Tobacco and Nicotine Products

"The Times They are A'Changing"

FOMA, 2019

NOVA SOUTHEASTERN UNIVERSITY AHEC

Dr. Nevin Zablotsky

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Cigarette Usage in U.S.A 1955

Ages Percentage

21-24 51.4%

25-34 63.4%

35-44 62.1%

45-54 56.9%

55-64 43.6%

All ages 52.6%

H.Wentzel.W,Green,D National Clearinghouse for Smoking (60,62,64)

Cigarette Usage in U.S.A 2018

Ages Percentage

21-24 13.1%_____

25-44 17.6%_______

45-64 18%______

>65 8.8%_____

Total: 15.1%

C.D.C 2018

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Florida Tobacco Fast Facts

2,701,900 Adult Smokers

16.1%

Tobacco Free Kids November 2018

Florida Tobacco Costs

■ $8.64 billion dollars annual costs directly related to smoking

■ $8.32 billion dollars lost in productivity

Tobacco History

First Cultivated 5000-3000B.C

in

Peruvian/Ecuadorian Andes

Tobacco

■ Total of 64 species of tobacco plant

■ Two used by man

■ Nicotiana rustica

■ Nicotiana tabacum

Tobacco

■ Nicotiana rustica

■ Strong and harsh

■ 20x more nicotine than tabacum

▪ Eastern Europe and Asia

▪ Used by S. American

shamans

Tobacco

■ Nicotiana tabacum

■ Milder

■ Multiple varieties

■ Used in most cigarettes

History continued…

■ Tobacco shamans

“doctor-priests”

■ Use tobacco in religious rites and as medical treatment

Tobacco continued…

Usage

■ Also used as mild analgesic and antiseptic

■ Treated toothaches by wrapping leaves around tooth

■ Leaves or juice applied to wounds

History continued…

■ Jean Nicot, 1559 French Ambassadorto Portugal, distributes tobacco seedsthroughout Europe

■ Agrees with Dr. Monardes and extols its ability to cure cancer, bad breath, toothaches, migraines, kidney stones, dandruff, tapeworms

■ Nicotine, the addictive drug in tobacco named in his honor

James “Buck” Duke 1889

■ Age 33 of North Carolina forms American Tobacco Company

Cigarette Production

■ Skilled hand roller produced 200 cigarettes in one hour

We Can Now produce

20,000 Cigarettes a Minute

■ Click to edit Master text styles

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Tobacco and Nicotine

Products

Cigarettes

It takes 5 seconds for a “hit”

to reach the brain

Chemicals In Cigarette Smoke

■ 7,000 chemicals , 80 Carcinogens

■ Benzene

■ Formaldehyde

■ Strychnine

■ Polonium 210

Tobacco Fast Facts: WHO 2017

1.2 billion people smoke cigarettes in the world

Prevalence C.D.C 2018

U.S Cigarette Adult Smoking Rates

■ 37.8 million people 18 years or older

■ 15.5%

■ 16 million Americans live with a smoking-related illness

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Cigars - Prevalence

■ In 2017, 12.3 million people aged 12 or over smoked cigars in the U.S

■ 9% of high school boys used cigars

■ 6.3% of high school girls used cigars

■ 1.5% middle school students

Cigars

■ All cigar smokers, whether they inhale or not are exposed to smoke and its toxic and cancer-causing chemicals affecting

■ Lips

■ Tongue

■ Throat

https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/cigars-fact-sheet

National Cancer Institute

Smokeless Tobacco

It takes 3-5 minutes for a

“hit” to reach

the brain

Smokeless Tobacco

▪ 3,000 Chemicals of which 28 are known carcinogens

▪ Arsenic

▪ Cyanide

▪ Polonium 210 (Nuclear Waste)

Snuff Tobacco

• Finely ground moist fire-cured tobacco

• Comes in pouch or can

• Tuck pouch or shreds between cheek and gums

• Buffered to alkaline pH that is easily absorbed

Smokeless Tobacco

• Comes in several forms

• Snuff or Snus

• Chewing(Dip,Pinch,Rub)

• Orbs, Sticks, Strips

SNUS

• Swedish word for snuff

• Scandanavian Snus is steam-pasteurized moist powdered tobacco

• Less nitrosamines

• Small bit placed in upper lip

• Not spit out

Chewing Tobacco

• Loose leaf

• Twist

• Plug

Smokeless Tobacco

Dip or chewing 8 to 10 times per day equals the nicotine of smoking 30 to 40 cigarettes a day.

Smokeless Tobacco

• Camel Orbs

• Camel Sticks

• Camel Strips

• 0.6-3.1mg nicotine

Electronic Nicotine Delivery Systems

E-Cigarettes

E-Cigarettes

■ First developed in China in 2003 by Hon Lik, Chinese pharmacist

■ In response to losing his father to lung cancer

■ Look for safer way to get nicotine

What Are They?

