Versus Science (an update). Audrey Darville, PhD, APRN, CTTS, FAANP. Certified Tobacco Treatment Specialist, . UK HealthCare. Co-Director, . Tobacco Prevention . &. Treatment Division, . BREATHE. ID: 661238
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Versus Science (an update)
Audrey Darville, PhD, APRN, CTTS, FAANP
Certified Tobacco Treatment Specialist,
March 2, 2017Slide2
the current state of electronic smoking products
Identify current use patterns of electronic smoking products
concerns associated with the use of electronic smoking devicesSlide3
What is an Electronic
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 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
“These data alone do not imply or
a claim of reduced risk or reduced
Primarily users are
current or former smokers, many
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
Nicotine: Concentrations can vary widely
Overall, significantly fewer chemicals than in combustible cigarettes (
Propylene glycol: Principle ingredient in vapor; known lung irritant
Some flavorings associated with known health risksFormaldehyde: A by-product of heating and oxidation
, silver, iron,
and aluminum. Concentrations of nickel are higher than
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
Progress in Cardiovascular Diseases 46
Cardiovascular Effect “Red Flags”
Oxidative stress markers are elevated with even short term use
, 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.
carbonyls such as formaldehyde, acetaldehyde, acetone,
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
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
nitiation5.6 million Americans aged <18 years who are alive today are projected to die prematurely from smoking-related
Are e-cigarettes a “gateway product”?
Estimated percentage of high school students who currently use
(past 30 day) any
≥2 tobacco products
and select tobacco
National Youth Tobacco Survey 2011–2015Slide16
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.
Tobacco Treatment Specialist Training Program: An Intensive Evidence-Based Training Program for Health
the core competencies for tobacco treatment specialists developed by the Association for the Treatment of Tobacco Use and
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 (
) for more informationSlide19
Case Conference Electronic cigarettes: a review
of safety and clinical issuesMichael Weaver, MD, FASAM, Alison Breland
BS, & Thomas
PhDNIH Public Access Manuscript: J Addict Med. 2014; 8(4): 234–240. doi:10.1097/ADM.0000000000000043.Slide20
Bhatnagar A. E-cigarettes and cardiovascular disease risk: evaluation of evidence, policy implications, and recommendations.
Risk Rep. 2016;10:1-10.
Benowitz, N. L., & Goniewicz, M. L. (2013). The Regulatory Challenge of Electronic Cigarettes. JAMA.
, C., et al. (2013). Electronic cigarettes for smoking cessation: a
controlled trial. Lancet. doi: 10.1016/S0140-6736(13)61842-5Carnevale R, Sciarretta S, Violi F,
L, Peruzzi M,
AGM, De Falco E,
G, Acute impact of tobacco versus electronic cigarette smoking on oxidative stress and vascular function, CHEST (2016),
LJ, et al. (2015) Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J
Med. 2015;doi 10.1016/j.amepre.2015.01.015
, M. L., et al. (2013). Levels of selected carcinogens and toxicants in
from electronic cigarettes.
Grana R, et al. (2014) E-Cigarettes: A Scientific Review. Circulation;129(19):1972-1986
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.
H, et al. (2015). Electronic cigarettes for smoking cessation and reduction. Cochrane Database
M, Yin F, et al. Increased cardiac sympathetic activity and oxidative
in habitual electronic cigarette users: implications for cardiovascular risk [published online February 1, 2017]. JAMA
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
, M., et al. (2013). Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol.
One, 8(3), e57987.
, L., Pavlov, D.,
, A., Ng, G.,
, D., Selby, P., (
Concurrent e-cigarette use during tobacco
dependence treatment in primary care settings: Association with smoking cessation at 3- and
SH, et al. (2014). Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation.