Tina Grosowsky, MA
Project Coordinator
Central MA Tobacco Free Community Partnership
A program of UMass Medical School/UMass Memorial Health Care
Greg Seward, MSHCA, LADC-I, CTTS-M, CADC, CAS, LSW
Director, Tobacco-Free Initiative
Director, Tobacco Consultation Service
Instructor in Psychiatry, School of Medicine
UMMMC, UMMS
gregory.seward@umassmemorial.org
NOTE: Audiorecording and slides will be available on: www.umassmed.edu/CCTS/Community
Disclosure
 We have no actual or potential conflict of interest in
relation to this presentation.
What is an e-cigarette?
 An e-cigarette is a nicotine delivery device utilizing
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cartridge containing nicotine, propylene glycol and
flavoring and a separate battery which heats the mixture.
It is also called “e-hookah”, “vaporizor”, “vape pen”, “mod.”
It contains no tobacco.
Uses “e-juice” – can be made from vegetable material.
Vegetable glycerin: generally recognized as safe.
When heated and vaporized, can form acrolein, which can
cause upper respiratory irritation.
Propylene glycol is in other consumer items, but at levels
approved by the FDA, which has not occurred with e-cigs.
Inside of Electronic Cigarette
Types of e-cigarettes
http://www.nytimes.com/2014/03/05/busine
ss/e-cigarettes-under-aliases-elude-theauthorities.html?_r=0
E-cigarettes are not regulated
• As of today, e-cigarettes are unregulated and not approved
by the FDA for use.
• The FDA has begun testing these devices, and has already
found that in addition to the drug nicotine they may
contain carcinogens and toxic chemicals such as diethylene
glycol, an ingredient used in antifreeze.
• Vapor exhaled from e-cigarettes is from a solution that is
neither FDA-approved nor analyzed to determine if the
solution components are safe to inhale.
No FDA regulation
 FDA has issued their deeming document for proposed
rulemaking, currently accepting public comment.
 No Consumer Products Safety Commission oversight.
 ANYONE can manufacture and sell.
 Most of the market is from China.
What FDA regulation does NOT do
 Does not ban flavors.
 Does not restrict TV ads.
 Does not ban marketing restrictions of any kind.
Advertising
 Advertising is completely unrestricted – TV ads shown
first time since 1971.
 Advertising looks like cigarette advertising.
 Using sexual images and seductive language.
 Ads in popular magazines – Sports Illustrated.
Advertising
What Do E-cigarettes Contain?
 Nicotine, propylene glycol and flavoring
 Diethylene glycol toxic chemical also found in some
toothpastes.
 Symptoms of DEG poisoning: vomiting, fever, renal
failure, kidney and liver failure.
Amounts of Nicotine?
 Because e-cigarettes are not regulated it is hard to
determine how much nicotine is in each one. One ecigarette cartridge can hold up to the same amount of
nicotine as one pack of cigarettes or more.
 There is currently no mechanism to prevent people
from filling the cartridges with other solutions.
Types of E-Cigarettes
• One time use = 1,000 puffs.
• Multi-use – replacable cartridges
• Re-chargable battery
• Vaporizor – Vaporizers are customizable, allowing
smokers to put the devices together themselves,
choosing their own refillable cartridges, heating coils
and liquid drippers. Vaporizers hold more liquid than
regular e-cigarettes. They produce bigger vapor clouds
and last longer.
How are E-cigarettes sold?
• E-cigarettes can be sold to minors (under the age of 18)
unless a local regulation is in place restricting the sale.
• E-cigarettes are being marketed and sold in areas that
contain a high volume of youth, such as malls.
• Many communities do not have laws regulating the age
in which people can purchase e-cigarettes or refill
cartridges.
• E-cigarettes come in kid-friendly flavors such as
bubble gum, cotton candy and sweet tarts.
E-cigarettes social norms
 E-cigarette use undermines gains that have been made
to reduce the use of tobacco in public settings.
 Makes smokefree workplace law harder to enforce and
allows vaping in places people cannot smoke.
 It is harder for smokers to break their addiction; and
entices youth to begin smoking.
Resources
 www.makesmokinghistory.org
 www.ctfk.org
 www.tobaccofreemass.net
 www.aap.org/richmondcenter
 http://www.umassmed.edu/psychiatry/resources/Tob
acco/Tobacco-Free-Community-Partnership/
Contact Information
 Tina Grosowsky
 Project Coordinator
 Central MA Tobacco Free Community Partnership
 Department of Psychiatry, UMass Medical School
 365 Plantation Street, Worcester, MA 01605
 508-856-5067
 Tina.grosowsky@umassmed.edu
Greg Seward, MSHCA, LADC-I, CTTS-M, CADC, CAS, LSW
Director, Tobacco-Free Initiative
Director, Tobacco Consultation Service
Instructor in Psychiatry, School of Medicine
UMMMC, UMMS
gregory.seward@umassmemorial.org
This products are often not called e-cigarettes by users.
Other names include E-CIG, e-hookah, shisha pens,
vape pens and “electric” cigarettes
Propylene glycol is one of two main base
ingredients of e-liquid.
