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Daily Dose

E-Cigarettes

1:30 to read

E- cigarettes which were a relatively obscure curiosity only 5 years ago are now available at not only “vape shops” but are also easy found at gas stations and pharmacies and the e-cigarette market has exploded. Unfortunately,  with the increased availability of e- cigarettes, there has been a steady rise in adolescent e-cigarette use (vaping).  

 

The Surgeon General stated, “exposing the developing brain to nicotine has been shown to alter its structure and function in a way that introduces long-lasting vulnerability for addiction to nicotine and other substances of abuse”. Yearly studies in high school students about their use of e-cigarettes showed that the percentage of students reporting e-cigarette use in the past 30 days went from 1.5% in 2011 to 16% in 2015.  The use of e-cigarettes by teens is becoming a major public health issue.

 

In a study recently reported in JAMA (Journal of the American Medical Association), 10th grade students were surveyed in the Los Angeles public schools and found that about 37% of 10th graders have used e-cigarettes. In the same study it was reported that “teens who vaped frequently were about 10 times more likely to become regular smokers six months later, compared to teens who never vaped”. Additionally, “20% of the regular e-cig users transitioned into frequent smokers, while less than 1% of kids who had never vaped smoked cigarettes at follow-up”. It would seem from this and other studies that e-cigarettes may serve as a “gateway” to smoking cigarettes.

 

Those teens who were more frequent “vapers” might sensitize their brain to the addictive effects of nicotine and find even more “pleasure” when they start using cigarettes and may progress to adult smokers.

 

The FDA published its “deeming” rule and regulatory authority over e-cigarettes in May of 2016, and banned the sale of e-cigarettes to minors, as well as requiring warning labels on e-cigs. But the FDA did not ban e-cigarette TV ads, nor did it address the role of flavoring in attracting youths to use e-cigarettes.  (flavors such as cotton candy and gummy bear - really targeting teens) . Youth oriented advertising, not only on TV, but in stores and on the internet must be addressed as well, as studies again show that greater exposure to ads is associated with higher odds of e-cigarette use. 

 

So…once again parents  and pediatricians)  need to be discussing the use of e-cigarettes, “vaping” and life long risk for nicotine addiction.   

Daily Dose

Help Your Child Stop Smoking

Today is the National Smoke Out where every smoker is supposed to put out his or her cigarettes for the day on the road to stop smoking. Why am I writing about this on a kid's health Web site? Well, unfortunately teenage smoking is still an ever-present issue. There are still thousands of kids every day who begin smoking, as young as 11 or 12 years of age. Statistics show that 50% of high school teens will have smoked at some time in their life, and many of them will continue to smoke.

Smoking is glamorized in movies, in magazines and in ads appealing to kids. But you know, the consequences of smoking are never shown. Why don't they show you the yellow teeth (all of the models have pretty white teeth, right)? They don't talk about disgusting breath, or smelly clothes and hair and what about lung cancer and emphysema? The list is so long and the consequences of nicotine addiction are so great, but our kids don't get that message. We in the media need to educate, not glamorize or fail to report consequences. Second had smoke is also an issue. More and more data is being released about the effects of second hand smoke including promoting allergies, asthma, and even lung cancer. Who wants their children exposed to smoke as they walk out of malls, office buildings, restaurants and airports? So, if you smoke, this is the day to set the example for your child and STOP SMOKING. If you have a teen who is smoking, sit down once again and talk to them about nicotine addiction, and the cumulative effects of smoking. Teens really do listen; you just have to tell them more than once or even twice...don't give up. That's your daily dose, we'll chat tomorrow.

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Parenting

“Live Long and Prosper”

2:00

Leonard Nimoy, the actor who played the iconic character Spock in the Star Trek television series and films, passed away last week from chronic pulmonary obstructive disease, also known as COPD.  He was 83.

Spock’s Vulcan salute, accompanied with the phrase “live long and prosper”(LLAP), was recognized around the world as a symbol of friendship and good wishes.

So what does the passing of an elderly movie star have to do with kid’s health?  Kids, teens and adults were fans of Nimoy’s beloved character, Mr. Spock. In his final months, he reached out to his fans with a farewell warning. 

Nimoy attributed his COPD to years of smoking, even though he quit three decades ago around the age of 50.  A few months ago he tweeted a simple but cautionary warning to young adults and teens, “Don’t smoke. I did. Wish I never had. LLAP.”

