Transcript Electronic Cigarettes AKA: ENDS, Vaping Products

Electronic Cigarettes
AKA: E-cig, ENDs, Vaping Products, Mods, eGo
Holly A. Tucker, DC
Master’s of Public Health Candidate
University of Tennessee - Knoxville
April 2015
About the Presenter
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BS Exercise Science
BS Human Biology
DC Doctor of Chiropractic
*MPH Master’s of Public Health
*Health Policy Certificate
Anatomy of an e-cigarette
• Cartridge (nicotine
and other liquids)
• Vaporizer, Atomizer
or heating element
• Battery and
electronics
E-Liquid or Juice Contents
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Nicotine
Water
Propylene glycol
Glycerol
Flavoring agents
Examples of different electronic cigarette (e-cigarette) products.
Grana R et al. Circulation. 2014;129:1972-1986
Copyright © American Heart Association, Inc. All rights reserved.
The Debate
Pro
Con
Research Agenda
Standards:
contents &
emissions
Biomarkers &
Physiological
Effects
Use/User
patterns, role
in cessation,
behavioral
Research: Who uses e-cigarettes?
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
2010
30.00%
2013
20.00%
10.00%
0.00%
Adult Use
Current Smkr Ever-Use
Former Smkr Ever-Use
Adult Awareness
2013
2010
Youth Ever-Use
Youth Dual-Use
Research: Are they harmful to users?
• Published February 6, 2015
• ENDs are hazardous to lung
tissue
– Cause oxidative stress,
inflammation
– Changes to lung cell
morphology and affect viability
• Flavor agents (i.e., cinnamon)
can cause damage in absence
of nicotine
Research: Are they dangerous to
children?
• Accidental Exposures
• Secondhand vapor
– Inhaling the byproducts
• Thirdhand vapor
– Skin exposure to vapor
residue
Poison Control Centers
1
215
September, 2010
February, 2014
1 Call to Poison Control
per month
214 Calls to Poison
Control per month
Calls related to electronic cigarettes
Over 50% of calls involved a child under 5 years
Research: Are they dangerous to
bystanders?
• “Second-hand e-cigarette emissions contain
cancer-causing chemicals, and could put
children and others at risk if they are in
proximity to users”
– Kimberly Amazeen, VP of Public Policy and
Advocacy, American Lung Assoc.
Research: What’s in the e-liquid?
• No labeling laws
• Amount of nicotine
may vary
• Amount of other
chemicals may vary
Research: Are they safer than
cigarettes?
• Conflicting reports
• Contain possible carcinogens, particulates
• Some sources imply safer option for those
who have failed other methods
• Explosions and fires
• Less inflammatory response in tissues
Research: Compare Cig vs. E-cig
• Smoking related diseases: oxidative stress,
activation of inflammatory pathways and toxic
effect of 4000 chemicals and carcinogens in
tobacco smoke
• Nicotine: Literature shows it is not linked to
cardiovascular disease. Other forms of nicotine
delivery useful in smoking cessation, Parkinson’s,
depression, dementia and UC.
• In vivo effects of e-cigarettes not studied
(longitudinally)
• No more likely to have quit smoking at 1 year
Research: Are they a
Gateway Product?
• Children and non-smokers will initiate nicotine use
greater with ENDS than expected when ENDS did not
exist
• Renormalization – making ENDs attractive may
enhance smoking’s attractiveness due to similarity in
product image
• The promotion of ENDs comes with at least one of the
following messages or a combination of them:
– (a) try to quit smoking and if everything fails use ENDS as
the last resort;
– (b) you do not need to quit nicotine addiction, just
smoking; and
– (c) you do not need to quit smoking, use ENDs where you
cannot smoke.
Research: Why are they flavored?
• Youth find flavors more
attractive
• Marketed toward youth
• Use more flavors than
adults
• Lead to dependence,
lower intent to quit
• Create tolerance of harsh
flavors
Research: Who can buy them?
• Some states have not passed laws to prohibit
minors from purchasing
• Internet/Non face-to-face sales
– Tax evasion
– No age verification
(open to minors)
• North Carolina Study
Research: Who makes them?
Conflicts of interest
• Tobacco companies own/buy e-cigs
companies
– “Pretending” to be part of the solution of tobacco
use
• Tobacco companies supporting government,
opposing e-cigs
• Pharmaceutical companies
– GSK Nicoderm, Nicorette, Zyban feel heat from ecigs
Research: How are they advertised?
Following in Tobacco’s path
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2013 $82.1 million industry advertising
Free samples
Event sponsorships, recreation and youth-oriented
NASCAR sponsors
TV, Radio, Internet
Celebrities selling masculinity, glamour, sex
Conventional cigarette advertising has been banned
from television since 1971.
