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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-cigarettes Wednesday, July 23, 2014 - Orlando, FL Christine Cheng, Partner Relations Director

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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

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E-cigarette User’s Exhale

10

Look Familiar?

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

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Cost Savings Claims

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

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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/

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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?”

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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

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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

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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

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23 million likes on FB10 million Twitter followers

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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

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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

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• 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

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www.blucigs.com,

Last Words …

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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]