According to the Centers for Disease Control & Prevention, chronic lower respiratory disease, most of it COPD, killed 149,205 Americans in 2013, making it the third-leading cause of death after heart disease and cancer. Chronic respiratory disease killed more people than accidents, stroke, or Alzheimer’s disease. And that’s only the tip of the iceberg.

I personally know how COPD can slip into your life and kill you, even years after you’ve crushed out your last cigarette butt. My mother died of COPD 20 years after she quit smoking. She smoked from the time she was in her teens till her 60s. While she did live to be in her 80s, many of those years were spent gasping for air and hooked to an oxygen tank. She also warned her kids and grandkids not to smoke. Like so many other teens, they didn’t listen.  Now, they wish they had.

An online article by Forbes’ Matthew Herper, eloquently states the difference in the fictional character of Spock and the man, Leonard Nimoy, and how we can honor both.

“It’s ironic — bitterly so — that a man who became famous playing a character who was the epitome of logic and clear thinking died because of one of humanity’s most illogical flaws: our propensity toward addiction and for risking our health for momentary pleasure. It would be a fitting way to honor him if we could approach the problem of smoking with the kind of logic that Spock would have. As we deal with a whole lot of tobacco-related issues, including how to deal with e-cigarettes which are putatively safer than traditional cigarettes but whose manufacturers seem intent on proving no such thing, we could use some Vulcan clarity.”

As much as the phrase “ this is a teaching moment” has been misused and over used, I think it applies in this case. Many pre-teens, teens and young adults know and appreciate the Spock character and the man who played him all these years. What they probably don’t know much about is what killed him.

As they say, the door is open and this might be an excellent time to talk about smoking with your child. Whether it’s cigarettes, e-cigarettes or chewing tobacco. They are all highly addictive and each holds it’s own serious health issues.  E-cigarettes are still being studied for health complications. More in-depth research is beginning to expose the chemicals used to vaporize the nicotine that is inhaled into a user’s lungs.  The findings are not good.

It’s hard for many kids to care about the possible long-term health effects of something that feels so good at the moment. But irritating symptoms such as coughing, shortness of breath and loss of stamina will start adding up. If you smoke, you will experience all of these symptoms at some time.

COPD is incurable. There is nothing that can reverse it. Typically it occurs in people 65 and older, however, 2 percent of COPD cases involve men aged 18 to 24 and 3 percent involve women in the same age group. The numbers increase slightly for people aged 25 to 44 with 2 percent of cases in men and 4.1 percent of cases in women.

My niece-in-law died from COPD at the age of 48. She first showed symptoms at age 22 – she started smoking at age 12.

People who have never smoked can develop COPD from second-hand smoke, air pollution, chemicals or dust. However, smoking accounts for 9 out of 10 COPD –related deaths.

Now is a good time to use some of Spock’s clarity of details to talk with your child about smoking, whether it’s with cigarettes, e-cigarettes, paperless tobacco, hookahs or anything else that is inhaled into the lungs.

Nimoy’s last tweet reminds us that life is bittersweet, “"A life is like a garden," he wrote. "Perfect moments can be had, but not preserved, except in memory. LLAP"

Not smoking doesn’t guarantee a long life, but it certainly helps one live a healthier life and that’s a blessing every child deserves. 

Sources: Matthew Herper, http://www.forbes.com/sites/matthewherper/2015/02/27/want-to-live-long-and-prosper-dont-smoke/

Kristeen Cherney, http://www.healthline.com/health/copd/age-of-onset#Overview1

 

Your Teen

Studies: Smoking and Students

1.45 to read

Everyone knows that smoking is really bad for you. But, how do you help kids keep from starting the expensive and nasty habit in the first place? Peer pressure seems to help. And for young adults who are already smokers, what will it take to break the habit? Perhaps being able to breathe better is a key motivator.

Kids as young as 10 admit to sneaking a smoke every once in a while, while 17 percent of high-school students and 5.2 percent of middle-school students admit to being daily cigarette smokers. Many college students bring their habit with them when they enroll.

What helps kids keep from starting to smoke? A new study suggests that kids who are involved in team sports with teammates, who do not smoke, are less likely to start. 

Interestingly, the study showed that girls involved in sports with teammates who do smoke, are more likely to give it a try. Peer pressure seems to have more of an impact among girls.

