CADCA Mid-Year Training Institute What’s Trending in Tobacco: E-cigarettes Wednesday, July 23, 2014 - Orlando, FL Christine Cheng, Partner Relations Director.
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CADCA Mid-Year Training Institute
What’s Trending in Tobacco:
E-cigarettesWednesday, July 23, 2014 - Orlando, FL
Christine Cheng, Partner Relations Director
Overview• History: invented by a Chinese pharmacist in 2003
• Rapid evolution of devices: a moving target
• Poll questions
• YouTube videos: from Consumer Reports, http://
www.youtube.com/watch?v=100b-l_0z9s from CNN, http://
www.youtube.com/watch?v=EqvlxEQaQnE2
Poll Questions1. Show of hands, how many have tried an
e-cigarette?
2. How open are you to discussing the potential benefits and risks of e-cigarettes as a smoking cessation tool?
3. Are you willing to incorporate e-cigarettes into a smoking cessation treatment plan?
3
Fluids Contain• Many come premixed from China, but some are
now made in the US and Europe
• Origins and quality of the ingredients are generally not known
• Fluids* may contain:
Nicotine (in varying concentrations 0-100 ml/mg)
Humectants: propylene glycol (or vegetable glycerin) for vapor production
Flavorings (tobacco, menthol, coffee, vanilla, fruit, cotton candy, etc.)
*Metals particle have also been found in the fluids6
• E-cigarette fluid and vapor contains toxic metals and nanoparticles• Vapor contains tobacco-related toxins and chemicals – less than
cigarettes, more than nicotine inhaler Formaldehyde Acrolein Acetaldehyde VOCs NNN and NNK
• Exposure studies - Puff Topography not accounted for
Goniewicz et al, Tobacco Control 2013
8
Look Familiar?
Videos from www.smokestik.com Image from www.ecigaretteschoice.com; www.v2cigs.com
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12
What Attracts and Sells
http://www.npr.org/2014/03/03/284006424/e-cigarette-critics-worry-new-ads-will-make-vaping-cool-for-kids
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Cost Savings Claims
http://tobacco.stanford.edu/tobacco_main/index.php
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Prevalence of E-cigarette Use: Smokers and Recent Ex-smokers
2011-2
2011-3
2011-4
2012-1
2012-2
2012-3
2012-4
2013-1
2013-2
2013-3
2013-4
2014-1
05
101520253035404550
AnyDaily
Perc
ent o
f sm
oker
s and
rece
nt e
x-sm
oker
s
N=11,666 adults who smoke or who stopped in the past year; increase p<0.001
Growth in prevalence of e-cigarette use may have slowed
www.smokinginengland.info/latest-statistics/
16
Clinical Scenario #1
“I’m a heavy smoker and both my parents were smokers who died of lung cancer. I’ve tried all the meds but never quit for more than a week. I’ve heard that e-cigarettes can help smokers to quit and I really want to give it a shot. What can you tell me about them?”
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Clinical Scenario #1 Response1. Support Quit Attempt 2. Assess motivation and dependence3. Assess prior quit attempts and inform
about all treatment/support options4. Inform on what we know and what we
don’t know about e-cigarettes5. Assist smoker to develop a plan to quit
smoking6. Arrange a follow-up 18
Clinical Scenario #2• 50 y.o. primary care patient with back pain,
hypertension, hyperlipidemia, depression and PTSD, here for routine follow up, incidentally noted she is still smoking 3 to 5 cpd, reduced from 10 cpd• She quit once “cold turkey” for 9 months 2 years ago• “not interested” in any medications, counseling, or
nicotine replacement• She is willing to set a quit date in the next 30 days
(her son’s birthday) and remarks, “Maybe I’ll get one of those electric cigarettes to quit, what do you think?” 19
“not interested”
• “I’ve tried everything” • Frequently NRT misused or incorrectly used• Unassisted quit attempts
• Correct misperceptions of approved therapies• Correct misperceptions of e-cigarettes• Treat Depression, PTSD
Shiffman S, Ferguson SG, Rohay J, Gitchell JG. Perceived safety and efficacy of nicotine replacement therapies among US smokers and ex-smokers: relationship with use and compliance. Addiction. 2008 Aug;103(8):1371-8
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Clinical Scenario #2 Response1. Opportunity to engage patient in
counseling2. This is a “light” smoker 3. Significant psychiatric history4. ASK: why is she interested in e-cigarette?5. What does she think is different from
approved therapies?6. History of past quit attempts and
assistance? 21
Clinical Scenario #2 Follow Up
• This patient ended up with • Nicotine inhaler prescription (unfilled)
• Quit with nicotine gum and counseling on proper use• Saw a therapist to help manage stress• Remains tobacco free today
22
Clinical Scenario #3• 21 y.o. female presents for work physical for
restaurant job. Denies significant past medical history except asthma, treated with Albuterol (once or twice a day)• Denies smoking. Drinks 4-5 alcoholic drinks on
weekends. Has been using a vapor pen when out at parties sometimes. • She lives with her mom and 5 siblings. Mom (39)
recently quit smoking using an e-cigarette, which she continues to use. • Is her nicotine exposure significant? How do you
counsel her?23
Clinical Scenario #3 Background1. Screening challenges2. Binge drinkers frequently smoke 3. May present themselves as nonsmokers4. Need to screen specifically (only smokes
when drinks)5. Vapor pens = e-cigarettes6. Also e-hookah, vapes, sticks, hookah pens7. Recreational use common8. Young adults have highest rates of use9. May lead to or increase nicotine addiction
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Clinical Scenario #3 Asthma1. Inadequately controlled2. Personalized reason not to smoke or be
exposed to secondhand smoke or aerosol3. One study found acute pulmonary effects4. 5 minutes of e-cigarette use in healthy
smokers increased airway resistance5. Unknown clinical significance6. May affect susceptible people
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Clinical Scenario #3 Response1. Discourage recreational “vapor pen” use2. Personalize to patient’s medical conditions3. Fetal exposure to nicotine not harmless4. Support mom’s quit attempt!5. Preserve smoke – and vapor free homes6. E-cigarettes are not harmless toys
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• Average 1 per month increased to 215/month• Most common adverse events were vomiting, nausea,
and eye irritation29
Advice for Provider
• Screen for poly tobacco use including e-cigarettes• Field and devices are rapidly evolving• Engage with new opportunities to discuss
smoking cessation• Misinformation and false claims are rampant• Data are scarce • Continue to recommend approved NRTs and Rx• Monitor use in your clients, document and report
health concerns 30
Advocacy and Coalition Action
• Include e-cigarettes in tobacco free policies• Prohibit cessation and health claims• Apply cigarette advertising restrictions to
electronic cigarettes
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Contact SCLC for Technical Assistance
Visit us online
• http://smokingcessationleadership.ucsf.edu
Call us toll-free
• 1-877-509-3786
Christine Cheng
• email: ccheng@medicine.ucsf.edu33
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