■ Battery-powered nicotine delivery systems that produce heated aerosol instead of smoke

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Usage

■ Slow steady draw to fill mouth and hold for 3-5 seconds

■ Inhale in lungs and exhale through nose and mouth

■ Will feel hit in about 30 seconds

■ After 3-7 draws take a short break

The Hype

Are E-Cigarettes Safer To

Use Than Cigarettes?

The Hype

Are E-cigarettes Effective

Smoking Cessation Aids?

So They Promote Them

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N.Y Times: April 14, 2014

■ Major producers targeting young people

■ Giving away free samples at music events and sporting events

■ Running advertisements on radio and television on youth oriented programs

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CDC / E-Cigarette and Vaping

It is estimated that 10.8 million adults in the U.S are vaping

Noncigarette Tobacco Products and Future Use of Cigarettes in Youth

JAMA 1/2/18

■ Use of e-cigarette,hookah,non-cigarette combustible tobacco, or smokeless tobacco

■ Youth using any of these producets are more likely to use cigarettes one year later

■ Using more than one of these products even more likely to use cigarettes

Flavoring Chemicals in E- Cigarettes

■ 7,000 e-cig flavorings presently on the market

■ Harmful chemicals now being detected

■ Diacetyl

■ 2,3-Pentanedione

■ Acetoin

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E-Cigs

■ F.D.A has analyzed samples

■ Some contain propylene glycol

■ Nitrosamines

■ Toxic chemicals

■ Carcinogens

■ Tobacco

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Death of First Child FromLiquid Nicotine

McClatchy Washington Bureau

January 13,2015

BY LINDSAY WISE

■ The 1-year-old boy died in Fort Plain, NY, on December 9 after ingesting liquid nicotine. Local police said the death appeared to be a accident.

■ Child’s death revives call for federal government to regulate liquid nicotine for e-cigarettes

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Int J Environ Res Public Health. 2018 Jan; 15(1): 75.

"At present, the research on E-cigarettes is fragmentary and incomplete, and there has been no systematic review of its safety "

■ Survey finds compared to non-users

E-cigarette users had a 71 percent higher risk of stroke

■ 59 percent higher risk of heart attack

■ 40 percent higher risk of heart disease.

Feb. 6th 2019

American Stroke Association

International Stroke Conference

E-Cigs

No Scientific Proof Yet

of Their Safety

Are E -Cigarettes a Real Tobacco Cessation Aid?

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Dual Use

• A 2018 report from the National Academies of Sciences, Engineering, and Medicine showed

• Among adults in, 58.8 percent of e-cigarette users also smoked cigarettes.

• Among young adults in, 40 percent of e-cigarette users also smoked cigarettes

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American Lung Association2019

The FDA has not found any e-cigarette to be safe and effective in helping smokers quit. If smokers are ready to quit smoking for good, they should call 1-800-QUITNOW or talk with their doctor about finding the best way to quit using proven methods and FDA-approved treatments and counseling.

■ A year long, randomized trial in England with 885 subjects used either e-cigarettes or traditional nicotine replacement therapies.

■ Both groups also participated in at least four weekly counseling sessions

■ They noted that 80 percent of the study participants who had quit by using e-cigarettes were still vaping at one year, while only 9 percent of the NRT group was still using nicotine products.

2019 NEJM: E-Cigarettes Vs. Traditional NRT

as Effective Cessation Aids

Positive Cessation Aid?

■ Both groups also participated in at least four weekly counseling sessions, an element regarded as critical for success.

■ They noted that 80 percent of the study participants who had quit by using e-cigarettes were still vaping at one year, while only 9 percent of the NRT group was still using nicotine products.

Big Tobacco Enters

the Scene

E-Cigarette Finances

■ Blu Ecigs founded in 2009

■ Blu Ecigs sold to Lorillard in 2012 for $135 million dollars

■ Becomes first big tobacco company to enter the e-cigarette market

E-Cigarette Finances

■ R.J Reynolds buys Lorillard in 2015 for $29.5 billion dollars includes Blucigs, Kool, Winston, Salem and Maverick brands

JUUL

■ JUUL's hardware is made in Shenzhen, China

■ The JUUL pods are made in the United States

■ Highly concenterated nicotine vaporizer

■ User inserts flavored pod into stick

Nicotine/Nicotinic Salts

Nicotine

• First isolated in 1828 in Heidelberg

• Clear liquid, poisonous alkaloid

• Natural insecticide

• Found in tobacco,also in tomatoes, potatoes, eggplants in insignificant concentrations

Nicotine

■ Nicotine naturally occurs in tobacco as a base

■ In 1960s Phillip Morris scientists added ammonia and created unprotonated (Freebased) nicotine

■ Making it more basic and lipid soluble and easier for it to be absorbed into the lungs

Nicotine

■ Cigarettes and most e-liquids use freebase nicotine

■ Freebase nicotine easily passes through the blood brain barrier

■ Inhaling freebase nicotine is harsh to the mouth and throat

Side Effects of Nicotine

So What are JUULs ?

