BEYOND CIGARETTES

The Risks of Non-Cigarette Nicotine Products and Implications for Tobacco Control

March 2017

Types of Nicotine Products

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Smoked

Tobacco

Smokeless

Tobacco

Electronic Nicotine

Delivery Systems (ENDS)

Cigarettes Chewing tobacco Electronic cigarettes

(e-cigarettes; cigalikes)

Cigars

(large cigars, little cigars,

cigarillos)

Dry snuff/pouch Vape pens

Pipes Moist snuff Modified e-cigarettes

Advanced personal

vaporizers

‘MODS’

Water pipe/hookah Snus Electronic water

pipe/hookah

Dissolvables

Non-Cigarette Nicotine Products:

Mixed Messages

• Although not risk-free, non-cigarette nicotine products

that do not have tobacco (such as ENDS) may be less

harmful alternatives to cigarettes for smokers who cannot

or will not quit by using approved smoking cessation aids

• BUT, they are addictive due to nicotine, have toxic

ingredients, and may encourage or perpetuate cigarette

smoking and other substance use and addiction

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Nicotine is Not Harmless

• Increase in blood pressure, respiration, and heart rate

• Adversely affects nervous, cardiovascular, respiratory,

and reproductive systems

• May contribute to cancerous tumor development

• Can be lethal if orally ingested

• Associated with poor reproductive health outcomes

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Nicotine is Not Harmless

• Early exposure can produce lasting effects on brain and

lung development

• Early exposure is associated with cognitive, emotional,

and behavioral deficits

• Perpetuates the use of harmful tobacco products

• Increases the risk of nicotine addiction and alcohol and

other drug use and addiction

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Data Analysis

• To explore prevalence and patterns of nicotine product

use among youth and adults

• Analyses of recent, publicly available, nationally

representative data from the U.S. Centers for Disease

Control and Prevention (CDC) on nicotine product use in

the United States

• Middle and high school students (2014 data)

• Adults aged 18 and older (2013-2014 data)

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Prevalence

• Approximately 26% of adults and 16% of middle and

high school students reported current use of at least

one nicotine product

– Approximately 16% of adults and 15% of middle and

high school students reported current use of at least one

non-cigarette nicotine product

– Young adults, aged 18 to 24, were the age group most

likely to report current use of a non-cigarette nicotine

product (37%)

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Prevalence Among Adults

by Key Demographics

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Prevalence Among Youth

by Key Demographics

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Most Commonly Used Products

• Among Adults

– Cigarettes (18%)

– Cigars (7%)

– E-cigarettes (7%)

• Among Middle and High School Students

– E-cigarettes (9%)

– Water pipe/hookah (6%)

– Cigarettes (6%)

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Multiple Nicotine Product Use

is Common

• 38% of adults and 50% of middle and high school

students who engaged in current use of nicotine

products used more than one nicotine product

• Among current users of nicotine products, 8% of adults

and 20% of middle and high school students reported

using more than one non-cigarette nicotine product

• Multiple nicotine product use elevates the risks of

nicotine addiction, alcohol and other drug use, and other

harmful consequences

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Nicotine Addiction

• An estimated 4.5% of adults and less than 1% of middle

and high school students who reported current use of

non-cigarette nicotine products (and not cigarettes) met

criteria for nicotine addiction

• More than half of adults and half of middle and high

school students who only used non-cigarette nicotine

products reported at least one symptom of nicotine

addiction

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Nicotine Addiction by Type of Product:

Adults

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20.2

12.3 12.6

8.0

19.3

13.5

16.1

Cigarettes Cigars Pipes Hookah ENDS Chewingtobacco

Snus

Nicotine Addiction Among Adults who Reported Current Nicotine Product Use by Type of Product Used 2013-2014 (Percent)

Nicotine Addiction by Type of Product:

Youth

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Quit Attempts and Former Use

• Quit Attempts

– Nearly half of adults and nearly one-third of middle and

high school students who reported current use of nicotine

products also reported attempting to quit using them in the

past year

• Former Use

– Approximately one-half of adults and middle and high

school students who reported ever having used a nicotine

product indicated that they were no longer using them

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Most of the Controversy is Around

ENDS Products

• Questionable safety due to nicotine and toxic ingredients

in flavorings, liquids, and aerosols

• Use is skyrocketing among youth, even those who never

smoked or intended to smoke a cigarette

• Efficacy in aiding smoking cessation is questionable

• May be renormalizing smoking and reversing years of

progress in improving the public health

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Summary of Risks and Benefits of

ENDS Products

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Risks Benefits

For Nonsmoking Youth

Increased exposure to nicotine

Nicotine addiction

Increased risk of initiation of smoked cigarettes

Adverse effects on brain development

Future disease

For Current Smokers

Slower or delayed tobacco cessation Reduced tobacco-related disease morbidity and mortality for those who switch

to ENDS and significantly reduce or quit smoking cigarettes

Increased risk of nicotine exposure and addiction with continued dual use of

ENDS and smoked cigarettes

For Former Smokers

Re-initiation of cigarette smoking

Nicotine addiction

For Nonsmokers and Society

Secondhand aerosol exposure and associated health risks and costs Reduced costs associated with tobacco-related disease morbidity and mortality

Re-normalization of smoking

Accidental/unintentional poisoning

A Closer Look at the Research

Evidence on ENDS

• Who are the main users of ENDS products?

