E-cigarettes

Shelia Evans L.P.N.

Manager Community Health Program

353-5767

Objectives

• Understand what e-cigarettes are and how they work

• How e-cigarettes are marketed and the laws regarding them

• Know health implications of e-cigarettes• How to counsel patients on e-cigarettes

E-cigarette Defination & History

• Electronic cigarettes (e-cigarettes) are products that deliver a nicotine-containing aerosol (commonly called vapor) to users by heat

• It was invented in the current form by a Chinese pharmacist in the early 2000s

• The US patent application describes the e-cigarette device as “an electronic atomization cigarette that functions as substitutes for cigarettes and quitting smoking”

Components

Available ProductsDisposable e-cigarette

Rechargeable e-cigarette

Pen-sized Rechargeable e-cigarette

Tank-style, large size, rechargeable e-cigarette

Popular E-cigarettes on Market• They range in size from cigarette size, to

compact flashlight size, and you can get one in almost any color and style.

Halo $44.99

VaporFi™ $29.99

V2 Cigs $34.95+

Green Smoke$59.99+

blu $79.95

$99.95

Additional Components

• Every e-cigarette has at least three main components inside - the battery, the tank, and the atomizer.

• Sometimes there is another component between the liquid and the atomizer. This can be either a clearomizer or a cartomizer.

E-cigs and E-liquid

• Comes in a variety of flavors and nicotine levels

• Many of the products leak creating the potential for dermal nicotine exposure and potential nicotine poisoning

• Many fluids are from China, but are now being made in United States, Germany, and Europe

Terminology

• E-cigarettes - often called e-cigs, personal vaporizers, PVs, Electronic Nicotine Delivery Devices (ENDS)

• Liquid nicotine - E-liquid, e-juice or smoke juice

• Vaper - Person who uses electronic cigarettes

• Vape or Vaping - the act of smoking an e-cig

• Vape or Vapor Shops - Retail stores selling electronic cigarettes

Rationale for E-cigarettes

• Traditional cigarette sales are declining • Tobacco industry needed alternative

product to redefine itself• Designed to mimic cigarettes• Presented as a safe alternative• Avoids tobacco laws and taxation

Dangers of Liquid Nicotine

• Poison Control Centers shows that poisoning incidents involving e-cigarettes and liquid nicotine jumped by 156% in the past year

• More than half the calls involved a child under the age of six, and one child has died

• A typical cigarette has approximately 9 mg of nicotine but we only consume about 2-3 mgs– Low strength = 4-8mg of nicotine per milliliter– Mid strength = 10-14mg nicotine per millimeter– High strength = 16-18mg per millimeter– Extra-high strength = 24-54mg per millimeter

Tobacco Free Campaign

Main Ingredients in Vapor

• Basic ingredients (as listed by most e-cigarette manufacturers): propylene glycol or glycerin, nicotine, flavoring chemicals

• Additional chemicals found through product testing: – Diethylene glycol – TSNAs (low levels) – Formaldehyde

Carcinogens– Acetaldehyde – Acrolein

Propylene Glycol

• The Dow Chemical Company, a major manufacturer of propylene glycol, states in its product safety materials that the “inhalation exposure to [propylene glycol] mists should be avoided” (Dow Chemical Company, 2013)

• The American Chemistry Council warns against its use in theater fogs due to its potential to cause eye and respiratory irritation

Health Risks of E-cigs

• There is little research on direct health effects

• One study shows short-term pulmonary effects

• There is evidence of cytotoxicity in animals and humans

• No safety standards for e-cigarette components

• A few of the additional toxins in vapor: – Ethylbenzene, Benzene, Toluene, Acetaldehyde,

Naphthalene, Styrene, Acrolein, Nickel, Chromium, Cadmium, Selenium, Arsenic , Lead, Cobalt, Chlorobenzene, Crotonaldehyde, Chrysene, Retene FDA 2012, Harmful and Potentially Harmful Substances – Established List

Do E-cigarettes Reduce Harm?