"This result suggests that peers on athletic teams influence the smoking behavior of others even though there might be a protective effect overall of increased participation in athletics on smoking," study leader Kayo Fujimoto, who conducted the research while at the University of Southern California, said in a journal news release.

Researchers questioned 1,260 sixth through eighth graders about their smoking behavior. The children were middle class, lived in urban areas and ethnically diverse. The study, appearing Feb. 8 in Child Development, found that the more sports the kids played, the less likely they were to smoke.

The authors of the study believe that these findings may be helpful in improving anti-smoking campaigns aimed at children.

"Current guidelines recommend the use of peer leaders selected within the class to implement such programs," said Fujimoto. "The findings of this study suggest that peer-led interactive programs should be expanded to include sports teams as well."

Another recent study focused on college students who smoke.

Researchers at the University of Texas MD Anderson Cancer Center in Houston, studied 327 college students- ages 18 to 24 years old- who participated in a program to help motivate them to quit smoking. More than half the students smoked five to 10 cigarettes a day and had smoked for one to five years.

Participants who quit smoking for two weeks or more reported substantially fewer respiratory symptoms, especially coughing, than those who failed to kick the habit.

"That the benefit of stopping smoking starts in days to weeks -- not years or decades -- is important. Now health care providers can counsel young smokers that their breathing can feel better soon after they stop. This can help to motivate young adults to stop smoking before the severe damage is done," journal editor Dr. Harold Farber, an associate professor of pediatrics in the pulmonology section at Baylor College of Medicine in Houston, said in a journal news release.

Smoking has continued to decrease on college campuses, perhaps due to stricter smoking policies. Many colleges prohibit smoking anywhere on campus, and others do not allow smoking within a certain amount of feet from doorways. Cigarettes are expensive as well. Many college students are barely getting by with the increase costs in tuition. Something has to give, and cutting out cigarettes can save a pretty tidy sum. Also, smoking has lost a lot of its “cool” factor. Many students just find it annoying. 

Health professionals are always looking for ways to impress upon young people that smoking isn’t only a social nuisance, it can also become a serious long-term health problem.

Perhaps these studies can offer counselors, parents and friends, new discussion points in the battle to help kids avoid smoking or to help them quit. 

Sources: http://consumer.healthday.com/Article.asp?AID=66152 /  http://www.doctorslounge.com/index.php/news/hd/26596

Team Sports Can't Compete With Films to Keep Kids From Smoking

Taking part in team sports lowers the odds of children smoking. But even playing a sport can't compete with the powerful influence of smoking in movies, a new study finds. Movies can shape popular taste and behavior, from clothing to cultural habits. Other studies have found that seeing smoking in movies increases the chances that children will light up. Researchers say as many as 30 percent to 50 percent of adolescent smokers attribute their smoking to seeing it in films.

"Team sports is clearly protective to prevent youth from smoking," said lead researcher Anna M. Adachi-Mejia, a research assistant professor in the Department of Pediatrics at the Hood Center for Children and Families, at Dartmouth Medical School in Lebanon, N.H. But movies can undo that positive effect, Adachi-Mejia said. "Parents need to be aware of the need to minimize their child's exposure to movie smoking," she said. "So even if their child plays sports, that's not enough." Her study appears in the July 2009 issue of the Archives of Pediatrics & Adolescent Medicine. In the study, Adachi-Mejia's team collected data on 2,048 children, first in 1999 and again in 2007. Smoking exposure in movies was assessed when the children were 9 to 14 years old, and participation in team sports was assessed when the same youths were 16 to 21. At follow-up, 17.2 percent of the individuals were smokers. Those who said they saw the most movies with smoking when they were aged 9 to 14 were much more likely to be smokers compared with those who saw the fewest movies with smoking at an early age, the researchers found. Although people who did not take part in team sports were twice as likely to become smokers as those who played sports, "in both team sports participants and nonparticipants, the proportion of established smokers increased from lowest to highest levels of movie smoking exposure by the same amount, 19.3 percent," the researchers wrote. In addition, smokers were more likely to be male, older, have parents with lower levels of education, have more friends who smoked, have parents who smoked, have poorer school performance and be more likely to engage in risky behaviors. Smokers were also less likely to be in school when they were 16 to 21, the researchers found.

