CADCA Mid-Year Training Institute What’s Trending in Tobacco: E-cigarettes Wednesday, July 23, 2014 - Orlando, FL Christine Cheng, Partner Relations Director.

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

E-cigarette Devices Currently Available

4

Components of E-Cigarettes

Battery

“Clearomizer”

Battery

5

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

“Harmless” Vapor

7

• 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

9

E-cigarette User’s Exhale

10

Look Familiar?

Videos from www.smokestik.com Image from www.ecigaretteschoice.com; www.v2cigs.com

11

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

13

Cost Savings Claims

http://tobacco.stanford.edu/tobacco_main/index.php

14

15

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?”

17

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

20

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

24

25

23 million likes on FB10 million Twitter followers

26

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

27

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

28

• 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

31

www.blucigs.com,

Last Words …

32

Contact SCLC for Technical Assistance

Visit us online

• http://smokingcessationleadership.ucsf.edu

Call us toll-free

• 1-877-509-3786

Christine Cheng

• email: [email protected]