JUUL

■ 2007 Adam Bowen and James Monsees found Ploom Labs

■ They create the PAX vaporizer and introduce JUUL e-cigs in 2015 at PAX Labs and spin off in 2017 to JUUL Labs

Nicotine

In 2007 JUUL labs mixes freebase nicotine with benzoic acid creating nicotinic salt in a biologically accepted liquid

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JUUL/Nicotinic Salts

■ This combination can be absorbed readily and is inhaled smoothly

■ Delivers 2x concentration of nicotine as other e-cigs

■ Speed of "hit" mimics cigarettes

Campaign for Tobacco-Free Kids www.tobaccofreekids.org

JUUL - Highly Addictive

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JUUL/ CNN Feb.7th 2019

BMJ Journal Tobacco Control: Dr. Robert Jackler

Stanford Research

• In 2015 the majority of companies had 1%-2% nicotine concentration

• JUUL released it 5% nicotine pods

• In 2019 competing brands reach into the 5% to 7% range of nicotine concentration

• "This makes it potently addictive to nicotine-naive teenagers"

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JUUL

■ In September of 2018 JUULs has a 72% market share of the e-cigarett market

JUUL

■ USA Today Oct. 2017

■ New vaping has "gone viral" on middle and high school, college campuses

■ Flavors like creme brulee, mango and fruit medley

JUUL

■ Can fill with THC

■ Can be mistaken for a USB stick

■ Can be charged in computer

E-Cigarettes and Vaping

■ September 2018 JUUL labs valued at $15 billion dollars

■ December 2018 Altria purchases a 35% stake in JUUL labs for $12.8 billion dollars

■ JUUL's value equals $38 billion dollars

■ “Nobody is quite sure what to do with those wanting to quit, as this is all so new,” said Ira Sachnoff, president of Peer Resource Training and Consulting in San Francisco

E-Cigarette and Vaping

E-cigarette and Vaping

Heat Not Burn Products

History of Heat-Not-Burn Products

All of These Products Attempt to

Simulate Smoking Cigarettes

History of Heat-Not-BurnProducts

■ These systems use heated tobacco not burning tobacco

■ Constituents are heated to 350 degrees fahrenheit and aerosolized

■ Device then removed and smoked like a real cigarette

History of Heat-Not-Burn Products

■ Iqos

■ Glo

■ Ifuse

■ Ploom

Iqos

■ Iqos marketed by Philip Morris International

■ PMI has spent $3 billion dollars developing these types of products

Iqos

■ 1994 launched in Japan and Italy

■ 2016 available in 20 countries

■ As of March, 2017 3 million devices sold in Japan

■ Demand has outstripped supply

January 25th, 2018

■ FDA advisory panel said PMI should not be able to claim IQOS is safer than smoking

■ PMI still awaiting FDA final decision

Please Don't Forget

About the Impact

of Cigarettes

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■ 7 million people in the world die from tobacco related illness per year

■ Every 6 sec. someone dies in the world from tobacco-related use

One Billion People Will Die in This Century

From Tobacco Use

Tobacco is the single greatest cause of disease in the U.S and is responsible for 480,000 deaths annually

Centers for Disease Control and Prevention

16 Million Americans Live

With a Smoking-related

Illness

Florida Tobacco Mortality Rates

■ 32,300 deaths directly related to smoking per year

■ 2,960 deaths from 2nd hand smoke per year

Tobacco Free Kids 2018

You Can Make A Difference

■ A brief 3 minute conversation with a health care provider followed by a referral to cessation services can more than double the chances of quitting.

■ Ask every patient about their tobacco use

■ Advise patients of the benefits of quitting

■ Refer to tobacco cessation servicesSource: Treating Tobacco Use and Dependence –

Clinical Practice Guideline, 2008 Update

USDHHS – Public Health Service

Where can you

refer patients?

■ Local Group Cessation Programs offered FREE in every county in Florida■ Group Quit programs offered through your

local AHEC and Tobacco Free Florida ■ 877-848-6696, ahectobacco.com■ Free NRT – Patches, Gum, Lozenges■ Groups facilitated by Tobacco Treatment

Specialists■ Statewide: Tobacco Free Florida’s Phone Quit

(over the phone counseling) and Web Quit (online cessation program)