Electronic Cigarettes: Hype - PowerPoint Presentation

Slide1

Electronic

Cigarettes: Hype

Versus Science (an update)

Audrey Darville, PhD, APRN, CTTS, FAANP

Certified Tobacco Treatment Specialist,

UK HealthCare

Co-Director,

Tobacco Prevention

&

Treatment Division,

BREATHE

March 2, 2017Slide2

Learning Objectives

Describe

the current state of electronic smoking products

Identify current use patterns of electronic smoking products

Explore

cardiovascular

concerns associated with the use of electronic smoking devicesSlide3

What is an Electronic

Smoking Device?

Developed in China in 2003; introduced in Europe and the US in 2006-2007 and banned for sale/distribution in many countries; tested by the FDA in 2009 where inconsistencies were found in labeling versus actual ingredients and the product was refused approval in the U.S.Slide4

The Tobacco

Control

Act gives

the FDA jurisdiction

to regulate tobacco products

(

e-cigs, cigars, pipe tobacco, and hookah), and as of August, 2016 they have been deemed tobacco productsSlide5

Why the Initial Concern?

Cessation treatment claims led FDA to initially pursue regulation as a drug delivery device

FDA testing found nicotine levels varied widely

Toxins (di-ethylene glycol=antifreeze) was found in one sample and ingredients were variable in others

Early reports raised concern for potential harmful effects to the lungsSlide6

Over 400 types of Devices

Range from “cig-alike” designs to large tank-style devices with adjustable voltage batteries

Designed & marketed with youth appealSlide7

Heat Not Burn Devices

Initially developed in late 1980’s by tobacco companies; use tobacco not e-juice

No real market appeal until recently

Provide “hit” effect of conventional cigarette that is lacking in electronic cigarettes

Recent market expanding as e-cigarette market is slowingIndustry looking to have them regulated as “reduced-risk” productsSlide8

From PMI:

“These data alone do not imply or

represent

a claim of reduced risk or reduced

exposure…”(pmiscience.com)Slide9

Use Patterns

Primarily users are

current or former smokers, many

with

intent to reduce smokingExperimentation in non-smokersNo current evidence that

long term quit rates are significantly higher than

“cold turkey”Dual/multiple product use is commonDevices are modified for use with substances/drugs other than nicotine

Growing evidence that use may deter cessationSlide10

Constituents

Nicotine: Concentrations can vary widely

Overall, significantly fewer chemicals than in combustible cigarettes (

40-60

versus 7000)

Propylene glycol: Principle ingredient in vapor; known lung irritant

Some flavorings associated with known health risksFormaldehyde: A by-product of heating and oxidation

Aerosolized Particulates

:

tin

, silver, iron,

and aluminum. Concentrations of nickel are higher than

conventional cigarettes

Oxidizing chemicalsSlide11

Health Concerns

Lung Effects

:

Immediate

effects on lung function and nitric oxide levels

variable but somewhat

consistent with conventional cigarettes. Lipoid pneumonia attributed to e-cig use in a young woman

Cardiovascular Concerns: Arrhythmias and hypertension with e-cigarette use have been reported

Cytotoxic/teratogenic Effects: Uncertain at this time but concerns have been raisedSlide12

Benowitz

(2003)

Progress in Cardiovascular Diseases 46

(1), 91-111. Slide13

Cardiovascular Effect “Red Flags”

Oxidative stress markers are elevated with even short term use

(

Carnevale

, et al, 2016, Chest DOI: http://dx.doi.org/10.1016/j.chest.2016.04.012)

Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in young, healthy subjects

(Moheimani, et al, 2017; JAMA Cardiol.

doi:10.1001/jamacardio.2016.5303)

Particulates and

carbonyls such as formaldehyde, acetaldehyde, acetone,

acrolein

, and

butanol in e-cigarettes are

associated with impaired regulation of blood pressure, increased clotting, and accelerated formation of atherosclerotic lesions (Bhatnagar, 2016, doi:10.1007/s12170-016-0505-6)Slide14

The Harm Reduction

D

ebate

Current controversy in tobacco control and public health communities

Perceived as less harmful, but harms are largely untested with controlled studies

Multiple studies are ongoing

Many devices developed/marketed by the tobacco industryLong range impact on tobacco prevalence & cessation rates is debated and largely unknownSlide15

Impact on

Y

outh

I

nitiation5.6 million Americans aged <18 years who are alive today are projected to die prematurely from smoking-related

disease

Are e-cigarettes a “gateway product”?

