E cigarettes 8/15/2017. CME Statement. Objectives. The Rise of E cigarettes
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1 CME Statement Up in Smoke: E-cigarettes & Other Tobacco Products A presentation on electronic tobacco trends for healthcare providers Pete Dehnel, MD Medical Director Physician Advocacy Network This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Minnesota Medical Association and the Twin Cities Medical Society. The Minnesota Medical Association is accredited by the ACCME to provide continuing medical education for physicians. The Minnesota Medical Association designates this live activity series for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Financial Disclosures: None Objectives Identify and describe current trendy tobacco products such as e-cigarettes Identify specific health and medical risks associated with e- cigarettes List current accepted tobacco cessation recommendations Describe appropriate language and strategies for discussing e-cigarettes with clients, patients and families The Rise of E cigarettes E cigarettes Sales restricted to minors in MN Child resistant packaging for e-liquids in MN First available in U.S Included in MCIAA 2016 FDA Deeming Regulations Surgeon General s Report Zhu, Sun, Bonnevie, Cummins, Gamst, Yin & Lee,
2 FDA Regulations Surgeon General s Report Vapers 2022 Samples and vending machine sales banned EC Supply, 2016 U.S. Surgeon General, 2016 Disposable vs. Rechargeable How Does and E cigarette Work? Battery Cost Comparisons (for a pack per day ) Disposable E-cigarette $7-$9: Can last as long as two packs of cigarettes Yearly costs = $1,280-$1,640 Atomizer heats e liquid Clearomizerholds e liquid Mouthpiece Conventional Cigarette $9: One pack Yearly costs = $3,285 Rechargeable E-cigarette $60-$200 for a start pack/$15 bottles = 6 packs $700-$900/year for e-liquid cartridges/bottles Yearly costs= $760-$1,100 Source: Vaper Train, 2015 Kulwin, 2014; Neporent, 2014; American Academy of Pediatrics, 2014; Fontem,
3 Buying E cigarettes Gas Station/ Convenience Store Internet Retail Specialty (Adultonly) Shops Liquid nicotine E-juice E-liquids 99.6% of e cigarette products sold contain nicotine. Marynak et al, Ecigarette Reviewed, 2016 Southington Steps Coalition, 2016 Youth are 6 times more interested in trying menthol, candy or fruit e cigarette than trying a tobacco e cigarette Pepper, Ribisl & Brewer, 2016 CDC,
4 Youth Perceptions 47% believe e cigarettes are less addictive than cigarettes One in five adolescents did not believe or were unsure of whether e cigarettes contain nicotine Tobacco Free Kids,2013 Amrock, Lee & Weitzman, 2016 Youth E cigarette Use Adult E cigarette Use Conventional cigarette use fell by nearly one third since 2013 Youth e cigarette use is now more than double cigarette use 18 % of adult Minnesotans have tried an e cigarette at least once Youth Tobacco Use in Minnesota Half of e cig users report dual use Minnesota Department of Health, 2016 Minnesota Department of Health, Adult Tobacco Survey, 2014 Flavored Tobacco Products Other Trendy Products Nationally, 70% of all current youth tobacco users have used at least one flavored tobacco product in the past 30 days CDC,
5 Menthol Hookah All other flavored cigarettes were banned in the US in 2009, but menthol cigarettes were left out of the ban Menthol cigarette use exceeded non menthol cigarette use in youth and young adult smokers in % of high school students reported ever smoking tobacco with a hookah Regan, Dube & Arrazola, 2012 Villanti et al., 2016 CDC, Health Risks of E cigarettes Stand AZ, 2016 Pharmacologic Effects of Nicotine Highly addictive Increases risk for heart disease Those with diabetes can experience Insulin resistance High blood sugar/ Higher hgb A1c levels Increases blood pressure Damages vascular tissue Sciencepics, n.d. (Used with permission) Ellis, 2014 Cleveland Clinic Heart & Vascular Team, 2014 Bajaj,
6 Pregnancy and Nicotine Nicotine Poisoning Fetal exposure to nicotine can have negative long-term effects, including impaired fetal brain and lung development. Ingestion Skin contact 1/8 of a teaspoon is enough to poison children under 5 years old. Eye contact Minnesota Department of Health, 2015 Minnesota Department of Health, 2015 Child Nicotine Poisonings National Nicotine Poisonings Cases per year Minnesota Department of Health, 2015 American Association of Poison Control Centers, 2017 Tobacco Cessation Recommendations The Trade off July 2017 study found a 1.1% increase in cessation rate for the U.S. population associated with increased success of quit attempts when vaping Despite that success, vaping causes increased youth nicotine addiction at much higher rates Zhu et al,
