E-cigaretes, Dripping, and Automated Dripping Devices (ADD)

Transcription

1 E-cigaretes, Dripping, and Automated Dripping Devices (ADD) Presented by: Paul Truman Harrell, Ph.D. Eastern Virginia Medical School Department of Pediatrics Division of Community Health and Research

2 Research reported in this presentation was supported by NCI and FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. Grant number R03CA Co-investigators: Thomas Brandon, Gwen Quinn, Stephen Stark, Vani Simmons

3 Talk Outline Background of E-cigarette Use and Current Knowledge E-cigarette device characteristics Dripping and Automated Dripping Devices (ADD) background Data on dripping among local college students

4 Over 400,000 deaths per year in the United States + 85, , ,000 > 20, ,000 Lung cancer deaths: 82% attributable to smoking 16,000 Head and neck cancers: 75%+ attributable to alcohol and smoking Mokdad et al., 2004; Hashibe et al., 2009; Lancet, 2017; USDHHS, 2014

5 Projections suggest that 5.6 million US youth or 2 out of every 27 children currently under 17 years of age today will die prematurely from smoking. 9 out of 10 with a history of daily smoking had their 1st cigarette before out of 100 had their 1st cigarette before 26 Shiffman et al., 2002; USDHHS, 2012, 2014;

6 Helping Smokers Quit Most smokers report wanting to quit, but rates of quitting are low. Quit rates can be enhanced by medication assistance. Nicotine Replacement Therapies (NRT) can also be effective, providing a safer form of nicotine delivery. However, even among those who use NRT, only 5-15% are able to quit. (Counseling improves rates) Burns & Levinson, 2008; CDC, 2011; Shiffman et al., 2002; USDHHS, 2014

7 Electronic Nicotine Delivery Systems ( E-cigarettes ) Modern e-cigarette introduced in China in 2004; In 2007, imported into US; FDA seized NJOY shipment in 2009; Court of Appeals ruled e-cigs are Tobacco Products, not drugs. In 2012, Lorillard (Newport, Maverick) purchases Blu e-cigs; in 2013, RJ Reynolds (Camel, Kool) test markets Vuse; In 2014, Altria (Marlboro) released Mark Ten

8 Past-30 day use among Middle school students During , among middle school students, a linear decrease occurred in current use of any combustible tobacco products, cigarettes, cigars, and pipe tobacco, whereas no significant trends were observed for current use of any tobacco product or 2 tobacco products. A nonlinear increase occurred in current use of e-cigarettes. During , among middle school students, e-cigarette use decreased. Jamal A, Gentzke A, Hu SS, et al. Tobacco Use Among Middle and High School Students United States, MMWR Morb Mortal Wkly Rep 2017;66:

9 Past-30 day use among High School students Among all high school students, current use of any tobacco product did not change significantly from 2011 to 2016 however, a nonlinear decrease occurred in current use of any combustible tobacco product and 2 tobacco products during this time. Nonlinear increases occurred for current use of e-cigarettes and hookahs; however, a linear decrease occurred in current use of cigarettes. Among high school students, during decreases occurred in the use of any tobacco product, any combustible tobacco product, 2 tobacco products, e-cigarettes, and hookah (p<0.05). Jamal A, Gentzke A, Hu SS, et al. Tobacco Use Among Middle and High School Students United States, MMWR Morb Mortal Wkly Rep 2017;66:

10 Any Vaping Current (past 30 day) use From 2015 to 2016, current vaping declined in all grades (e.g., from 16% to 13% among 12th graders). From 2016 to 2017, vaping questions were altered: asked separately for nicotine (11%), marijuana (5%), and just flavoring (10%), rather than about any vaping in general. Rates were similar to 2016 in 2017 in all grades, according to MTF press release, although some (12th grade) appear to return to 2015 levels (17%). Except for little cigars, other tobacco product use in high school students continued to decline in Johnston et al., 2018

