. There’s no standard regulation on that.
Host: Does this help to explain a little bit why for some, the adverse effects happen so quickly, so unexpectedly because they just have no idea what they are about to ingest into their bodies?
Dr. Fagan: The other fallacy that I’d like to debunk is that these things happen suddenly. It is now reaching the point of being noticed in the media and as people report cases, and they look at their own symptoms, more cases are being reported. So, when we think about what happened with the HIV epidemic as people began to realize what was happening, more cases started being reported. We have known for several years that e-cigarettes with nicotine can cause heart damage. We have known for several years that e-cigarette liquids can irritate airways, can cause inflammation and other systematic changes that are respiratory related.
So, we’ve known that there are published scientific papers on that, that occurred prior to the epidemic. So, we’ve known that. We also know that when you mix nicotine based liquids with THC based liquids; that they also cause irritation in the respiratory airways as compared to if you were using one of those products alone. And so now, that cases are being reported, you have more cases being reported because people are paying attention to the symptoms.
Host: Right, so experts like yourself, there at UAMS, you’ve known this for years and you have been fighting the good fight. It’s only now that it seems like the media is finally catching up and maybe that’s why we are hearing about so much. Okay so here’s what I want you to do doctor, let’s drive this home. Really explain in detail what are the effects of vaping and why should everybody think twice before doing it.
Dr. Fagan: Well I think the most important thing to keep in mind is that it’s highly addictive. Nicotine is as addictive as crack cocaine and heroin. It doesn’t matter whether it’s in cigarettes, it it’s in an e-cigarette, whether it’s in a pipe or a cigar. Nicotine is highly addictive. So, what does that mean?
When a product is highly addictive, that means it’s difficult to get children off the product. It may lead them to using other harmful tobacco products as well. The second thing is that we know that there are health effects associated with electronic cigarettes that people are seeing in the news. We don’t know all of the chemicals that may be causing the health effects, but we know that there are health effects associated with these particular products. And again, we know from the prior literature that nicotine is a culprit in heart disease. We know that from cigarette smoking, we also know that nicotine activates biological pathways that lead to cancer. We do not call nicotine a carcinogen because it doesn’t directly cause cancer, but we know from the 2010 Surgeon General’s Report on biological pathways related to tobacco related disease that nicotine activates certain pathways that lead to cancer.
And so, nicotine is not a harmless constituent. And some people may say well it’s just addictive. It is not just addictive. And I’m sure that parents would not want their kids to be addicted to any product even if it were just addictive. But we do know that it is associated with heart disease, we know that it is associated with pathways that lead to cancer particularly lung cancer. And so, if I were some of the parents and the teachers listening; I would be concerned about nicotine based products because nicotine itself is harmful.
The second thing is all of these other chemicals. I don’t think anyone would want to drink formaldehyde. I don’t think that anyone would want to put acrolein in their system. And so we have to question why is it that people perceive that these products don’t contain harm. And the reason is because we have these flavorings associated with it. So, if you have ever smelled e-liquids, they smell great. Blueberry flavor smells fantastic. The coffee flavor smells very appealing. The donut flavor is also extremely appealing to a wide variety of users but particularly young people.
So, when disguised with a flavor; people can perceive that these products are less harmful. And so, we just want parents and teachers to know that these flavorings are part of the problem. Without the flavorings; there are still harmful constituents in these products. They are highly addictive, and I think it’s important for us to recognize that children who use these products can graduate to using other tobacco products that can later cause harm in adulthood.
Host: Dr. Fagan, you are so knowledgeable. So amazing to have you on. What else can we tell listeners about the work you are doing at UAMS, about vaping, about e-cigarettes, all of it?
Dr. Fagan: We are doing research in our laboratory looking at – we’ve looked at the constituents in e-cigarettes. That’s how we have identified a lot of sugars and aldehydes in these particular products even when they are not heated. We are monitoring what they are selling in retail stores particularly in Arkansas, Virginia and several other states. And we are monitoring the flavors that they are selling, how many stores there are in specific states because ultimately, as FDA tightens up some of its regulation, we should start to see some of these products come out of the market and some of the retailer start to close.