7 U.S. Preventive Services Task Force Current evidence is insufficient to recommend e-cigarettes for tobacco cessation in adults, including pregnant women. Minnesota Department of Health Nicotine is highly addictive. Nicotine may harm brain development during adolescence. Nicotine is harmful to fetal health during pregnancy. Nicotine causes harmful physical effects, and can be toxic at any age. Minnesota Department of Health, 2016 FDA Approved Medications Combination Therapy Nicotine Gum Nicotine lozenge Nicotine inhaler Nicotine nasal spray Varenicline in combination with short acting NRT Nicotine patch in combination with bupropion Bupropion tablets Varenicline tablets Nicotine patch in combination with short acting NRT Nicotine patch In highly dependent smokers there is significant benefit to use of 4 mg gum vs. 2 mg gum Source: Chang et al, Stead et al, Ask Asking more than do you use tobacco? Patient Conversations Ask Do you vape? Do you use e-cigarettes? Do you use hookah? Follow Up Do you smoke menthol cigarettes? Do you use flavored products? 7
8 Ask: Is the patient trying to quit? Ask: Engagement Questions Yes Encourage and ask what additional resources needed How many times in the last year have you thought about quitting? One other quick thing, do you have kids or grandkids? We see a huge rise in kids using e cigarettes which are dangerous and a gateway to nicotine addiction. Just wanted you to know. No Ask Engagement Questions The quitting feeling comes and goes. I can connect you to some free resources What made you think about quitting? HealthPartners, 2017 HealthPartners, 2017 Advise: Motivational Interviewing Advise: Discuss Misconceptions E-cigarettes help you quit It s just water vapor E-cigarettes aren t tobacco Flavored products are safer The water in hookah filters out the toxins HealthPartners, 2017 Advise: Patient Resources Refer: QuitPlan Anyone Do not need a doctor s prescription. They work with all insurance companies. Fully Interactive Text messaging Phone calls Counselors Promotions and Research Mini-quit Monday Provides the latest news and research about tobacco and quitting. Clearway MN,
9 Support Clear Indoor Air Clearway MN Tobacco 21 Raising the tobacco sale age to 21 would prevent 30,000 young people from becoming smokers over the next 15 years Tobacco 21: Edina Tobacco 21: St Louis Park Menthol: Minneapolis 9
10 Addressing Tobacco Use in your Community Support policies that protect youth from tobacco Share your concerns with your city council Questions? Join the Physician Advocacy Network References Grace Higgins, MPH Projector Coordinator Physician Advocacy Network 1.American Academy of Family Physicians. (2014, December 31).Pharmalogic Product Guide. 2.American Academy of Pediatrics, State Advocacy Focus, American Association of Poison Control Centers. (2016, January 31).Electronic Cigarettes and Liquid Nicotine Data. 4.American Lung Association. (2014). Helping Smokers Quit: Tobacco Cessation Coverage. 5.American Medical Association. (2014). H Electronic Cigarettes, Vaping, and Health: 2014 Update. Retrieved from American Medical Association database. 6.American Medical Association. (2014). H Use of Electronic Cigarettes in Smoking Cessation Programs. Retrieved from American Medical Association database. 7.Amrock, S., Lee, L., Weitzman, M (2016). Perceptions of e-cigarettes and Noncigarette Tobacco Products Among US Youth. Pediatrics. Retrieved from 8. Association for Nonsmokers-Minnesota & Project Watch. (2013). Hookah: Background, history, and health consequences. 9.Bajaj. (2012). Nicotine and Insulin Resistance: When the Smoke Clears. Retrieved from American Diabetes Association database. 10.Bhatnagar, A., Whitsel, A., Ribisl, K., & et. al. (2014, August 14). Electronic Cigarettes: A Policy Statement From the American Heart Association. Circulation: Journal of the American Heart Association. Retrieved from 11.Black Cat E-cigarettes. (2014). Retrieved from 12.Cahill et al (2016). Nicotine receptor partial agonists for smoking cessation (Review). Cochrane Database of Systematic Reviews; Campaign for Tobacco Free Kids. (2015). E-Cigarette Marketing Continues to Mirror Cigarette Marketing. Retrieved from 14.Centers for Disease Control and Prevention (2014). Nictone: Systemic Agent. Retrieved from 15.Centers for Disease Control and Prevention (2014). E-cigarette use among youth is rising as e-cigarette advertising grows. Retrieved from 16.Centers for Disease Control and Prevention (2015). Youth and Tobacco Use. Retrieved from 17.Chang, P., Chiang, C., Ho, W., Wu, P., Tsai, J., & Guo, F (2015). Combination therapy of varenicline with nicotine replacement therapy is better than varenicline alone: a systematic review and meta-analysis of randomized controlled trials. BMC Public Health, 15(689). 