Implications of E-cigarette for Behavioral Health Populations

Sharon Cummins, Ph.D.UCSD

Disclaimer•Not FDA approved•Unknown safety profile•Insufficient data on efficacy•Not endorsing or suggesting you

recommend

Acknowledgements•Gary Tedeschi PhD•Lesley Copeland MA•Leslie Zoref PhD•Shu-Hong Zhu PhD• Supported by a grant from the NIH/NCI #U01 CA154280

through the State and Community Tobacco Control (SCTC) initiative

Potential problems with e-cigarettes•Possible gateway for nonsmokers to

cigarettes•Not safe—

▫“Water vapor”▫Not all use good product manufacturing

processes▫Calls to poison centers are up

•Could delay or prevent quitting among smokers—end up with dual use

Why consider e-cigarettes?•E-cigarettes have the potential to act as a

nicotine replacement therapy▫Could help individuals quit cigarettes▫Broader appeal = greater reach▫Potential population impact?

•There is no product likely to be deadlier than cigarettes▫Orders of magnitude▫Looking for “game changer”

Most Important reason?•Credibility

Why consider the behavioral health population in this discussion?•High rates of smoking•Both greater uptake and less cessation•High rates of morbidity and mortality

from smoking•A tobacco disparity population

▫Important that regulations not result in disproportionate harm

Tobacco control among those with behavioral health conditions•Many myths around quitting•Excluded from much of the research•Changing

▫Smoke-free policies in facilities▫Recommendation of greater assistance▫Recognition

Need to quit Want to quit Can quit

E-cigarettes and behavioral health•It’s already happening•High consumers of cigarettes•E-cigarettes are most salient to smokers•Bring data to bear

A way to view e-cigarettes•Perceptions from clinicians—what would

you do if someone wanted to quit using e-cigarettes?▫Physicians▫Paraprofessional cessation counselors

•Data from a national probability survey▫Focus on those with Mental Health

Conditions•Clinical practice implications

Methods•Family Physicians (N=21) from Family

Medicine Department at the UCSD School of Medicine

•Cessation counselors (N=57)

Patient/client interest% Yesof MDs

% Yesof Cessation Counselors

Patients/clients asking

70.0 96.5

Physicians/coaches seeking advice

0 66.7

Beliefs About Health Risks% of MDs % of Cessation

CounselorsRiskier than NRT 14.3 40.4Riskier than varenicline

33.3 49.1

% Strongly agree % Strongly agreeExposure to secondhand e-cigarette vapor is harmful

5.0 14.3

E-cigarettes are highly addictive

30.0 33.9

Beliefs About EffectivenessE-cigarettes are an effective quitting aid

% of MDs % of Cessation Counselors

Strongly agree 15.0 0Somewhat agree 60.0 26.8Somewhat disagree 15.0 60.7Strongly disagree 10.0 12.5

Beliefs About Regulation% of MDs

Strongly agree

% of Cessation Counselors

Strongly agree

Should be illegal in places where smoking is illegal

47.6 58.9

Use by minors should be illegal

57.1 73.7

Should be taxed like regular cigarettes

25.0 64.3

Advertisement should be banned like regular cigarettes

33.3 54.4

Summary of Perceptions•E-cigarettes are relevant•See them as higher in health risks than NRT

or varenicline•See them as not very effective•Important to clinicians that FDA has not

approved them as quit aid•With little data to go on, they are erring on

the side of being against e-cigarettes▫Treat like cigarettes—taxes, advertising,

youth access, use in smoking-restricted areas

Likely answer?•If a smoker wanted to quit smoking by

using e-cigarettes, what would you do?▫Most would discourage him from using

e-cigarettes to quit smoking▫Offer alternative to e-cigarettes such as

NRT, bupropion, varenicline▫Recommend and provide or refer to

behavioral cessation counseling

What if…?•The patient had tried and been

unsuccessful with all the recommended pharmacotherapies (as is true of many with behavioral health issues)?

•Insisted that he would only try to quit if he could use e-cigarettes?

•Was unwilling to give up smoking at all, but was willing to switch to e-cigarettes?

Then need to consider the likely impact of e-cigarettes?•Need to weigh:

▫Potential to prompt a quit attempt▫Ongoing nicotine addiction▫Potential to delay quitting cigarettes

Mental Health Conditions•High smoking prevalence•More difficulty quitting•Use of other tobacco products not known•E-cigarettes

▫Do they use them?▫If so, why?▫Are they likely to use them in the future?

Implications•Beneficial?

▫Decrease cigarettes▫Increase quitting

•Detrimental?▫Maintain smoking▫Delay quitting

•Tobacco Control Policy▫Accessibility▫Pricing▫Advertising

Methods•Conducted through GfK’s Knowledge

Panel•National probability sample (N=10,041)•Asked about diagnosis of Anxiety

Disorder, Depression, or “Other Mental Health Condition”

•Early 2012

Mental Health Condition by Smoking Status

Never smok-ers (N=3254)

Long-term former

smokers (N=3263)

Recent former smokers (N=413)

Current smokers

(N=3111)

0

5

10

15

20

25

30

13.4

16.4

26.027.8

Use of E-cigarettes

Ever e-cig Current e-cig0

2

4

6

8

10

12

14

1614.8

3.1

6.6

1.1

Mental Health Condition

Perc

ent

Ever Use of E-cigarettes by Smoking Status

 

Never smokers

(n=3,254)

Long-term former

smokers† (n=3,263)

Recent former

smokers‡ (n=413)

Current smokers

(n=3,111)Mental Health Condition

0.5 (0-1.0)

3.3 1.1-5.6)

31.0 (19.2-42.8)

40.3(34.6-46.0)

No Mental Health Condition

1.1 (0.6-1.6)

2.2 (1.6-2.9)

25.7 (19.6-31.9)

28.7(25.5-31.9)

Over all1.0

(0.6-1.5)2.4

(1.7-3.1)

26.8(21.4-32.4)

32.2 (29.3-35.0)

† smokers who quit more than 12 months prior to survey‡ smokers who quit within 12 months of taking the survey

Reasons for Using E-cigarettes

 Product

Mental Health Condition(N=359)

NoMental Health

Condition(N=813)

Safer than cigarettes54.6

(44.9-64.3)48.5

(42.3-54.7)Cheaper than cigarettes

36.7 (27.5-45.9)

27.9(22.7-33.1)

Easy to use when I can’t smoke

50.4 (40.6-60.2)

42.5(36.6-48.4)

To try to quit smoking cigarettes

59.6(50.0-69.2)

52.9(46.8-59.0)

Susceptibility to Using E-cigarettes

Never smokers Long-term former

smokers

Recent former smokers

Current smokers

0

10

20

30

40

50

60

70

2.84.9

29.5

60.5

2.6 3.1

23.8

45.3

Mental Health Condition

Perc

ent

Summary for Individuals with MHC•They are using e-cigarettes•Mostly appeals to smokers•And for the same reason as other smokers

▫To try and quit cigarettes▫Perceived as more safe than cigarettes

•MHC have tried many quitting aids ▫May be looking to try something new

•MHC have higher susceptibility▫Appeals to smokers, not nonsmokers

Clinical Implications•Encourage long-term use?•Encourage short-term use?•Discourage any use?

Things to think about•Absolute risk•Relative risk•Your own risk tolerance•Likelihood of quitting without it•Patient’s belief•Your goal

Questions?•scummins@ucsd.edu