New Challenges of E-Cigarettes

8/9/2019 New Challenges of E-Cigarettes

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The New

Challengeof ElectronicCigarettes

Dean E. Schraufnagel MDUniversity of Illinois at ChicagoMarch 16, !1"

National #ress $oun%ation

No conflict of interest, &ut &ias.

Many a%verti'ing i(ages fro(htt)*++to&acco.stanfor%.e%u+to&acco(ain+in%e-.)h)


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$IS


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FIRS role

• Experts of each of the societies of the Forumof International Respiratory Societiesdeveloped a statement on E-cig that was

presented in conjunction with a U meeting onnon-communica!le diseases"

• Statement - given to # discussed with $%& ' Schraufnagel et al"( )m * Respir +rit +are ,ed ./01/2.34//-5

• $%& statement adopted all points


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Electronic cigarettes(Electronic nicotine delivery systems)

/istory


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Electronic nicotine deliverysystems

• /24.6s3 7o!acco companies adjustnicotine in cigarettes

• /28/3 9ichtnec:ert and 9undgren ' ; nicotine gum 3 E?S developed in +hina ' %on 9i:( pharmacist ; Ruyen

• ..4-.83 E-cigs;Europe( US)


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• +omponents

• icotine( propylene glycol( flavoringvapori@ed

From Wollscheid and Kremzner. Am J Health Syst Pharm 2009;66:!"0#2


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• $%&S ' may not deliver nicotine

• Electronic cigarettes ' may not loo(li(e ci)arettes *+en or memory stic(a,oid notice-


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Awareness and use

• )wareness has increased exponentially ' ..23 /4A1 ./.3 >A in US)

' Regan et al"( 7o! +ontrol ./>13/2->

' .//3 Indonesia3 //A aware1 .">A users ' $orld %ealth &rgani@ation Regional &ffice for South East

)sia" Blo!al adult to!acco survey3 Indonesia report .//"./"

' ./3 US 8>A1 UC D0A1 +anada 0.A1 )ustralia .A

' )d:ison et al" )m * rev ,ed ./>1003.8-/D


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Awareness today

• early everyone aware1 millions have tried

• ,ulti!illion !usiness

• &E? ./0 word of the year ; GvapingH ' Usage dou!led in the last year

' >. increased from years ago

• F?)3 $ill exceed com!usti!le cigs in /. y


10/740ho uses the(


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Use

• $ho uses themJ ' Kounger( higher incomes( heavy smo:ers

' >2A who had tried ' current users ' )d:ison et al" )m * rev ,ed ./>1003.8-/D

' $hite( younger( exposed to advertising ' %arrington et al"( icot 7o!ac Res ./01


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User profle

• >D58 users responded to Luestionnaire ' 8.A former smo:ers( 4/A M( mean age 0/ y

' /. puffsNday( D refillsNday( 28A nicotine

• Reasons ' erception that it was less toxic than to!acco


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oking cessation


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Use or smoking cessation

• >.. smo:ers who did not intend to Luit ' doses of nicotine and non-nicotine cig

' )ll groups reduced com!usti!le cigarette use

• o difference• o significant side-effects

' +aponnetto et al"( 9oS &E ./>151e44>/8

• Same authors ; D.A P in nonLuitters ' 0A lost to follow-up1

' )uthors - advisors to e-cig company ' olosa et al"( Intern Emerg ,ed ./>123D>8-04


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Use or smoking cessation

• 4D8 smo:ers randomi@ed e-cig( patches(place!o e-cig ' )!stinence3 8">A( D"5A( 0"/A Q S

' Oullen et al"( 9ancet ./>1>53/42->8

• Survey of recently Luit smo:ers ' >5A tried e-cig !ut not associated with success

' opova and 9ing" )m * u! %ealth ./>1/.>32>->.

• com!usti!le cigarettesNday( !ut not Luitting ' )d:ison et al"( )m * rev ,ed ./>1003.8-/D


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2outh


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Youth

• Oetween .// and ./ use dou!led ' From >"/A to 4"5A 14382-8>.


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20"

• Used within last month

' ational Institute on ?rug )!use"http3NNwww"druga!use"govNnews-eventsNnews-releasesN./0N/Nteen-prescription-opioid-a!use-cigarette-alcohol-use-trends-down

electroniccigarettes

om!usti!lecigarettes

/th raders /.!1 ."1

0th )raders 6.21 .21

2th )raders !.1 6.!1


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"revalenceunderestimated

• G/8 y" o" denied e-cig use( as she draggedon peach-flavored hoo:ah penH

• )dvertising to youth3 avoid the term GcigaretteH ' GTape penH

' *ust vaping flavorings

' Social networ:ing mar:eting

• Underestimate e-cig use ' http3NNwww"nytimes"comN./0N.>N.DN!usinessNe-cigarettes-

under-aliases-elude-the-authorities"htmlJrV.


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$lavorings


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3a&iesina%vertise(ents


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E4cigarettes

withoutnicotine5Trainingsets


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Electronic

cigarettea%vocates

h


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The )re(ise

E4cigarettes tar, therefore, safer.#Tar e()hyse(a, &ronchitis, cancer$


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#ro&le(swiththe )re(ise


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"ro!lem with premise

• /" 7he comparator is to!acco"

• " It assumes well-manufactured( regulatedproduct"

• >" It ignores nicotine6s harmful effects"

• 0" It assumes harms are :nown"

• D" It does not account for population effects"


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nything co()are% to to&acco shoul% &e safe