• Dow Chemical Company states to avoid
inhalation exposure to propylene glycol mists
• American Chemistry Council warns against its
use in theater fogs because of the potential for eye
and respiratory irritation
• When heated and vaporized, propylene glycol can
form propylene oxide, an International Agency for
Research on Cancer class 2B carcinogen
Circulation. 2014;129:1972-1986
British Doctor’s Study (1951-2001)
“The mortality of doctors in relation to their
smoking habits”
• in 1956 provided convincing statistical proof
of linkage between smoking and lung cancer, MI
MI, respiratory disease and other
smoking-related illnesses
• This was a prospective cohort study of
registered physicians in the UK
Sir William
Richard Doll
• Will we follow a similar path with E-CIG’s?
www.ncbi.nlm.nih.gov/pmc/articles/PMC437141/pdf/bmj32801529.pdf
(1912 – 2005)
Poison centers are reporting increases in calls
about exposures to E-CIG’s
and liquid nicotine (219% 2013 from 2012)
• 50% of these reported exposures have occurred in
children under the age of 6
– consistent with National Poison Data System exposures to
all substances combined.
– Some have become very ill; some requiring ER visits with
nausea and vomiting being the most significant symptoms.
• Use care to protect skin when handling the products,
and keep them out of sight and reach of children.
• Dispose of them properly to prevent exposure to pets
and children from the residue or liquid left in the
container.
www.aapcc.org/alerts/e-cigarettes
Infant Who Swallowed E-Cigarette Refill Liquid
Highlights Emerging Danger
May, 2014 - Philadelphia
• “With the growing use of e-cigarettes, physicians need to
be alert for nicotine poisoning”
http://www.nlm.nih.gov/medlineplus/news/fullstory_146
117.html
• Dr. Robert Bassett, of Einstein Medical Center, reported in
the May 7 issue of the New England Journal of Medicine.
Just "one teaspoon of a 1.8% nicotine solution could be
lethal" to a 200 lb person
http://www.nejm.org/doi/full/10.1056/NEJMc1403843
• Conflicting reports and data re: human toxicity
– Animal studies
– Reports of survival at higher dose
Arch Toxicol. 2014; 88: 5–7.
Nicotine poisoning symptoms
Call 1-800-222-1222
• Poisoning from liquid nicotine can happen in 3 ways:
swallowing it; inhaling it; or absorbing it through the skin
or membranes in the mouth and lips or eyes
• initial symptoms (mainly due to stimulatory effects):
nausea and vomiting, excessive salivation, abdominal
pain, sweating, tremor, headache, dizziness, seizures, etc.
• later symptoms can occur: symptoms of hypotension,
bradycardia, CNS depression, coma, muscle weakness /
paralysis difficulty breathing or respiratory failure.
• Ideally know: patient's age, weight, and condition, name
of product (as well as the ingredients and strength if
known, when it was swallowed or inhaled and the
amount swallowed or inhaled
Massachusetts and Rhode Island
Poison Control Center data
• 2010: 0 calls
• 2011: 2 calls (2 adults – one age 29, one age
20-29)
• 2012: 4 calls (18 month old, 2 years,
20-29 year old, 33 year old)
• 2013: 8 calls (20 + 23 month olds; 3, 7, and 10
years old, 2 adults)
• 2014: 2 calls (20 months and 24 years)
Puppy’s overdose on e-cigarette
• The owner urged the makers of
e-cigarettes to warn users that
the fluid can be lethal
• WHO: swallowing between
0.5mg and 1mg per kg of the
drinker’s weight can prove fatal
• http://metro.co.uk/2014/02/18/puppys-overdoseon-e-cigarette-could-have-killed-a-child-4309310/
Secondhand e-cigarette aerosol:
not just water vapor
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People exposed to aerosol exhaled by the user.
metals in e-cigarette aerosol include chromium, nickel, and tin nanoparticles
Exhaled e-cigarette aerosol contains propylene glycol, glycerol, flavorings, and
nicotine, along with acetone, formaldehyde, acetaldehyde, propanal, diacetin, and
triacitine
At least 10 chemicals identified in e-cigarette aerosol are on California’s Proposition
65 list of carcinogens and reproductive toxins,
People exposed to e-cigarette aerosol absorb nicotine (measured as cotinine), with
one study showing levels comparable to passive smokers.
The amount of 2nd hand exposure to nicotine from E-CIG’s is about 1/10 that of
tobacco cigarettes – but it is still there.
– More research is needed to evaluate health consequences of this exposure
especially with vulnerable populations such as children, pregnant women and
people with cardiovascular conditions
http://no-smoke.org/pdf/ecigarette-secondhand-aerosol.pdf
Circulation. 2014;129:1972-1986
Nicotine and Tobacco Research, December, 2013
Syracuse hospital bans e-cigarettes after patient on
oxygen catches fire while using one: 4/22/14
• “The patient was burned across her face from
ear to ear” said St. Joe's spokeswoman.