Daily Dose

K2: New Legal "Drug" For Teens?

1.30 to read

I was seeing patients the other day when I saw a teenage boy that I have taken care of since he was born (one of the perks of being a pediatrician).  He came in over lunch with his mother, as she had called me earlier that morning, and she wanted him to have a drug screen. She had found a “pipe” in some pants of his and she was concerned that he was smoking marijuana.  I am often asked to perform drug screens on kids, and I really think it is important to sit down with the child and parents to discuss their concern, rather than ruin the trust of the teen, and blindside them with the results of a drug screen obtained under false pretenses. So…the point of this is that the adolescent told me that he had been smoking K2.  He told me that it was a “legal” substance that you could buy over the internet or in smoke shops. K2 is a mixture of herbal and spice products that are then sprayed with a psychotropic drug.  When asked why he would smoke it, he told me that it had similar effects as marijuana with an overall feeling of feeling good, sleepy, and relaxed.   Seeing that I did not know anything about this new substance, I got my computer, brought it into the exam room and “googled” K2, only to see many different articles. The most interesting was an article in LiveScience written earlier this year, that explained how K2 had been developed by a research scientist who was studying cannabinoid receptors in the brain.  He had published articles about this substance (which when first discovered went by his initials, JWH-018),  and had found that that K2 binds to the same receptors in the brain as marijuana, and that it is actually much more potent than marijuana. K2 may be 10 times more active than THC (marijuana) and while it may have many of the same effects as the high with marijuana, it  has also been found to cause hallucinations, and seizures. Upon further investigation, I found that it is becoming a problem in many states with plenty of information on the internet. K2 has already been declared illegal in the state of Kansas.  There are concerns that this drug has caused adverse effects and ER visits due to hallucinations, vomiting, elevated blood pressure and heart rate, which are not typical symptoms seen with marijuana.  K2 does not show up on routine drug screens.  There is a researcher in St. Louis who is studying K2 and is seeking urine samples obtained from teens who have used the substance.  I called several private labs in my area and they did not have the capability of testing for it. The good news in my patient’s case is that he told me about K2, had not smoked it in the last several weeks, and his urine drug screen was negative for marijuana and other drugs. Oh the things we must learn to keep up with adolescents! How someone discovered the article written in scientific journals in the late 1990’s and extrapolated that this compound, which binds to the same receptors in the brain as marijuana, could be used “legally” for a high similar to “weed”  is beyond me.  But kids are really “smart and clever” and will do almost anything for a “high” especially in this case with a product that is easily obtained and is legal.  After a lengthy discussion with this boy and his mother I understand that K2 use is quite prevalent in his high school, even among the “non-drug” crowd. I am going to continue researching this topic and will keep you posted. But if you have an adolescent who you think exhibits odd behavior and may even require a visit to the ER for a suspected overdose, and the drug screen turns out to be negative, be aware of K2. Lastly, talk to your teens, they are probably already in the know. That's your daily dose.  We'll chat again tomorrow.

Your Child

40% of Children 3 to 11 Are Exposed to Secondhand Smoke

2:00

The good news is that exposure to secondhand smoke dropped by half in the United States between 1999 and 2012. While more and more people are giving up the unhealthy habit, the amount of children being exposed to secondhand smoke is still significant – particularly in the African-American population. 

In a recent report, The Centers for Disease Control and Prevention (CDC) estimated that 58 million American nonsmokers are exposed to secondhand smoke.

In that group, the CDC suggests that 40 percent of children aged 3 to 11 are breathing in secondhand smoke and among black children, the number is much higher at 70 percent.

"Secondhand smoke can kill, and too many Americans -- and particularly too many children -- are still exposed to secondhand smoke," Dr. Tom Frieden, director of the CDC, said during a midday press conference.

Frieden, citing the U.S. Surgeon General, said, "There is no safe level of exposure to secondhand smoke." Tobacco smoke contains over 7,000 chemicals including about 70 that can cause cancer, he added.

The connection of secondhand smoke and illnesses in children has been widely studied and reported. In infants and children, secondhand smoke has been linked to sudden infant death syndrome (SIDS), respiratory infections, ear infections and asthma attacks.

In adult nonsmokers, passive smoke has been tied to heart disease, stroke and lung cancer, according to Frieden.