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%o!acco

• Cills a!out 4(...(... people each year ' )!out 4..(... from indirect smo:e

• Cills up to half its users

• +auses ' D.. !illion economic damageeach year ' $%& 7o!acco fact sheet >>2

http3NNwww"who"intNmediacentreNfactsheetsNfs>>2NenN


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$ilters* healthier

cigarette

1954:cigarettes health danger


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Micronite ingre%ient*

croci%oliteas&estos7un8nown har(

at that ti(e9


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3y 1:6!filtere% cigarettes%o(inate% the (ar8et


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;ightcigarettes


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Never shown

to re%uceto&acco %eathsor %isease


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•D" It does not account for population effects"


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#ro&le(* Electronic cigarettes are unregulate%.1!! (a8ers


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Unregulated &in many places'

• o drug or to!acco controls

• o restrictions on sales to minors

• o control of advertisements( promotions

• o reLuirement to state ingredients or dose ofnicotine

• o reLuirement for uniform ingredients or Lualitycontrol


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Nicotine


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(icotine ) direct to*icity

• 9ethal dose ' )dults3 ."D-/". mg per :g !ody weight

' +hildren3 ."/-." mg per :g !ody weight ' $oolf et al" ediatrics /2281223e0

'


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(icotine comple*pharmacology

• Stimulates and desensiti@e receptors ;unpredicta!le actions1

• E"g" %eart rate3 nicotine ;

' Excitation of sympathetic ganglia # paralysis ofparasympathetic ganglia ;W%R

' aralysis of sympathetic ganglion # excitation ofparasympathetic ganglion ;P%R

' Effect on carotid and aortic !odies ; %R ' Effects O ; !aroreceptors ; %R

' Epinephrine release from adrenal ; %R and O


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(icotine neural tissue

• Simulates( then suppresses autonomic ganglia

• Stimulates +S ' 9ow dose wea: analgesia

' %igh dose tremors and sei@ures• Stimulates respiration

' !ut large doses ; respiratory failure from central #peripheral !loc:ade


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(icotine ) lung

• 9ung ' ;3%e4roe+ithelial 5odies *5ranchin)

small cell ca-

' Wan) et al. J. Pathol 9/";"":/9#00

' Smaller l4n) 3cell t4rno,er 3ty+e 77 cells ' 8aritz. iol %eonate 9//;:6#!0

' hildren o< smo(in) mothers ; l4n)


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(icotine + ardiovascular

• )cute nicotine


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Nicotine$ sy()athovagal%ysregulation $ re%uce% erectile

tu(escence ?/arte. Urology !1@AB*1!:4B

Effects s)er(characteristics fertility

4yeyi)o et al., e)ro% Infertil !11A1*!15!F


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(icotine ) other organs

• BI ' icotine ; peptic ulcer # BI cancer

' +hu et al"( +urr harm ?es ./>1/23D-/.

' ?elayed gastric emptying


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(icotine acts on everyorgan

• )ffects essentially every organ ' 7hrough neuroeffector( chemosensitive(

sympathetic and parasympathetic(

epinephrine( Wcortisol( endothelial cell injury(lipid effects


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(icotine

• Exposure in utero ; P !irth weight( prematurity(neonatal mor!idity and mortality

' li,er et al. >5stet ynecol 99;/:62#0

• In-utero exposure ; adult disease ' Impaired fertility

' 7ype dia!etes

' &!esity

'%ypertension( atherosclerosis( aortic aneurysm ' euro!ehavioral defects

' Respiratory dysfunction ' Oruin et al"( 7oxicol Sci ./.1//43>40-80


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To&acco* %eca%es &efore %angers 8nown


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Saety + Flavorings

• Safety of inhaled flavorings ; un:nown

• +linical !ronchiolitis o!literans in wor:ers at a microwave-popcorn plant" Creiss et al"( Engl * ,ed" ..1 >083>>.-5"

• Respiratory symptoms and lung function a!normalities relatedto wor: at a flavouring manufacturing facility" +ummings et al"(&ccup Environ ,ed" ./018/3D02-D0"

• )sthma arising in flavoring-exposed food production wor:ers"Saha:ian et al"( Int * &ccup ,ed Environ %ealth" ..51/3/8>-8"


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%%iction %enor(ali'ing


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Gateway to a%%iction

ddi i


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ate?ay to addiction

• Smo:ing precedes cocaine use ' 58"2A smo:ers1 D"8A same time1 >"DA cocaine

first1 "2A never smo:ed '

Tanyu:ov et al"( ?rug )lc ?epend ./1/>-/8• )mong all cocaine users ; dependence

' 20.21 smo(er 5e


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Addiction time in yo4th

• ,ethods ' 4th graders for prospectively for 0 years

' ?efinitions3 G9oss of autonomyH . days

' %alf lost autonomy smo:ing 8 cigarettes per month

' Smo:ers salivary cotinine3 D">D ngNm9


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ate?ay to addiction

• Addiction -0>

ddi i * i -


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ate?ay to addiction *mice-

• Histone acetylation;constraints ondo+aminer)ic ne4rons

• hronic nicotine; synaptic plasticity in

nucleus accum!ens


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Denor(ali'ing


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&enormalizin) to5acco

• 7o!acco use decrease attri!uta!le to ' 3aBes

' an in +45lic +laces

' &enormalizin)• G c4lt4ral chan)e


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&4el 4sers

• 7o!acco and electronic cigarettes

• Electronic cigarette can deliver ' %ashish oil

' +ocaine solutions

' Escape detection

• &ther su!stance a!use


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Su((ary


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S4mmary

• Electronic nicotine delivery devices ; ' opular and heavily and cleverly advertised

• ,ay reduce com!usti!le cigarette use in

an esta!lished smo:er ' Oenefit for smo:ing cessation modest

• oorly regulated( safety ris: un:nown

• +oncern3 3nicotine use( addiction(renormali@ing to!acco

Than8 you


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Than8 you

Documents

New Challenges of E-Cigarettes