11 E-cig use among non-smokers, by age

12 E-cigarettes are a tempting introduction to nicotine use E-cigarettes are the most commonly used tobacco product among adolescents. E-cigarette use is associated with the initiation of cigarette smoking. This is especially true among those who previously were not smokers, indicated less willingness to smoke, or have other baseline indicators suggestive of low risk to smoke Leventhal et al. 2015; USDHHS, 2012, 2014; Wills et al., 2016

13 Meta-analysis, cited in National Academies of Science, Engineering, & Medicines report Soneji et al., 2017

14 2018 NASEM Report There is substantial evidence that ecigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults. Among youth and young adult e-cigarette users who ever use combustible tobacco cigarettes, there is moderate evidence that e-cigarette use increases the frequency, intensity, and duration of subsequent combustible tobacco cigarette smoking. There is insufficient evidence from randomized controlled trials about the effectiveness of e-cigarettes as cessation aids compared with no treatment or to Food and Drug Administration approved smoking cessation treatments.

15 Adapted from Goniewicz et al, 2014 by William E. Stephens, 2018; Tob Control;27:10-17

16 2018 NASEM Report There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes. There is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. Taken together, the evidence reviewed by the committee suggests that e-cigarettes are not without physiological activity in humans, but the implications for long-term effects on morbidity and mortality are not yet clear.

17 2018 NASEM Report There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated. There is conclusive evidence that, other than nicotine, the number, quantity, and characteristics of potentially toxic substances emitted from e-cigarettes is highly variable There is moderate evidence that variability in e-cigarette product characteristics is an important determinant of risk and severity of e-cigarette dependence. Etc.

18 E-cigarette elements Battery Heating element (atomizer) Liquid container (cartridge)

19 Types of E-cigarettes Breland et al., 2017

20 E-cigarette Flavoring Flavorings in e-cigarettes are not regulated Some e-cigarette flavor manufacturers advertise ingredients as food grade or generally recognized as safe (GRAS) as certified by FEMA, but As noted by FEMA, GRAS certification pertains only to ingestion, not inhalation Some chemicals certified as safe for ingestion appear to be unsafe when inhaled Use of some flavors in e-cigs may exceed established Occupational Exposure Levels Even if they do not, FEMA and the National Institute for Occupational Safety and Health has noted that levels below OEL thresholds should not be considered safe Hubbs et al., 2015, PMID:

21 Risky chemicals identified so far Diacetyl: Butter flavor, sweet flavors, associated with bronchiolitis obliterans, popularly known as popcorn lung due to high rates among microwave popcorn workers Acetyl propionyl (AP): popular replacement for diacetyl, but likely association with similar risks based on animal studies; Acetoin: also present in butter flavorings associated with popcorn lung, Cinnamon Ceylon: high cytotoxicity identified in vitro Benzaldehyde: common in cherry flavors, linked to irritation of respiratory airways in animal and occupational exposure studies Farsalinos, et al. (2015). Nicotine & tobacco research, 17(2), ; Tierney, P. A., Karpinski, C. D., Brown, J. E., Luo, W., & Pankow, J. F. (2015). Tobacco control.; Varlet, V., et al. (2015). International j of environmental r and public health, 12(5), ; Allen, J. G., et al. (2015). Environ Health Perspect.; Behar, R. Z., et al. Toxicology in vitro 28.2 (2014): ; Bahl, V., et al. (2012). Reproductive toxicology, 34(4), ;Kosmider, L.,... & Goniewicz, M. L. (2016). Thorax, thoraxjnl

