CADCA Mid-Year Training Institute
What’s Trending in Tobacco:
E-cigarettes
Wednesday, July 23, 2014 - Orlando, FL
Christine Cheng, Partner Relations Director
Overview
• History: invented by a Chinese pharmacist in 2003
• Rapid evolution of devices: a moving target
• Poll questions
• YouTube videos:
 from Consumer Reports,
http://www.youtube.com/watch?v=100b-l_0z9s
 from CNN,
http://www.youtube.com/watch?v=EqvlxEQaQnE
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Poll Questions
1. Show of hands, how many have tried an
e-cigarette?
2. How open are you to discussing the
potential benefits and risks of e-cigarettes
as a smoking cessation tool?
3. Are you willing to incorporate e-cigarettes
into a smoking cessation treatment plan?
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E-cigarette Devices Currently
Available
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Components of E-Cigarettes
“Clearomizer”
Battery
Battery
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Fluids Contain
• Many come premixed from China, but some are
now made in the US and Europe
• Origins and quality of the ingredients are
generally not known
• Fluids* may contain:
 Nicotine (in varying concentrations 0-100 ml/mg)
 Humectants: propylene glycol (or vegetable glycerin) for
vapor production
 Flavorings (tobacco, menthol, coffee, vanilla, fruit,
cotton candy, etc.)
*Metals particle have also been found in the fluids
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“Harmless” Vapor
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• E-cigarette fluid and vapor contains toxic metals and
nanoparticles
• Vapor contains tobacco-related toxins and chemicals – less than
cigarettes, more than nicotine inhaler
 Formaldehyde
 Acrolein
 Acetaldehyde
 VOCs
 NNN and NNK
• Exposure studies - Puff Topography not
accounted for
Goniewicz et al, Tobacco Control 2013
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E-cigarette User’s Exhale
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Look Familiar?
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Videos from www.smokestik.com Image from
www.ecigaretteschoice.com; www.v2cigs.com
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What Attracts and Sells
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http://www.npr.org/2014/03/03/284006424/e-cigarette-critics-worrynew-ads-will-make-vaping-cool-for-kids
Cost Savings Claims
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http://tobacco.stanford.edu/tobacco_main/index.php
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Percent of smokers and recent exsmokers
Prevalence of E-cigarette Use:
Smokers and Recent Ex-smokers
50
45
40
35
30
25
20
15
10
5
0
Growth in prevalence of e-cigarette use
may have slowed
Any
Daily
2011-2 2011-3 2011-4 2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4 2014-1
N=11,666 adults who smoke or who stopped in the past year; increase p<0.001
www.smokinginengland.info/latest-statistics/
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Clinical Scenario #1
“I’m a heavy smoker and both my
parents were smokers who died of
lung cancer. I’ve tried all the meds
but never quit for more than a
week. I’ve heard that e-cigarettes
can help smokers to quit and I really
want to give it a shot. What can you
tell me about them?”
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Clinical Scenario #1 Response
1. Support Quit Attempt
2. Assess motivation and dependence
3. Assess prior quit attempts and inform
about all treatment/support options
4. Inform on what we know and what we
don’t know about e-cigarettes
5. Assist smoker to develop a plan to quit
smoking
6. Arrange a follow-up
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Clinical Scenario #2
• 50 y.o. primary care patient with back pain,
hypertension, hyperlipidemia, depression and PTSD,
here for routine follow up, incidentally noted she is
still smoking 3 to 5 cpd, reduced from 10 cpd
• She quit once “cold turkey” for 9 months 2 years ago
• “not interested” in any medications, counseling, or
nicotine replacement
• She is willing to set a quit date in the next 30 days
(her son’s birthday) and remarks, “Maybe I’ll get one
of those electric cigarettes to quit, what do you
think?”
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“not interested”
• “I’ve tried everything”
• Frequently NRT misused or incorrectly used
• Unassisted quit attempts
• Correct misperceptions of approved therapies
• Correct misperceptions of e-cigarettes
• Treat Depression, PTSD
Shiffman S, Ferguson SG, Rohay J, Gitchell JG. Perceived safety and efficacy of
nicotine replacement therapies among US smokers and ex-smokers: relationship
with use and compliance. Addiction. 2008 Aug;103(8):1371-8
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Clinical Scenario #2 Response
1. Opportunity to engage patient in
counseling
2. This is a “light” smoker
3. Significant psychiatric history
4. ASK: why is she interested in e-cigarette?
5. What does she think is different from
approved therapies?
6. History of past quit attempts and
assistance?
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Clinical Scenario #2 Follow Up
• This patient ended up with
• Nicotine inhaler prescription (unfilled)
• Quit with nicotine gum and counseling on
proper use
• Saw a therapist to help manage stress
• Remains tobacco free today
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Clinical Scenario #3
• 21 y.o. female presents for work physical for
restaurant job. Denies significant past medical
history except asthma, treated with Albuterol
(once or twice a day)
• Denies smoking. Drinks 4-5 alcoholic drinks on
weekends. Has been using a vapor pen when out
at parties sometimes.
• She lives with her mom and 5 siblings. Mom (39)
recently quit smoking using an e-cigarette, which
she continues to use.
• Is her nicotine exposure significant? How do you
counsel her?
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Clinical Scenario #3 Background
1.
2.
3.
4.
5.
6.
7.
8.
9.
Screening challenges
Binge drinkers frequently smoke
May present themselves as nonsmokers
Need to screen specifically (only smokes
when drinks)
Vapor pens = e-cigarettes
Also e-hookah, vapes, sticks, hookah pens
Recreational use common
Young adults have highest rates of use
May lead to or increase nicotine addiction
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23 million likes on FB
10 million Twitter followers
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Clinical Scenario #3 Asthma
1. Inadequately controlled
2. Personalized reason not to smoke or be
exposed to secondhand smoke or aerosol
3. One study found acute pulmonary effects
4. 5 minutes of e-cigarette use in healthy
smokers increased airway resistance
5. Unknown clinical significance
6. May affect susceptible people
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Clinical Scenario #3 Response
1.
2.
3.
4.
5.
6.
Discourage recreational “vapor pen” use
Personalize to patient’s medical conditions
Fetal exposure to nicotine not harmless
Support mom’s quit attempt!
Preserve smoke – and vapor free homes
E-cigarettes are not harmless toys
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• Average 1 per month increased to 215/month
• Most common adverse events were vomiting,
nausea, and eye irritation
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Advice for Provider
• Screen for poly tobacco use including e-cigarettes
• Field and devices are rapidly evolving
• Engage with new opportunities to discuss
smoking cessation
• Misinformation and false claims are rampant
• Data are scarce
• Continue to recommend approved NRTs and Rx
• Monitor use in your clients, document and report
health concerns
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Advocacy and Coalition Action
• Include e-cigarettes in tobacco free policies
• Prohibit cessation and health claims
• Apply cigarette advertising restrictions to
electronic cigarettes
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Last Words …
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www.blucigs.com,
Contact SCLC for Technical Assistance
Visit us online
• http://smokingcessationleadership.ucsf.edu
Call us toll-free
• 1-877-509-3786
Christine Cheng
• email: ccheng@medicine.ucsf.edu
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