Up in Smoke: E-cigarettes & Other Tobacco Products

Transcription

1 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

2 CME Statement 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

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4 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

5 E cigarettes

6 The Rise of E cigarettes Sales restricted to minors in MN 2010 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, 2014

7 FDA Regulations Vapers 2022 Samples and vending machine sales banned EC Supply, 2016

8 U.S. Surgeon General, 2016 Surgeon General s Report

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10 Disposable vs. Rechargeable

11 How Does and E cigarette Work? Battery Clearomizerholds e liquid Atomizer heats e liquid Mouthpiece Source: Vaper Train, 2015

12 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 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 Kulwin, 2014; Neporent, 2014; American Academy of Pediatrics, 2014; Fontem, 2016

13 Buying E cigarettes Gas Station/ Convenience Store Internet Retail Specialty (Adultonly) Shops

14 Liquid nicotine E-juice E-liquids

15 99.6% of e cigarette products sold contain nicotine. Marynak et al, Ecigarette Reviewed, 2016

16 Southington Steps Coalition, 2016

17 Pepper, Ribisl & Brewer, 2016 Youth are 6 times more interested in trying menthol, candy or fruit e cigarette than trying a tobacco e cigarette

18 CDC, 2014

19 Tobacco Free Kids,2013

20 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 Amrock, Lee & Weitzman, 2016

21 Youth E cigarette Use Conventional cigarette use fell by nearly one third since 2013 Youth e cigarette use is now more than double cigarette use Youth Tobacco Use in Minnesota Half of e cig users report dual use Minnesota Department of Health, 2016

22 Adult E cigarette Use 18 % of adult Minnesotans have tried an e cigarette at least once Minnesota Department of Health, Adult Tobacco Survey, 2014

23 Other Trendy Products

24 Flavored Tobacco Products Nationally, 70% of all current youth tobacco users have used at least one flavored tobacco product in the past 30 days CDC, 2015

25 Menthol 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 2014 Regan, Dube & Arrazola, 2012 Villanti et al., 2016

26 Hookah 18% of high school students reported ever smoking tobacco with a hookah CDC,

27 Stand AZ, 2016

28 Health Risks of E cigarettes

29 Ellis, 2014

30 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) Cleveland Clinic Heart & Vascular Team, 2014 Bajaj, 2012

31 Pregnancy and Nicotine Fetal exposure to nicotine can have negative long-term effects, including impaired fetal brain and lung development. Minnesota Department of Health, 2015

32 Nicotine Poisoning Ingestion Skin contact 1/8 of a teaspoon is enough to poison children under 5 years old. Eye contact Minnesota Department of Health, 2015

33 Minnesota Department of Health, 2015 Child Nicotine Poisonings

34 National Nicotine Poisonings Cases per year American Association of Poison Control Centers, 2017

35 Tobacco Cessation Recommendations

36 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, 2017

37 U.S. Preventive Services Current evidence is insufficient to recommend e-cigarettes for tobacco cessation in adults, including pregnant women. Task Force

38 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

39 FDA Approved Medications Nicotine Gum Nicotine inhaler Nicotine nasal spray Nicotine lozenge Bupropion tablets Varenicline tablets Nicotine patch

40 Combination Therapy Varenicline in combination with short acting NRT Nicotine patch in combination with bupropion Nicotine patch in combination with short acting NRT 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, 2012.

41 Patient Conversations

42 Ask Asking more than do you use tobacco? 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?

43 Ask: Is the patient trying to quit? Yes Encourage and ask what additional resources needed No Ask Engagement Questions HealthPartners, 2017

44 Ask: Engagement Questions 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. The quitting feeling comes and goes. I can connect you to some free resources What made you think about quitting? HealthPartners, 2017

45 HealthPartners, 2017 Advise: Motivational Interviewing

46 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

47 Advise: Patient Resources

48 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, 2015

49 Clearway MN

50 Support Clear Indoor Air

51 Raising the tobacco sale age to 21 would prevent 30,000 young people from becoming smokers over the next 15 years Tobacco 21

52 Tobacco 21: Edina

53 Tobacco 21: St Louis Park

54 Menthol: Minneapolis

55 Addressing Tobacco Use in your Support policies that protect youth from tobacco Community Share your concerns with your city council Join the Physician Advocacy Network

56 Questions?

57 Grace Higgins, MPH Projector Coordinator Physician Advocacy Network

58 References 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.

59 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.