Each year, secondhand smoke kills more than 41,000 Americans from lung cancer and heart disease, and causes 400 deaths from SIDS, Frieden said. "These deaths are entirely preventable," he added.

Susan Liss, executive director of the Campaign for Tobacco-Free Kids, said in a statement: "The high level of child exposure to secondhand smoke also underscores the need for parents to take additional steps to protect children, such as ensuring that homes, cars and other places frequented by children are smoke-free. For parents who smoke, the best step to protect children is to quit smoking."

Smoking can become such a mindless habit that parents and caregivers forget that their children are breathing in the smoke they exhale. In nonsmoking homes, it can be difficult when friends or other family members want to light up when visiting. Asking people to either step outside or not smoke in the house has caused many a friends and family rift. But, standing your ground will protect your child from the influence of smoking and the polluted air that flows from a smoker.

Most restaurants, bars and workplaces have issued smoke-free policies but one's home and auto are open to personal choice. The number of U.S. households that are now smoke-free has increased in the past 20 years from 43 percent to 83 percent and that’s truly amazing considering our long love affair with cigarettes and cigars!

However, when 1 in 4 nonsmokers – including many children-are still being exposed, it’s going to take more parents, friends and family members to put down their cigarettes for good to finally stop children and adults from suffering the disastrous effects of breathing in secondhand smoke.

Source: Steven Reinberg, http://consumer.healthday.com/kids-health-information-23/adolescents-and-teen-health-news-719/58-million-americans-exposed-to-secondhand-smoke-cdc-696149.html

Your Teen

Teen’s E-cigarette Use Linked to Family and Friends

2:00

For many teens, e-cigarettes have taken the place of the traditional combustible cigarette. A new study suggests that teenagers are more likely to use electronic cigarettes if their friends or a family member uses them.

It’s a pretty safe bet that no teen ever started smoking traditional cigarettes because they tasted good. More than likely it was because someone thought it was cool, felt like walking on the edge of rebellion, watched family members light up on a daily basis or a friend pressured them to give it a try.

These days, the reasons teens smoke e-cigarettes are pretty much the same as they are for regular cigarettes. However, these new nicotine packed products have a number of appealing differences for those just starting out. They don’t smell bad or leave a lingering aroma, they taste a little like candy, and no one is quite sure whether they are producing unhealthy side effects that will come back to haunt you later in life.

“There is a lot of concern by the public health community that e-cigarettes may be recruiting a whole new group of people who never smoked cigarettes," said lead author Jessica Barrington-Trimis of the University of Southern California in Los Angeles.

Other studies have linked e-cigarette and traditional cigarette use, but this new study suggests that teens who begin smoking with e-cigarettes may belong to their own unique group.  

Researchers found that many of the teens in the study that said they'd recently used e-cigarettes, had never smoked traditional cigarettes. This was their first venture into smoking.

"If you think of e-cigarette and cigarette use as two circles, the overlap isn’t as big as expected," Barrington-Trimis said.

Using data collected in 2014 from 2,084 Southern California teens, the authors found that about 25 percent reported ever using e-cigarettes and about 20 percent reported ever using traditional cigarettes.

This finding is a cause for concern because e-cigarettes were the dominant tobacco product used, and a substantial proportion of e-cigarette users had no history of cigarette use, the authors noted in their report.

Fourteen percent of teens thought e-cigarettes are not harmful, compared to about 1 percent who thought cigarettes are not harmful. The teens also felt their peers were more likely to accept their e-cigarette use than traditional cigarette use.

Like many other studies on the use of e-cigarettes, this one can’t say with absolute certainty that smoking e-cigarettes leads to smoking traditional cigarettes. However, the researchers suggest that the more accepted these products become by teenagers, the more they contribute to the “re-normalization” of tobacco products.

"Our findings really suggest there’s a lot of kids who are using these e-cigarettes," Barrington-Trimis said.

The lack of research makes it difficult to know what to tell people about e-cigarettes, she added.

She said parents should tell their children that while research into the health effects of e-cigarettes is still in its infancy, nicotine is known to impact youngsters' developing brains.

Nicotine is also highly addictive and one of the most difficult drugs to break free from.  The longer you smoke – whether it’s e-cigarettes or combustible cigarettes – the harder it is to quit. Plus, little is known about the chemicals used to create the sweet tasting flavors of e-cigarettes.

