CADCA MidYear Training Institute Whats Trending in Tobacco

CADCA Mid-Year Training Institute What’s Trending in Tobacco: E-cigarettes Wednesday, 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 • You. Tube videos: ü from Consumer Reports, http: //www. youtube. com/watch? v=100 b-l_0 z 9 s ü from CNN, http: //www. youtube. com/watch? v=Eqvlx. EQa. Qn. E 2

Poll Questions 1. 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 “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: ü Nicotine (in varying concentrations 0 -100 ml/mg) ü Humectants: propylene glycol (or vegetable glycerin) for vapor production ü Flavorings (tobacco, menthol, coffee, vanilla, fruit, cotton candy, etc. ) *Metals particle have also been found in the fluids 6

“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 Ø Formaldehyde Ø Acrolein Ø Acetaldehyde Ø VOCs Ø NNN and NNK • Exposure studies - Puff Topography not accounted for Goniewicz et al, Tobacco Control 2013 8

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E-cigarette User’s Exhale 10

Look Familiar? 11 Videos from www. smokestik. com Image from www. ecigaretteschoice. com; www. v 2 cigs. com

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What Attracts and Sells 13 http: //www. npr. org/2014/03/03/284006424/e-cigarette-critics-worrynew-ads-will-make-vaping-cool-for-kids

Cost Savings Claims 14 http: //tobacco. stanford. edu/tobacco_main/index. php

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Percent of smokers and recent exsmokers Prevalence of E-cigarette Use: Smokers and Recent Ex-smokers 50 45 40 35 30 25 20 15 10 5 0 Growth in prevalence of e-cigarette use may have slowed Any Daily 2011 -2 2011 -3 2011 -4 2012 -1 2012 -2 2012 -3 2012 -4 2013 -1 2013 -2 2013 -3 2013 -4 2014 -1 N=11, 666 adults who smoke or who stopped in the past year; increase p<0. 001 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 Response 1. Support Quit Attempt 2. Assess motivation and dependence 3. Assess prior quit attempts and inform about all treatment/support options 4. Inform on what we know and what we don’t know about e-cigarettes 5. Assist smoker to develop a plan to quit smoking 6. 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 Response 1. Opportunity to engage patient in counseling 2. This is a “light” smoker 3. Significant psychiatric history 4. 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 Background 1. 2. 3. 4. 5. 6. 7. 8. 9. Screening challenges Binge drinkers frequently smoke May present themselves as nonsmokers Need to screen specifically (only smokes when drinks) Vapor pens = e-cigarettes Also e-hookah, vapes, sticks, hookah pens Recreational use common Young adults have highest rates of use May lead to or increase nicotine addiction 24

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23 million likes on FB 10 million Twitter followers 26

Clinical Scenario #3 Asthma 1. Inadequately controlled 2. Personalized reason not to smoke or be exposed to secondhand smoke or aerosol 3. One study found acute pulmonary effects 4. 5 minutes of e-cigarette use in healthy smokers increased airway resistance 5. Unknown clinical significance 6. May affect susceptible people 27

Clinical Scenario #3 Response 1. 2. 3. 4. 5. 6. Discourage recreational “vapor pen” use Personalize to patient’s medical conditions Fetal exposure to nicotine not harmless Support mom’s quit attempt! Preserve smoke – and vapor free homes E-cigarettes are not harmless toys 28

• Average 1 per month increased to 215/month • Most common adverse events were vomiting, nausea, and eye irritation 29

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

Last Words … 32 www. blucigs. com,

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. edu 33