Electronic Cigarettes: What are the Risks and Benefits?€¦ · •Include electronic cigarettes in clean indoor air policies •Prohibit use in outdoor spaces on premises •Integrate

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Mignonne C. Guy, Ph.D.Associate ProfessorVirginia Commonwealth UniversityCollege of Humanities and SciencesDepartment of African American Studies

Faculty InvestigatorVirginia Commonwealth UniversityCenter for the Study of Tobacco Products

21st Arkansas Cancer SummitJune 23, 2020

Electronic Cigarettes:What are the Risks and Benefits?

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COI/Acknowledgments• No conflict of interest.

• FDA and NIH: Some research reported in this presentation was supported by the National Institute on Drug Abuse of the NIH under Award Number P50/U54 DA036105 and the Center for Tobacco Products of the FDA. The content is solely the responsibility of the author and does not necessarily represent the official views of the NIH or the FDA.

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Electronic cigarettes…

• What are they?

• Who uses them?

• Why do they use them? Where do they use them?

• Can they help smokers quit?

• What are the risks associated with use?

• Recommendations for the workplace

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Electronic cigarettes: what are they?

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Electronic cigarettes: what are the types?

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Electronic cigarettes: new on the market.• Heat-not-burn tobacco

products are electronic devices that heat tobacco and produce an inhalable aerosol, instead of burning tobacco like traditional cigarettes.

• Heat-not-burn products use real tobacco, not the flavored liquid nicotine typically found in e-cigarettes.

• Heat-not-burn allows users to experience something that looks and feels like smoking a regular cigarette without inhaling combusted tobacco.

• Tobacco companies claim that these products are less harmful than cigarettes.

Currently, there is little research on the health effects of using or being exposed to heat-not-burn products, and no independently-verified evidence that they have a lower health risk.

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Electronic cigarettes: availability of flavors.

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Electronic cigarettes: availability of flavors.

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Electronic cigarettes: many brands and flavors.

From Zhu et al., 2014

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Electronic cigarettes: variety of nicotine concentrations.

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Electronic cigarettes: heterogeneity in power.

Great heterogeneityamong members ofthe class in terms ofelectrical power.

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Electronic cigarettes: who uses them?E-cigarettes are the most commonly used tobacco product among youth.

• In the United States, youth are more likely than adults to use e-cigarettes.

• In 2017, 2.8% of U.S. adults were current e-cigarette users.

• In 2015, among adult e-cigarette users overall, 58.8% also were current regular cigarette smokers, 29.8% were former regular cigarette smokers, and 11.4% had never been regular cigarette smokers.

• Among current e-cigarette users aged 45 years and older in 2015, most were either current or former regular cigarette smokers, and 1.3% had never been cigarette smokers. In contrast, among current e-cigarette users aged 18–24 years, 40.0% had never been regular cigarette smokers.

CDC, 2020

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Electronic cigarettes: why do adults use them?Adults cite primary three reasons for trying and using e-cigarettes:

• Aid to smoking cessation

• Safer alternative to conventional cigarettes

• A way to conveniently get around smokefree laws

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• Simple question to ask; complex question to answer, and verycontroversial...

• RCTs suggest minimal efficacy (e.g., Bullen et al., 2013):

Electronic cigarettes: can they help smokers quit?

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• Simple question to ask; complex question to answer, and verycontroversial...

• RCTs suggest minimal efficacy (e.g., Bullen et al., 2013):

• But used ECIGs that failed to deliver nicotine effectively..

Electronic cigarettes: can they help smokers quit?

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Longitudinal and cross-sectional surveys?

From Kalkhoran & Glantz, 2016.

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Electronic cigarettes = less quitting

From Kalkhoran & Glantz, 2016.

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E-cigarettes + cigarettes: who are the dual users?

From MMWR Morb Mortal Wkly Rep 2016;65:1177.

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Why bother using electronic cigarettes?

Reported use of ENDS to cut down on cigarette smoking, as an alternative to quitting tobacco, or because of belief that ENDS help people to quit cigarettes were significantly associated with increased odds of ENDS use in smoke-free places.

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Electronic cigarettes: what smokefree laws?

Most e-cigarette users did not think e-cigarettes are harmful to themselves or to by-standers, and thus should not be banned where smoking is; those who had used e-cigarettes where smoking is banned were even more likely to hold these views.

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Electronic cigarettes: what do they emit?

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Electronic cigarettes: are they safer?