Parents should make sure they know if their child or their child’s friends are using e-cigarettes. Unfortunately in this day and age, discussions about smoking and drug use have to begin early in a child’s life. Waiting till your child is a pre-teen or teenager to talk about e-cigarettes may be too little too late.  

Source: Andrew M. Seaman, http://www.reuters.com/article/2015/07/27/us-health-teens-smoking-ecigarettes-idUSKCN0Q11YC20150727

http://pediatrics.aappublications.org/content/early/2015/07/21/peds.2015-0639.full.pdf+html

Your Teen

AAP: Raise the Smoking Age to 21 for Tobacco, e-Cigarettes

2:00

The American Academy of Pediatrics (AAP) wants the minimum age to purchase tobacco products and e-cigarettes raised to 21 across the United States. In new policy recommendations, the AAP released a statement urging more than two- dozen tough regulations to help reduce youth smoking and addiction to nicotine.

Nicotine is considered physically and psychologically addictive, with some experts claiming that it is as additive and hard to kick as heroin and other hard narcotics.

The AAP also calls for the U.S. Food and Drug Administration (FDA) to finally regulate e-cigarettes the same way it regulates other tobacco products. The FDA has issued a proposed rule that would extend the agency’s tobacco authority to cover additional products that meet the legal definition of a tobacco product, such as e-cigarettes.

"Most adolescents don't use just one nicotine product but will commonly use or experiment with several," said Dr. Harold Farber, lead author of two of the statements and a pediatric pulmonologist at Texas Children's Hospital. "Research to date shows that adolescents who experiment with e-cigarettes and conventional cigarettes are much more likely to go on to become regular cigarette smokers and less likely to stop cigarette smoking."

Currently, only Hawaii and about 90 cities and communities in several other states have a law requiring a minimum age of 21 to purchase tobacco products, according to the Campaign for Tobacco-Free Kids.

"As the brain matures, the ability to make decisions with important health consequences should likewise improve," said Dr. Danelle Fisher, vice chair of pediatrics at Providence Saint John's Health Center in Santa Monica, Calif. "Thus, slightly older young adults may choose to forgo tobacco products," suggested Fisher, who was not involved with the new policy recommendations.

Not only would the AAP like to see e-cigarettes regulated, but also their candy-like flavors and menthol eliminated.

According to the U.S. Centers for Disease Control and Prevention,  more adolescents used e-cigarettes than any other tobacco product in 2014.

In addition to calling for FDA control of e-cigarettes, the AAP recommended that smoke-free laws expand to include e-cigarettes. The group recommends that use of any tobacco or nicotine products, including e-cigarettes, be banned in all workplaces, schools, dormitories, bars, restaurants, health care facilities, sidewalks, parks, recreational and sports facilities, entertainment venues and multi-unit housing.

"The jury on e-cigarettes remains out, but it is clear that carcinogens and potentially harmful substances are nonetheless present in this alternate nicotine delivery system," said Dr. Jack Jacoub, director of thoracic oncology at Orange Coast Memorial Medical Center's MemorialCare Cancer Institute in Fountain Valley, Calif.

Other policy recommendations include a ban on Internet sales of e-cigarettes, a tax on e-cigarettes at the same rate as traditional cigarettes and a requirement for adult ratings on any entertainment depicting e-cigarette use.

The AAP also recommended banning advertising of tobacco products and e-cigarettes in all media, including television, radio, print, billboards, signs and online, and in stores where children and teens might see them..

Another concern is the number of young children who have suffered nicotine poisoning from accidently ingesting liquid nicotine. Poison control centers receive more than 200 calls per month for accidental ingestion of nicotine for e-cigarettes, the AAP noted, and one toddler died last year from swallowing some. The APP recommends child-resistant packaging for these products.

"Toddlers and young children love to explore new things and to put things in their mouths, so it is imperative that packaging and childproofing be done to enhance the safety of their environments," Fisher said. "This is analogous to having childproof caps on pill bottles."

The new policies were presented Monday at the group's national conference and published online simultaneously in the journal Pediatrics.

Source: Tara Haelle, http://consumer.healthday.com/cancer-information-5/misc-tobacco-health-news-666/raise-smoking-age-to-21-u-s-pediatricians-group-urges-704535.html

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DR SUE'S DAILY DOSE

A few life lessons & fun with Elf on the Shelf!

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