18.Cleveland Clinic Heart and Vascular Team. (2014).E-Cigarettes: Tobacco-Free, But Your Heart May Still Be at Risk. Retrieved from Cleveland Clinic Database. 19.Clearway Minnesota. (2015). Flavored tobacco- delicious but dangerous. 20.Clearway Minnesota. (2014). Minnesota Youth Tobacco Survey 21.Corey, C., Ambrose, B., Apelberg, B., King, B., (2015). Flavored Tobacco Product Use Among Middle & High School Student- United States Morbidity and Mortality Weekly Report. 22. EC Supply (2016). How Regulations are Going to Affect You. Retrieved from 23.Ecigarette Reviewed (2016). The Basics of Vaping: Choosing PG/VG Ratios and Nicotine Levels. Retrieved from 24.Federal Drug Administration. (2015). Electronic Cigarettes. Retrieved from 25.Federal Drug Administration. (2016). FDA takes significant steps to protect Americans from dangers of tobacco through new regulation. Retrieved from 26.HealthPartners (2017). How to Ask about Smoking Without Lighting a Fire!. Unpublished manuscript. References 27. Johnston, O Malley, & Miech. (2014). Monitoring the future national survey results on drug use: Ann Arbor: Institute for Social Research. Minnesota Department of Health. (2014). Minnesota Adult Tobacco Survey 28. Marynak et al (2015). Sales of Nicotine-Containing Electronic Cigarette Products, Unites States, Minnesota Department of Health. (2015, June 10). Health Advisory: Nicotine Risks for Children and Adolescents. Retrieved from Minnesota Department of Health. (2016). Minnesota Youth Survey. 30. National Heart, Lung, and Blood Institute. (2011.) How Does Smoking Affect the Heart and Blood Vessels? Retrieved from National Heart, Lung, and Blood Institute Database. 31.Pepper, J. K., McRee, A.L., & Gilkey, M. B. (2014). Healthcare providers beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. Journal of Adolescent Health, 54, doi: /j/jadohealth Pepper, J.K. (2015). What are e-cigarettes? Webinar. 33. Pepper, J.K., Ribisl, K.M., Brewer, N.T. (2016). Adolescents' interest in trying flavoured e-cigarettes. Tobacco Control. Retrieved from Rigotti, N. A. (2015). e-cigarette use and subsequent tobacco use by adolescents: New evidence about a potential risk of e-cigarettes. JAMA, 314(7), Rath, J., Villanti, A., Abrams, D., & Vallone, D. (2012, January 20). Patterns of tobacco use and dual use in US young adults: The missing link between youth prevention and adult cessation. Journal of Environmental and Public Health. Doi: /2012/ Schroeder, M. & Hoffman, A. (2014, February 11). Electronic cigarettes and nicotine clinical pharmacology. Tobacco Control, 23(2). Retrieved from Tobacco Control Database. Ecigarettes. 37. Hildick-Smith, Pesko, Shearer, Hughes, Chang, Loughlin, & Ipp. (2015). A Practitioner s Guide to Electronic Cigarettes in the Adolescent Population. Journal of Adolescent Health. 38. Regan, A.K., Dube, S.R., Arrazola, R. (2012). Smokeless and flavored tobacco products in the U.S.: 2009 Styles survey results. American Journal of Preventive Medicine 42 (1). Retrieved from U.S. Preventative Services Task Force Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. Retrieved from and-interventions1 40. U.S. Surgeon General (2016). Know the Risks: E-cigarettes and Young People. Retrieved from Vaper Train. (2015). How Do I Choose an E-liquid Strength? 41. Vickerman, K., Carpenter, K., Altman, T., Nash, C., & Zbikowski, S. (2013, April 5). Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine & Tobacco Research, 15(10). Doi: /ntr/ntt Villanti, A. et al. Changes in the prevalence and correlates of menthol cigarette use in the USA, Tobacco Control. Retrieved from Warren, G., Marshall, J., Cummings, M., Toll, B. & et.al. (2013, May 8). Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. Journal of Thoracic Oncology, 8(5). Doi: /JTO.0b013e318288dc Zhu, S., Sun, J., Bonnevie, E., Cummins, S., Gamst, A., Yin, L., & Lee, M. (2014, May) Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tobacco Control, 23(3). Retrieved from Tobacco Control Database. 10
Up in Smoke: E-cigarettes & Other Tobacco Products
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