We’ve already seen some retail stores close. Certainly in the state of Arkansas since you cannot buy e-cigarettes online, we see a lot of the online sales in the state of Arkansas are disappearing. We also monitor what’s going on, on social media because we know young people are the biggest users of YouTube and receive a lot of their instructions related to how to use these products on YouTube. We have documented and have published on what we call unorthodox use of these products, that is using the product as not intended by the manufacturer. Things such as cloud chasing, and steeping and streeping, and dripping. All of these terms that young people are familiar with. So, we’ve been monitoring those kind of behaviors in the social media as well.
So, that’s some of the research that we do. We are also monitoring whether or not these manufacturers are using the FDA mandated warning that basically says that the product is addictive, and that nicotine is an addictive chemical and so, we’re monitoring whether or not on the websites and in social media these manufacturers are using the FDA mandated warning statements. So, that’s some of the research that we do.
We hope that listeners have a greater awareness of what e-cigarettes are, the fact that they are not harmless. That they contain over 80 constituents and some of these harmful things we already know such as formaldehyde, acetaldehyde and acrolein that all products that are on the market are really illegal and have not been approved by the Food and Drug Administration and that in 2020, many of these products will likely come off the market because they will have to submit an application to the Food and Drug Administration to receive approval to remain on the market.
Host: Dr. Fagan, thanks for your time and insight today. for more information on Dr. Fagan and the effects of vaping, visit www.uamshealth.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics that may interest you. This is UAMS Health Talk. Thanks for listening.
Addressing Vaping Concerns
Scott Webb (Host): It seems that vaping and it’s effects are in the news on a daily basis. My 16-year-old son tells me that vaping is out of control at his high school. It’s really frightening. My guest today is Dr. Pebbles Fagan. She’s the Director of the Center for Study of Tobacco with the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences. She’s also a professor in the Department of Health Behavior and Health Education in the College of Public Health. Let’s talk to Dr. Fagan about the vaping concerns and questions that many of us have.
This is UAMS Health Talk from the University of Arkansas for Medical Sciences. I’m Scott Webb. Dr. Fagan, thanks for joining me. I have so many questions for you, but let’s start here. What is vaping and how and why did it become so popular, so fast?
Pebbles Fagan, PhD, MPH (Guest): Vaping devices or E-cigarettes, they are the same thing, are battery powered devices that release an aerosol when heated. They contain things such as nicotine, flavorings, propylene glycol, vegetable glycerin, formaldehyde, acid aldehyde, acrolein and some other harmful chemicals that are released when heated through a battery. They come in all shapes and sizes. Sometimes we call cigarette looking ones cigalikes, those were the first generation of e-cigarettes to hit the market and then after that, we saw a number of other types of devices being released on the market such as the vape pens which are long and thin, the e-pipes, e-cigars, the large tanks, Sub-Ohm tanks and devices that contain pods such as JUUL and SOURIN. But all of these devices are battery operated. They heat the liquid that release an aerosol.
How did they become so popular? Well most of them contain nicotine and like cigarettes, nicotine is in cigarettes, nicotine is in e-cigarettes, nicotine is in smokeless tobacco. It is in all tobacco products which means that all of these products have the potential to be addictive. Nicotine is one of the most addictive substances on earth in fact. And as addictive as cocaine and heroin. And so when you talk about why did this product and these products that are on the market become so popular particularly among young people, it’s because they are highly addictive and they contain flavorants such as gummy bear flavor, cotton candy flavor, cheesecake flavor, blueberry flavor that appeal to young people.
Host: So, Dr. Fagan, you mentioned the flavors and I think that that’s probably what appeals so much to children. What can parents and teachers do to stop children from vaping? Because really, quite frankly, it’s becoming an epidemic.
Dr. Fagan: Well I think what’s most important is that they first have an awareness that many teens are using these products that go unnoticed. When you think about products like JUUL and SOURIN which are the pod type devices that look like a jump drive that you put on the computer; they can be hidden very easily. So, I still think it’s important for parents to be aware of what these products look like, to talk to their children about the harms of tobacco products because e-cigarettes, vaping devices are tobacco products because they contain nicotine. They should communicate to their children that even though some people perceive that these products are less harmful than cigarettes, they are still harmful. And so, we know from the many deaths that have been happening over the last two months that these products can cause harm but it’s important for parents to communicate to their children that less harmful does not mean harmless and they can use these case examples of what’s happening across the nation with these e-cigarette deaths and these hospitalizations to demonstrate to their children that these products do contain some harm.