• The patient had an e-cigarette in her mouth
and was using oxygen when the fire started.
www.syracuse.com/news/index.ssf/2014/04/syracuse_hospit
al_bans_ecigarettes_after_patient_catches_fire_while_using_one.html
E-CIG’s and explosions
• E-cigarette explodes in barmaid’s face after
being put on iPad charger
http://metro.co.uk/2014/04/08/video-e-cigarette-explodes-in-barmaidsface-after-being-put-on-ipad-charger-4692238/
• Electronic cigarette explodes in man's mouth,
causes serious injuries
http://www.cbsnews.com/news/electronic-cigarette-explodes-in-mansmouth-causes-serious-injuries/
Nicotine: Benefits?
• nicotine—without its host tobacco may have
some benefits at low doses:
– Some human and animal studies have shown
benefits as:
• a cognitive enhancer – stimulates memory and alertness
• Decreases appetite, increases intestinal activity
• treatment for relieving or preventing a variety of
neurological disorders (Scientific American, 2/9/14)
– In FDA approved products for nicotine withdrawal
Used as an insecticide
• After WWII over 2,500 tons of
nicotine insecticide were used
worldwide
• by the 1980s the use had
declined below 200 tons. This
was due to the availability of
other insecticides that are
cheaper and less harmful
• Currently, nicotine is
prohibited as a pesticide for
organic farming in the United
States
Pesticide
• Nicotine-Derived Pesticides Are Killing Canada's
Bees www.vice.com/read/nicotine-derived-pesticides-are-killing-all-ofcanadas-bees
• Nicotine sulfate is the most hazardous botanical
insecticide available to home gardeners
– extracted from tobacco by steam distillation or
solvent extraction.
– Highly toxic to humans and other warm blooded
animals (rapidly absorbed through the skin)
– 6 times more toxic than diazinon
www.herbmuseum.ca/content/tobacco-dust
FDA approved cessation devices:
• Patch, lozenge, gum, inhaler, NS, Chantix, Zyban
• None of these meds have CO, or any risk of fire, or explosion, or second
hand vapor.
• They have been studied and approved by FDA
• Inhaler: (Nicotine >mouth, not lungs as E-CIG) safer option worth
considering
• The E-Cig delivers nicotine into the lungs as does smoking regular
cigarettes.
– There are studies showing dual use.
– Too similar an agent to promote quitting.
– Not proven safe and effective by FDA
What to tell patients who want to use
E-Cigs as part of quitting:
• Don’t undermine motivation to quit!
• The safest and most proven smoking cessation
pharmacotherapies are the 7 FDA approved
meds
• Referral for counseling (UMass TCS 508-3345393 or QW 800-QUIT-NOW enhances
effectiveness of meds
• If patient insists on using E-CIG’s then:
Patients should be informed that:
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E-cigarette aerosol is likely to be less toxic than cigarettes, BUT the
products are unregulated, do contain toxic chemicals, and have not
been proven as cessation devices.
Do not use product indoors, around children or pets (exposure to
nicotine and toxins through passive exposure)
Do not use around oxygen (risk of fire)
Use only approved charging devices (risk of explosion)
There is a risk of explosion (documented reports even not while
charging)
Banned use in many places (hospitals, airlines, trains, public places, etc)
so be prepared (may want to try NRT)
There are no long-term safety studies of e-cigarette use: patients should
be urged to set a quit date – do not plan to use indefinitely
Secure E-Cig’s and refillable liquid away from kids and pets
E-CIG’s cost more than NRT medications
Work on plan
Why not do what works best?
• Medication + Counseling = highest success
rates
– Quitworks: 1-800-QUIT-NOW
– UMass TCS: (508-334-5393)
– Nicotine-Anonymous: www.nicotineanonymous.org
– NRT’s may be covered by insurance – copay’s may
be cheaper, also cheaper than most smoking or ecig’s
Research Gaps
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What information does the FDA need in order to regulate e-cigarettes? How should they be
regulated?
Who is using e-cigarettes? Why? When?
Health impacts of e-cigarettes to the person using them
– Children
– Teens
– Adults, including reproductive effects
– Reproductive effects on current adults and children
Health impacts of second-hand vapor
– Children
– Teens
– Adults, including reproductive effects
– Reproductive effects on current adults and children
Toxicity of different doses of nicotine
Prevalence of nicotine liquid poisoning -Who is at risk?
What other substances are being used with e-cigarettes? Who is using them? When? Where?
What are the effects?
What effect is the unregulated marketing having on use of e-cigarettes among children and
teens?
How are e-cigarettes being used for cessation? What are the successes? What are the risks?
Rates of new nicotine addiction among different ages and populations
Safety of flavors and other additives
Next Webinar
Using Social Media to Disseminate Health
Messages to the Community and Beyond
August 14th, from 10:00 – 11:30 AM.
Sherry Pagoto, PhD
Associate Professor
Division of Preventive and Behavioral Medicine
UMass Medical School
Save the Date!
Community Engagement and Research Symposium
Friday, November 7th, 2014
Albert Sherman Center
UMass Medical School
Worcester, MA