22 Use of e-cigarettes among youth and young adults In 2009, the Tobacco Control Act banned characterizing flavors in cigarettes as a way to reduce youth appeal 81.0% of adolescents (ages 12-17) in who have ever used e-cigarettes used a flavored product ( menthol fruit or other sweets ) % of adolescent (age 12-17) current (past-month) e-cigarette users used a flavored product; flavoring reported as a major reason for use 1 1Data from Population Assessment on Tobacco and Health, FDA CTP, Ambrose, B. K., Day, H. R., Rostron, B., Conway, K. P., Borek, N., Hyland, A., & Villanti, A. C. (2015). Flavored Tobacco Product Use Among US Youth Aged Years, JAMA, Data from National Health Interview Survey, Schoenborn, C. A., & Gindi, R. M. (2015). Electronic cigarette use among adults: United States, NCHS data brief, 217,

23 Breland et al., 2017

24 Talih et al., 2017

25 Dripping Figure 1. Schematic of electronic cigarette direct drip atomizer. Talih et al., 2016

26 Automated Dripping Devices Harrell and Eisseinberg, 2017 (OnlineFirst), PMID:

27 Dripping among Adolescents Study of 8 Connecticut high schools in Spring, 2015 (N=7045) Among 1080 ever e-cigarette user high school students, 26% reported ever dripping Reported using due to thicker clouds of vapor (64%), better taste (38.7%), stronger throat hit (27.7%), and curiosity (21.6%) Males, whites, polytobacco users, and more frequent e-cig users more likely to report ever dripping (Krishnan-Sarin et al., 2017) Social media-recruited sample of 1508 adolescents aged who reported past 30 day use of a vaping product in September % reported ever trying dripping (Pepper et al., 2018) Krishnan-Sarin et al, 2017; Pepper, MacMonegle, & Nonnemaker, 2018

28 E-cigarette use and Dripping among Young Adult College Students (18-24) E-cigarette Use n=368 Never Used n=365 Ever Used Dripping by Ever-vapers 44%, n=161 56%, n=207 Never Dripped Ever Dripped Community College students in Southeastern Virginia surveyed in Summer of 2017

29 Number (n) who reported ever use of type E-cigarette Device types used among College Student Vapers (18-24) Device Types Ever Used Device Used Most Often Currently n = 26, 7% 200 n = 122, 34% n= 182, 51% 50 0 No Current Use Refillable Tank System A Dripping Device Cartidge-based Disposable Other Community College students in Southeastern Virginia surveyed in Summer of 2017

30 Dripping among College Student Vapers (18-24 years old) Adjusted Odds of Ever Dripping Community College students in Southeastern Virginia surveyed in Summer of 2017

31 Dripping among College Student Vapers (18-24 years old) Expectancies *** *** *** *** *** *** ** * *** Community College students in Southeastern Virginia surveyed in Summer of 2017

32 Potential for increased risks from dripping Talih et al., 2016 Formaldehyde is a recognized carcinogen. During the first two puffs, formaldehyde emissions similar to conventional cigarettes. During puff 3-4, formaldehyde emissions are much higher. In general, higher temperatures and higher power levels (which may be necessary for dripping), are associated with higher carcinogenic volatile aldehyde emissions (Talih et al., 2017)

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34 Summary / Implications In Summer of 2017, in a convenience sample of young adults (18-24) surveyed at a local community college, over half (50.2%) reported ever vaping Young adults engaged in dripping and use of dripping devices at a greater rate than adolescents Over 2 in 5 young adult ever-vapers reported dripping (as compared to about 1 in 4 adolescent ever-vapers) 31% of ever-vapers reported ever using a dripping device (dripbox, squonk box, or bottom feeder) Need for continued monitoring of different electronic vapor technologies for safety concerns and potential regulations

35 Acknowledgments Thomas Brandon Gwen Quinn Stephen Stark Vani Simmons Tracey Barnett Tom Eissenberg Jean Forster Suchitra KrishnanSarin Kelli Will Richard Handel Bryanna Vesely Thomas Small Leigh Sitler Lauren Marshall Laurel Brockenberry Jacob Smith CINCH Amy Paulson Matt Herman YMCA Bacon Street Treatment Center