Host: And doctor, correct me if I’m wrong, but people aren’t just vaping tobacco alternatives, they are also vaping THC, correct?
Dr. Fagan: Yeah, that’s correct. And I think this is an important message for teens, for parents and for teachers. First of all, we already know that in these products, there are chemicals such as formaldehyde, acetaldehyde, and acrolein which are lung irritants and cancer causing agents. And so, in the news, you hear a lot about THC and children may be using THC based products, they may be using nicotine based products, or they may be using the combination of the two. What we know is that the harmful constituents that FDA has already deemed as harmful, include formaldehyde, include acetaldehyde and acrolein which is a lung irritant and so, I think we don’t want to confuse parents by just making them think that the THC in these products is the constituent that is causing harm.
The CDC and the FDA has not actually identified what chemicals in these products are causing the lung irritants. What they have identified is the fact that the children are using THC and nicotine based products. But we do know the harmful chemicals that exist in there. There are over 80 chemicals in e-cigarettes. And formaldehyde, acrolein and acetaldehyde are some of the chemicals that we should paying attention to.
Host: So doctor, I’m sitting here, I’m listening to you and I’m thinking to myself, we could be ingesting up to 80 things into our bodies that aren’t meant to be in our bodies? I’m trying to figure out how the industry convinced people that vaping and e-cigarettes was somehow safer than cigarettes.
Dr. Fagan: Well, there’s a difference between thing such as does the product contain less harmful chemicals without it being smoked versus when you actually heat it up, what then happens? There’s a chemical process that occurs that releases and converts some of these harmful chemicals into more harmful chemicals. So, a lot of times, the manufacturers are saying our products contain less carcinogens and other harmful chemicals but that’s in a state when it’s not been heated. When you heat these products, other harmful chemicals are released.
The second thing is that the manufacturers are distinguishing between combusted products and non-combusted products. So, combusted products like cigarettes burn when heated because they reach a particular temperature over 400 degrees. And so, these e-cigarette battery operated devices are being marketed as devices that are not combusted. We know when you burn things, you get more harmful chemicals that are released. And what the manufacturers are saying because it’s not combusted, like cigarettes are; then it’s releasing less harmful chemicals.
However, we know that the power in a lot of these batteries can reach combustion just like cigarettes and that the toxicity yields of these products depend upon not only the heat, but the amount of various constituents that are in these products and the type of device and the flavorants that are added. None of these products are regulated by the FDA. That’s a fallacy and there are no product standards related to any of these devices that are currently on the market. There’s no regulation of how much nicotine, how much propylene glycol, how much THC, how much vegetable glycerin, how much of a flavorant or how much of a salt is added to these devices. There’s no standard regulation on that.
Host: Does this help to explain a little bit why for some, the adverse effects happen so quickly, so unexpectedly because they just have no idea what they are about to ingest into their bodies?
Dr. Fagan: The other fallacy that I’d like to debunk is that these things happen suddenly. It is now reaching the point of being noticed in the media and as people report cases, and they look at their own symptoms, more cases are being reported. So, when we think about what happened with the HIV epidemic as people began to realize what was happening, more cases started being reported. We have known for several years that e-cigarettes with nicotine can cause heart damage. We have known for several years that e-cigarette liquids can irritate airways, can cause inflammation and other systematic changes that are respiratory related.
So, we’ve known that there are published scientific papers on that, that occurred prior to the epidemic. So, we’ve known that. We also know that when you mix nicotine based liquids with THC based liquids; that they also cause irritation in the respiratory airways as compared to if you were using one of those products alone. And so now, that cases are being reported, you have more cases being reported because people are paying attention to the symptoms.
Host: Right, so experts like yourself, there at UAMS, you’ve known this for years and you have been fighting the good fight. It’s only now that it seems like the media is finally catching up and maybe that’s why we are hearing about so much. Okay so here’s what I want you to do doctor, let’s drive this home. Really explain in detail what are the effects of vaping and why should everybody think twice before doing it.