Website Ads: 59 brands
100%
95%
93%
95%
88%
90%
80%
76%
71%
73%
70%
64%
60%
50%
40%
30%
20%
10%
0%
Healthier
Cheaper
Cleaner
Smoke
Anywhere
Curcumvent No Secondhand
Smoke Free
Smoke
Laws
Modern
Cessation
Statements
Internet Memes
Position: Pro E-cigarette
• Jeff Stier, National Center for Public Policy
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Helps smokers quit: cleaner nicotine, realistic replication of habit
No first or second hand smoke
Doesn’t normalize smoking
Not a gateway
Sin Taxes
“In fact, treating e-cigarettes like cigarettes would undermine a central
tenet of the U.S. FDA’s approach to securing the potentials benefit of
e-cigarettes, while minimizing any potential harm.”
• American Council of Science and Health, Dr. Ross
– Public Health message that e-cigarettes are bad keeps people
smoking, keeps tax income going. E-cig alarmists keep cigarette
business booming. Agencies don’t want legislation as “alternative to
tobacco product/regulation.” Pharmaceutical methods don’t work –
but they make money
E-cigarette Legislation
Federal
State
Local
Tax
Sales
Labeling
Advertising
Regulation
Ban
Use
Restrict
Types of Regulation
• Indoor/Smoke
Free Laws
• Definitions
• Nicotine levels
• Licensing of
vendors
• Labeling
• Package Safety
• Standards of
Content
Banning
Product
Regulation
Taxing
Restricting
• No sales to
minors
• Display and
advertising
Current FDA Regulation
• Current: FDA regulates cigarettes, cigarette tobacco,
roll-your-own tobacco and smokeless tobacco
• Proposed rule: Deeming products such as hookah,
electronic cigarettes, cigars, pipe tobacco, novel
products and future tobacco products as “tobacco
products,” subject to Food Drug & Cosmetic Act
regulations (enabling regulation)
– Proposed April 25, 2014. Decision slated for June 2015
• States can regulate in absence of federal preemption
• Only claims related to treat or cure disease subject to
current FDA regulation
Commentary: What should the FDA do?
• Mitch Zeller, FDA: “comprehensive nicotine
regulatory policy, continuum of risk” needed
• Interim Safety Guidelines
– Instill confidence for safer way to use tobacco, yet
caution its use
• Establish Good Manufacturing practices in
devices and liquids
• Limits on amounts of chemicals
• Nicotine levels
• Flavors
Insurance Implications
• NOT covered as smoking cessation tools or
preventative benefit
• If e-cigs are deemed tobacco products by FDA,
they could be subject to:
– Taxes, Regulation, Age restriction
– Surcharges and higher premiums on insurance
Legislation Attempt
• Child Nicotine Poisoning Prevention Act of 2015
would direct the Consumer Product Safety
Commission to issue rules requiring safer, childresistant packaging for any liquid nicotine sold to
consumers
• Feb. 26, 2015 – Committee ordered
amendment in nature of substitute
• US Sen. Bill Nelson (D-FL)
State Reports
Action: Deemed same as tobacco
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3 States (ND, NJ, and UT) 100% Smokefree with e-cig
Pending in CA
Minnesota: if liquid nicotine is tobacco derived
Air Force Surgeon General – all AF Installations
Action: Banning in public places or
indoors
• 15 States: Limited Restrictions (i.e., schools, workplaces)
– AR, CO, DE, GA, HI, KS, KY, MD, NH, OK, OR, SD, VA, VT, WI
– California: pending SB 140 Prohibits Smoking of E-Cigarettes at
Workplaces, Schools, Restaurants and Hospitals (supported by
ACS-CAN, AHA, ALA)
– Minnesota: 2014 Legislation banning indoor public buildings
(with counter display and packaging restrictions)
• Local entities
– City/County Ordinances
– Various schools, universities, daycares, hospitals and prisons
– Blount County, Tennessee – Health Board
Action: Child-resistant packaging
• Minnesota: required packaging for e-liquids
• Illinois: Special packaging required for
refillables
Action: Taxing
• Minnesota: 95% Tobacco Tax of whole sale
cost of e-juice cartridges or starter kit
• North Carolina (2014): $0.05 tax per mL of
liquid nicotine
• Utah: Looking to tax e-cigarettes, Gov. Gary
Herbert estimates $10 million revenue
• Introduced 2014 /Failed: DE, HI, IN,
KY, NJ, OK, OR, PA, RI, SC, VT, WA
Action: No sale to minors
• 40 states prohibit sales to over 18
year olds
– North Carolina 2013
• Few states age 19 years to
purchase
• New York City age 21 years to
purchase
New York City
• Mayor Bloomberg bans e-cig use wherever
smoking is banned (public places since 2011)
• Legal age to purchase tobacco products
(including e-cig) to 21 years
• Minimum price per pack of cigarettes $10.50
Action: Inaction
• Michigan: Vetoed bill to restrict sales to 18+
year olds because language also excluded
them from the definition of tobacco products
Action: Public Health Education
• California What Could Go Wrong
Other Countries
• European Union: Dec. 18, 2013 – deemed as
tobacco products. If 3 countries pull the
products for safety issues, all countries can
vote to ban.
• Mayor of Normandy, France – local ban
(France has 1.5 million users)
Winning vs. Losing
Arguments
Addictive to minors
Data on teen use, compared to
cigarettes, in lieu of tobacco
products, etc.