• There are still a lot of unknowns about e-cigarettes

• The hope that they will reduce harm by delivering "clean" nicotine is debatable and will not be realized in continuing dual users including the cardiovascular risk

• Cancer risk may only be modestly affected because smoking duration is more important than intensity

Can be Used for Other Drugs

• E-cigarettes can be altered by users and be used to deliver other drugs

Second-Hand Smoke

• E-cigarettes pollute the air less than conventional cigarettes, but they pollute the air

• They do not just emit "harmless water vapor"

• People passively exposed to e-cigarettes aerosol absorb nicotine (measured as cotinine), with one study showing levels comparable to passive smokers

Cessation• Marketed as healthier alternative to

tobacco smoking and as useful for quitting

• The temporal and causal relationships between e-cigarette use and smoking have not been determined

• There is a high level of dual use of e-cigarettes and conventional cigarettes among adults

• Used as a way to circumvent smoke-free laws by enabling users to “smoke anywhere”

Do They Help People Quit

• E-cigarettes have not been proven to help people quit smoking

• Longitudinal population studies show that e-cigarette use is associated with a lower odds of quitting

• The randomized trial comparing e-cigarettes to nicotine patch shows that in the context of low level behavioral support, the quit rate for those using e-cigarettes is low

The Rise of E-cigarettes

• Retail sales of over 1 billion • U.S. comprises 30% of the 6 billion

global market• Could surpass consumption of

traditional cigarettes in the next decade• Youth use rose from 4% in 2011 to 10%

in 2012• In 2012 over 1.78 million middle and

high school students used them

Marketing

• E-cigarettes are evolving rapidly and being marketed like cigarettes were in the 1950s and 1960s

• Aggressive placement in convenience stores (next to candy or medications)

• E-cigarettes are marketed via television, the Internet, and print advertisements (that often feature celebrities)

Youth

• Youth are rapidly adopting e-cigarettes• E-cigarettes contain candy flavors

(e.g., cherry, chocolate, turkish delight)

• Youth who use e-cigarettes are heavier smokers

• Youth who use e-cigarettes are much less likely to have stopped smoking

• There are high levels of dual use

Promotion of E-cigarettes

Jenny McCarthy promoting blu e-cigarettes.

Logo: Take Back Your Freedom

Marketing Sponsorships

Blu E-Cigs was the primary sponsor of an Indy car at the Toyota Grand Prix of Long Beach Race Event

(April 2013)

Tobacco Industry

• E-cigarette companies were competing with conventional cigarette companies, but now all the major cigarette companies are in the e-cigarette business

• E-cigarette companies are using the same political and public relations strategies as cigarette companies (most notably organizing users, similar to how the cigarette companies organized smokers)

http://www.transformtobacco.com/Pages/default.aspx

Higher Taxes Affect You. State legislators can push for higher cigarette taxes at any time. That’s why it’s important for you to make your voice heard on this important issue by contacting your elected officials today.Call your elected officials: 1.866.658.8337 (toll-free)• The excise tax on one pack of cigarettes in Indiana

is currently $0.995.• Take a closer look at the cigarette tax dollars being

collected in Indiana in FY2013. $434,473,203 Cigarette Excise Taxes $31,159,532 Other Tobacco Products Taxes$161,866,120 Cigarette Sales Taxes $129,467,003 Tobacco Settlement $756,965,858 Total Smoker Payments FY2013

Transform Tobacco: Issues in Indiana

Policy Making

• At a minimum, these policies should be implemented immediately:

• Prohibit the use of e-cigarettes anywhere where the use of conventional cigarettes is prohibited

• Apply the same restrictions on e-cigarette advertising and promotion that apply to conventional cigarettes

• Ban the use of characterizing flavors in e-cigarettes

Policy Making Continued

• Prohibit claims that e-cigarettes are effective smoking cessation aids until such time as there is convincing scientific evidence that such claims are true for e-cigarettes as they are actually used in the general population.

• Regulate e-cigarettes to set standards for product performance in order to minimize risks to users and bystanders

• Tax them like cigarettes

What to Tell Your Patient

• Be sure the advice you are giving doesn’t undermine their motivation to quit

• Follow the 5 As of evidence-based treatment:– ask, advise, assess, assist, and arrange

• Refer to the Quit line (1-800-QUIT-NOW)• If previous failure and wants to try

e-cigarettes, support them but– Inform patients that products are

unregulated, contain toxic chemicals, and are not proven cessation devices

Cessation Interventions

• Key recommendations: • Clinicians should prescribe the first-line

medications that reliably increase long-term smoking abstinence – Chantix– Zyban– NRT– classes

Three Phases of Nicotine Addiction

• Physical addiction – when your body and brain feel different from lack of tobacco.

• Psychological addiction – when you need tobacco to feel normal or deal with stress.

• Social addiction – when you see one of your smoking friends and it triggers you to want to use tobacco.

In order to quit, you must approach all three aspects of the addiction.

Questions

• What questions do you have?