Dr. Fagan: Well I think the most important thing to keep in mind is that it’s highly addictive. Nicotine is as addictive as crack cocaine and heroin. It doesn’t matter whether it’s in cigarettes, it it’s in an e-cigarette, whether it’s in a pipe or a cigar. Nicotine is highly addictive. So, what does that mean?
When a product is highly addictive, that means it’s difficult to get children off the product. It may lead them to using other harmful tobacco products as well. The second thing is that we know that there are health effects associated with electronic cigarettes that people are seeing in the news. We don’t know all of the chemicals that may be causing the health effects, but we know that there are health effects associated with these particular products. And again, we know from the prior literature that nicotine is a culprit in heart disease. We know that from cigarette smoking, we also know that nicotine activates biological pathways that lead to cancer. We do not call nicotine a carcinogen because it doesn’t directly cause cancer, but we know from the 2010 Surgeon General’s Report on biological pathways related to tobacco related disease that nicotine activates certain pathways that lead to cancer.
And so, nicotine is not a harmless constituent. And some people may say well it’s just addictive. It is not just addictive. And I’m sure that parents would not want their kids to be addicted to any product even if it were just addictive. But we do know that it is associated with heart disease, we know that it is associated with pathways that lead to cancer particularly lung cancer. And so, if I were some of the parents and the teachers listening; I would be concerned about nicotine based products because nicotine itself is harmful.
The second thing is all of these other chemicals. I don’t think anyone would want to drink formaldehyde. I don’t think that anyone would want to put acrolein in their system. And so we have to question why is it that people perceive that these products don’t contain harm. And the reason is because we have these flavorings associated with it. So, if you have ever smelled e-liquids, they smell great. Blueberry flavor smells fantastic. The coffee flavor smells very appealing. The donut flavor is also extremely appealing to a wide variety of users but particularly young people.
So, when disguised with a flavor; people can perceive that these products are less harmful. And so, we just want parents and teachers to know that these flavorings are part of the problem. Without the flavorings; there are still harmful constituents in these products. They are highly addictive, and I think it’s important for us to recognize that children who use these products can graduate to using other tobacco products that can later cause harm in adulthood.
Host: Dr. Fagan, you are so knowledgeable. So amazing to have you on. What else can we tell listeners about the work you are doing at UAMS, about vaping, about e-cigarettes, all of it?
Dr. Fagan: We are doing research in our laboratory looking at – we’ve looked at the constituents in e-cigarettes. That’s how we have identified a lot of sugars and aldehydes in these particular products even when they are not heated. We are monitoring what they are selling in retail stores particularly in Arkansas, Virginia and several other states. And we are monitoring the flavors that they are selling, how many stores there are in specific states because ultimately, as FDA tightens up some of its regulation, we should start to see some of these products come out of the market and some of the retailer start to close.
We’ve already seen some retail stores close. Certainly in the state of Arkansas since you cannot buy e-cigarettes online, we see a lot of the online sales in the state of Arkansas are disappearing. We also monitor what’s going on, on social media because we know young people are the biggest users of YouTube and receive a lot of their instructions related to how to use these products on YouTube. We have documented and have published on what we call unorthodox use of these products, that is using the product as not intended by the manufacturer. Things such as cloud chasing, and steeping and streeping, and dripping. All of these terms that young people are familiar with. So, we’ve been monitoring those kind of behaviors in the social media as well.
So, that’s some of the research that we do. We are also monitoring whether or not these manufacturers are using the FDA mandated warning that basically says that the product is addictive, and that nicotine is an addictive chemical and so, we’re monitoring whether or not on the websites and in social media these manufacturers are using the FDA mandated warning statements. So, that’s some of the research that we do.
We hope that listeners have a greater awareness of what e-cigarettes are, the fact that they are not harmless. That they contain over 80 constituents and some of these harmful things we already know such as formaldehyde, acetaldehyde and acrolein that all products that are on the market are really illegal and have not been approved by the Food and Drug Administration and that in 2020, many of these products will likely come off the market because they will have to submit an application to the Food and Drug Administration to receive approval to remain on the market.
Host: Dr. Fagan, thanks for your time and insight today. for more information on Dr. Fagan and the effects of vaping, visit www.uamshealth.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics that may interest you. This is UAMS Health Talk. Thanks for listening.