Not enough research to restrict
use
Not Big Tobacco, propaganda
Target minors – sensationalizing
smoking image
Public Health responsibility to
allow cigarette alternative on
market without sin taxes or
restriction (harm reduction)
Not a proven cessation tool
#vapingsavedmylife
Poison Control Calls
Government relies on tobacco tax
Tennessee HB309/SB411
• Tobacco products, restricts under age 18,
adds:
– Store owners/managers train employees on sale
of vapor products
– Child-resistant safety standards for liquid nicotine
– Exempts definition of smoking//allows for use
where smoking current prohibited
• Status: Passed the Senate Committee April 6th
Tennessee Department of Health
February 11, 2014
• Advisory urges caution:
– Inadequate research on health effects
– No regulation on manufacture
– Levels of nicotine or contaminants vary
– Untested as smoking cessation devices
– Health threats to children (battery, liquid)
– Dual users of cigarettes, cumulative health impact
– Pregnant warning, effects of nicotine
• Update December 11, 2014: Use at Own Risk
Tennessee Health Dept. Survey
• County Health Dept. and Regional Office
Directors (54 contacts)
• 72 responses – County/Metro or Region
• 57 of 95 counties represented, including 5
Metros
• 7 of 7 regions represented
Survey Results: Policy Landscape
To your knowledge, have any of the following local entities banned the use of
tobacco (100% Smoke Free) from their property? T=172
Other: Health
Departments
Other
Local City Government
Unsure
Local County
Government
Hospital
Private business
Higher
Education
Institution
Public School
Survey Results: Policy Landscape
To your knowledge, has a local (city/county)
public policy on e-cigarette use or sales been
established? T=72
24%
15%
Yes
No
Unsure
61%
What governing body established the local e-cigarette polcy?
T=21
6
5
4
3
2
1
0
Survey Results: E-cig Prevalence
To your knowledge, how often are clinical staff
interacting with e-cigarette users? T=68
To your knowledge, has any level of staff
encountered the use of e-cigarette devices in your
facility? T=72
Unsure
40
3%
Yes
No
Unsure
30
No
23%
20
10
Yes
74%
0
Daily
Are patients being asked their e-cigarette
status during encounters at this facility? T=70
35
30
25
20
15
10
5
0
Weekly
Monthly
Never
Unsure
How are clinical staff counseling patients on e-cig use? T=79
Responses
50
40
30
20
10
0
Every Visit Some Visits First Visit
Only
Never
Unsure
Encouraging use Not counseling
Unsure
Cautioning use
Discouraging
use
Survey Results: Education Resources
Which of the following entities have requested information
from your health department on e-cigarettes? T=135
None requested
Health Board or Health Council
Individuals/Patients
Public School or School Board
Local County Government
Private Businesses
Higher Education Institution
Hospitals or Physicians
Local City/Municipality Government
Other Health Department
Other: Media
Other: TSF Planning
29
25
21
17
E-cigarette educational materials T=72
13
8
6
60
5
5
50
4
40
1
1
Yes
30
No
20
Unsure
10
0
We have
materials
What format do you prefer for educational
materials on e-cigarettes? T=200
Other: PSAs, Online CEU, Targeted materials
Webinars
On-site Training
Presentations
Pamphlets
Flyer/Handout/Fact Sheet
0
10
20
30
40
50
60
We use
materials
Materials are
effective
Want more
materials
Survey Results: Community Beliefs
What do you think the beliefs are about e-cigarettes in
your community? T=113
Safer than cigarettes
3%
3%
3% 2% 2%
Cessation Tool
Public Unsure/Unaware
4%
44%
11%
Harmless vapor/No adverse health
effects
Unsafe or Health Threat
Other
13%
Youth Appeal/Coolness
15%
Unsure
Survey Results: Community Attitudes
What do you think the attitudes are about e-cigarettes
in your community? T=101
2%
3% 3%
Acceptance/Positive/Safe
6%
Varied, Indifferent,
Ignoring
6%
No health threat/Not
"smoking"
8%
51%
10%
Opposition/Negative
Unsure
11%
Youth Appeal, coolness,
status symbol
Survey Results: Other Comments
• Lack of resources for tobacco education in
schools
• Combination of ground/media campaigns
• Ban does not educate about dangers
• E-cigs in PHN protocols
• TDH needs to advocate and support FDA
regulation
• Need for more, fact-based information
• Clarify pre-emption status and definitions
Notable Quotes
• “…Interviewees were unaware even that the
devices contained nicotine, for example.
Anecdotally, we have heard people refer to them
as a healthier NRT for smokers. It seems likely,
given the history of such things, that the
community's initial beliefs will be formed largely
by the propaganda of advertisement, which, in
the absence of some governmental regulation,
will almost certainly be better financed and more
prevalent than any factual counter-argument
derived from research and evidence.”
Success Stories
• Blount County
• Other Counties with information:
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Montgomery
Carroll
Knox
Giles
Greene
Sumner
Bedford
Questions