Estimated percentage of high school students who currently use

(past 30 day) any

tobacco products

,

≥2 tobacco products

,

and select tobacco

products—

National Youth Tobacco Survey 2011–2015Slide16

In Summary

Safety regulations

and

standards regarding electronic cigarettes and vaping devices are pending: Product use is not “risk free” but “risk unknown” at this time

Nicotine is highly addictive and has been found in e-juices claiming to be nicotine free

There is increasing concern that e-cigarettes are a gateway to

other forms of tobacco use in youthThere is no solid evidence that e-cigarettes help people quit smoking and growing evidence that they may be deterring cessation in certain casesThe tobacco industry is investing heavily in “Reduced-Risk Products”Slide17

Association for the Treatment of Tobacco Use and Dependence

An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user.

www.attud.org

Slide18

BREATHE

Tobacco Treatment Specialist Training Program: An Intensive Evidence-Based Training Program for Health

Professionals

Teaches

the core competencies for tobacco treatment specialists developed by the Association for the Treatment of Tobacco Use and

Dependence

The online course with approximately twenty-five hours of instruction time, which is broken down into five sequential modulesCurrently piloting/applying for accreditation but will re-open registration in late spring/early summer

Contact Audrey Darville (

audrey.darville@uky.edu

) for more informationSlide19

If

i

nterested in

clinical case

studies see:Clinical

Case Conference Electronic cigarettes: a review

of safety and clinical issuesMichael Weaver, MD, FASAM, Alison

Breland

,

PhD,

Tory Spindle,

BS, & Thomas

Eissenberg

, PhDNIH Public Access Manuscript: J Addict Med. 2014; 8(4): 234–240. doi:10.1097/ADM.0000000000000043.Slide20

Selected References:

Bhatnagar A. E-cigarettes and cardiovascular disease risk: evaluation of evidence, policy implications, and recommendations.

Curr

Cardiovasc

Risk Rep. 2016;10:1-10.

Benowitz, N. L., & Goniewicz, M. L. (2013). The Regulatory Challenge of Electronic Cigarettes. JAMA

.

doi

:

10.1001/jama.2013.109501

Bullen

, C., et al. (2013). Electronic cigarettes for smoking cessation: a

randomised controlled trial. Lancet. doi: 10.1016/S0140-6736(13)61842-5Carnevale R, Sciarretta S, Violi F,

Nocella

C,

Loffredo

L,

Perri

L, Peruzzi M,

Marullo

AGM, De Falco E,

Chimenti

I,

Valenti

V, Biondi-

Zoccai

G,

Frati

G, Acute impact of tobacco versus electronic cigarette smoking on oxidative stress and vascular function, CHEST (2016),

doi

: 10.1016/j.chest.2016.04.012.

England

LJ, et al. (2015) Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J

Prev

Med. 2015;doi 10.1016/j.amepre.2015.01.015

Goniewicz

, M. L., et al. (2013). Levels of selected carcinogens and toxicants in

vapour

from electronic cigarettes.

Tob

Control.

doi

: 10.1136/tobaccocontrol-2012-050859

Grana R, et al. (2014) E-Cigarettes: A Scientific Review. Circulation;129(19):1972-1986

.

Hajek

P, et al. (2014) Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction;109(11):1801-1810.

McRobbie

H, et al. (2015). Electronic cigarettes for smoking cessation and reduction. Cochrane Database

Syst

Rev. 2015;12:CD010216.

Moheimani

RS,

Bhetraratana

M, Yin F, et al. Increased cardiac sympathetic activity and oxidative

stres

in habitual electronic cigarette users: implications for cardiovascular risk [published online February 1, 2017]. JAMA

Cardiol

. doi:10.1001/jamacardio.2016.5303.

Vardavas

CI, et al. Acute pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance and exhaled nitric oxide. Chest. 2012;141(6):1400-1406

.

Williams

, M., et al. (2013). Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol.

PLoS

One, 8(3), e57987.

doi

:

10.1371/journal.pone.0057987

Zarwertailo

, L., Pavlov, D.,

Ivanova

, A., Ng, G.,

Baliunas

, D., Selby, P., (

2017).

Concurrent e-cigarette use during tobacco

dependence treatment in primary care settings: Association with smoking cessation at 3- and

6-months.NTR19(2

):183-189.

Zhu

SH, et al. (2014). Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation.

Tob

Control;23(

Suppl

3):iii3-9.