– Youth or Adults? Youth, including young adults, generally

report higher rates of ENDS use than adults

– Cigarette Smokers or Nonsmokers? Most people who

use ENDS also smoke cigarettes; however, many people

who use ENDS, especially among youth, never smoked a

cigarette

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A Closer Look at the Research

Evidence on ENDS

• Do nonsmokers who use ENDS products end up

smoking cigarettes?

– Non-cigarette smoking youth who use ENDS are

significantly more likely to report intentions to smoke and to

end up smoking cigarettes in the near future

– Even non-cigarette smoking youth who specifically

expressed no intention to smoke cigarettes in the future but

used ENDS products are significantly more likely to end up

smoking in the near future

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A Closer Look at the Research

Evidence on ENDS

• Do cigarette smokers who start using ENDS

products reduce/quit smoking or do they continue to

use both types of nicotine products?

– Smokers who use ENDS generally are not more likely to

reduce or quit smoking cigarettes and many become ‘dual

users’ of cigarettes and ENDS

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Government Regulation

• Federal Laws and Regulations

– The 2009 Family Smoking Prevention and Tobacco Control Act

• Only applied to cigarettes, loose tobacco, roll-your-own tobacco,

and smokeless tobacco

– The 2016 FDA Final Rule for all Tobacco Products

• Broadens FDA coverage to all tobacco products, including ENDS,

cigars, pipes, water pipe/hookah, and dissolvables

• Still does not restrict flavoring in non-cigarette products and does

not prohibit advertising these products to youth

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Government Regulation

• State and Local Laws and Regulations

– State and local governments are allowed to enact more

stringent tobacco regulations than the federal government with

regard to:

• Sales and distribution restrictions (minimum legal age of sale, retail

and packaging requirements)

• Youth possession restrictions

• Smoke-free (clean air) laws and regulations

• Taxation

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Barriers to Reducing Use • Public Perceptions

– The risks and harms of non-cigarette nicotine products tend to be minimized or dismissed

• Addiction

– Nicotine is addictive, regardless of the delivery device

• Industry Practices

– Product marketing (e.g., healthier alternatives to cigarettes, useful for smoking cessation,

circumvent smoke-free laws)

– Product design (appealing flavors, packaging)

– Influence on science, policy, and government oversight (lobbying)

• Social Influences (Peers, Family, Media)

• Inconsistent Research Findings and Clinical Practice

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Recommendations:

Policy

• Federal Government

– Ban all characterizing flavors in all nicotine products

– Restrict the advertising and marketing of all nicotine products

– Prohibit Internet sales of all nicotine products

– Prohibit “low-risk” or “reduced-harm” claims

– Control product design, packaging, and labeling

– Fund quality research

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Recommendations:

Policy • State and Local Government

– Increase minimum legal sale age to 21 for all nicotine products

– Broaden smoke-free clean indoor/outdoor air laws to include all

nicotine products

– Prohibit the sale of all flavored nicotine products

– Control nicotine product retail outlet density and location

– Tax tobacco products at a higher level than ENDS to discourage

youth from using and to encourage smokers to cut back or quit

– Expand tobacco cessation insurance coverage

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Recommendations:

Practice • Health Care Professionals

– Patient education, screening, brief intervention, treatment

• Educators

– Prevention programming that includes all nicotine products

– Include all nicotine products in tobacco-free campus policies

– Ban all nicotine product advertising and promotions in and near schools

– Offer students (and staff) cessation services

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Recommendations:

Practice • Parents and Families

– Establish healthy relationships with open, honest communication

– Convey strong anti-use messages and set and enforce rules fairly and consistently

– Set a good example: do not use nicotine products and prohibit use at home and in cars

• Media

– Restrict advertising of non-cigarette nicotine products, especially to youth

– Integrate anti-nicotine messages into media programming

– Ban brand identification of all nicotine products in television shows and movies

– Include the presence of nicotine product use in determinations of ratings for movies,

television shows, and video games

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Recommendations:

Research • Improve Surveillance

– Conduct longitudinal surveys

– Assess prevalence via detailed measures of recency, frequency, and

intensity of use that are applicable to all nicotine products

– Include measures of alcohol and other drug use and addiction

– Include measures of treatment of nicotine addiction

• Improve Assessment of Nicotine Addiction so that it is Relevant to

All Types of Nicotine Products

• Improve Understanding and Documentation of the Contents (and

Toxicity) of Non-Cigarette Nicotine Products

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Conclusions • There remains considerable debate regarding the risks and potential benefits

of non-cigarette nicotine product use, especially ENDS

• There is a strong need to accumulate more definitive, unbiased evidence

regarding the risks and potential benefits of these products

• Emerging evidence is pointing to the conclusion that their risks and harms

generally outweigh their benefits

• The evidence is clear that nicotine use, regardless of the delivery device, can

lead to addiction and other adverse health effects

• Evidence-based government policies, health care practice, and prevention

initiatives can help to protect the public from the harms of nicotine products

• We must implement a comprehensive, research-based approach to curbing all

forms of tobacco and nicotine product use and their associated health effects

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