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Electronic cigarettes: what is emitted?

Bhatnagar, 2016.

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Electronic cigarettes: what is emitted?

Bhatnagar, 2016.

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Electronic cigarettes and cardiovascular risks.

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Electronic cigarettes and lung disease• ↑ Productive cough

Experimental Studies:• ↑ Airflow resistance• ↓ Cough reflex• Mucus: Inflammatory changes, ↑ damaging enzymes

(elastase)• Nasal scrapes: Immune gene suppression• Bronchial brush proteomics: >100 proteins ecigs > cigarettes

Case reports of inflammatory lung disease:

• Non-infectious pneumonias• Hypersensitivity pneumonitis

From Glantz & Bareham, 2018

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Electronic cigarettes and lung disease?

Lung disease – pulmonary effects

• 2013-4 PATH• including emphysema, chronic bronchitis

• Ecigs every day or some day• Propensity score matching

• Including smoking and SHS• COPD odds ratio 1.86 (95% 1.22-

2.83)

Perez et al., 2018

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Electronic cigarettes: impact on user’s lungs.

Ghosh et al, 2018

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Electronic cigarettes: additional evidence of risk.

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Electronic cigarettes: is there a risk for cancer?

From Tang et al., 2019

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Electronic cigarettes: is there a risk for cancer?

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Electronic cigarettes: how can they increase risk for cancer?

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Electronic cigarettes: they won’t kill you.

See also Miller et al., 2008; Zosel et al., 2010.

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Recap of constituents and health effects.

• Aerosolized propylene glycol, vegetable glycerin, and flavorants that are intended to be eaten and notinhaled.

E-liquidBase

• Other toxicants (e.g., formaldehyde) depend on device/liquid combination and how the products are used.

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Electronic cigarettes: what about non-users?

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Electronic cigarettes: potential risk for others.

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Electronic cigarettes and COVID-19

• SARS-CoV-2 virus, transmitted by droplets and aerosolization.

• Highly contagious and manifests with severe or critical bilateral pneumonia in 20% of symptomatic infected cases.

• COVID-19 infection is characterized by respiratory distress and decreased oxygen saturation.

• Vaping products should be considered at risk of enhancing respiratory disease caused by SARS-CoV-2.

• Aerosols and vapor generated by ENDS could disseminate virus to other in the close proximity of SARS-CoV-2 infected vapers.

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Electronic cigarettes and COVID-19

• Vape devices would increase humidity in the lungs and prevent COVID-19 infections.

• Vape devices might offer promise for administering COVID-19 medication to the lungs.

• Deliver organic oregano oil, a substance alleged to destroy the virus.

• PG role in possibly being able to destroy harmful COVID-19 airborne contagions.

• To date, there is no evidence substantiating vaping as a potential protective factor against COVID-19.

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Electronic cigarettes and COVID-19

• Smokers and those who vape are more vulnerable to COVID-19 infections or more likely to develop serious complications.

• Studies show coronavirus associated with COVID-19, remains stable for several hours to days in aerosols and on surfaces

• Virus may be transmitted from surfaces such as vaping devices

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Electronic cigarettes…

• What are they?

• Who uses them?

• Why do they use them? Where do they use them?

• Can they help smokers quit?

• What are the risks associated with use?

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Summary• Electronic cigarettes (ECIGs) are a constantly evolving class of

products with a variety of designs, flavors, nicotine concentrations, and power.

• In U.S. high school students, ECIG use is more prevalent thantobacco cigarette use.

• Most adults who use ECIGS are dual users.

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Summary• E-cigarettes have been widely promoted for harm reduction and

as a way to quit smoking.

• Evidence regarding ECIG effectiveness for smoking cessation is equivocal at best. For most, ECIGS hurt quit attempts.

• While we know there are some toxicants in ECIG emissions, we have limited information about the long-term health effects of ECIGs. But the data we have now do not look good.

• While likely less carcinogenic than conventional cigarettes, the risks of heart and lung disease are becoming more evident.

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Recommendations for the workplace• Include electronic cigarettes in clean indoor air policies

• Prohibit use in outdoor spaces on premises

• Integrate in health promotion and wellness initiatives

• Emphasize dangers of dual use

• Discourage claims that ECIGS help people quit smoking

• Provide tailored cessation support for cigarettes, electronic cigarettes and dual use.

• Support repeated quit attempts

• Promote evidence-based cessation programs

• FDA approved medications

• Smoking cessation counseling

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