Welcome to the New England QIN-QIO Webinar: The Truth About E-Cigarettes

Transcription

1 Welcome to the New England QIN-QIO Webinar: The Truth About E-Cigarettes Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: Passcode: Slides are available for 1

2 The Truth About E-cigarettes BRIAN A. KING, PHD, MPH DEPUTY DIRECTOR FOR RESEARCH TRANSLATION OFFICE ON SMOKING AND HEALTH

3 1 Patterns of Use 2 Health Effects 3 Hot Topics 4 Policy Options

4 1 Patterns of Use 2 Health Effects 3 Hot Topics 4 Policy Options

5 Adult cigarette smoking prevalence High school smoking prevalence The Good News: Cigarette Smoking Is Down Adults 18+ High School Students 0 Source: Adult cigarette smoking prevalence data are from the National Health Interview Survey (NHIS). High school cigarette smoking prevalence data are from the National Youth Risk Behavior Survey.

6 The Bad News: The Landscape Is Evolving Cigarettes Cigars, Cigarillos Little Cigars Smokeless Pipes Snus Tobacco Hookah Bidis Dissolvables Kreteks ENDS Heated Tobacco Products

7 E-cigarettes: A Rapidly Diversifying Class

8 Percentage (%) Ever Use of E-cigarettes Among Adults, by Cigarette Smoking Status U.S., Current Cigarette Smoker Former Cigarette Smoker Never Cigarette Smoker Year Source: CDC. Styles Survey

9 Current E-cigarette Use Among Adults, by Age National Health Interview Survey, U.S., 2016 Source: QuickStats: Percentage of Adults Who Ever Used an E-cigarette and Percentage Who Currently Use E-cigarettes, by Age Group National Health Interview Survey, United States, MMWR Morb Mortal Wkly Rep 2017;66:892.

10 A Majority of Adult E-cigarette Users Also Smoke Conventional Cigarettes. Cigarette smoking status among current adult e-cigarette users, by age group Source: QuickStats: Cigarette Smoking Status Among Current Adult E-cigarette Users, by Age Group National Health Interview Survey, United States, MMWR Morb Mortal Wkly Rep 2016;65:1177.

11 Current Tobacco Product Use Among U.S. High School Students by Tobacco Product NYTS Cigarette 15.8% Cigar 11.6% 11.7% Smokeless Hookah Pipe E-cigarette 7.9% 4.1% 4.0% Bidi 2.0% 1.5% 7.7% 7.6% 5.5% 3.3% 0.8% 0.7% YEAR Source: [Pending publication] MMWR. Tobacco Use Among Middle and High School Students United States,

12 Frequency of Youth E-cigarette Use DAYS 3-5 DAYS 6-9 DAYS DAYS DAYS ALL 30 DAYS Middle School High School Source: Neff LJ, Arrazola RA, Caraballo RS, Corey CG, Cox S, King BA, Choiniere CJ, Husten CG.MMWR Morb Mortal Wkly Rep Oct 2;64(38): Frequency of Tobacco Use Among Middle and High School Students U.S., doi: /mmwr.mm6438a1.

13 1 Patterns of Use 2 Health Effects 3 Hot Topics 4 Policy Options

14 2014 Surgeon General s Report E-cigarettes could have negative and positive individual and population health impact This shift in patterns of tobacco use could have a number of potential impacts, ranging from the positive effect of accelerating the rate at which smokers quit smoking cigarettes completely to a negative effect of slowing down the decrease in the use of all tobacco products, especially cigarettes Chapter 15, Page 859 Source: The health consequences of smoking 50 years of progress: a report of the Surgeon General. Atlanta, GA. : U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

15 Is there a potential benefit for e-cigarettes? Answer: Under certain circumstances Complete long term substitution by established smokers Assist in rapid transition to a society with little or no use of combustible products Short-term use if shown to produce successful & permanent cessation of combustible products Cutting back is not enough even a few cigarettes per day is dangerous

16 Potential Health Risks of E-cigarettes Leads to initiation of combustible tobacco use among nonsmokers, particularly children Leads to relapse among former smokers Diminishes the chances that a smoker will quit Discourages smokers from using proven quit methods Exposes children, pregnant women, and nonusers to secondhand aerosol Glamorizes or renormalizes tobacco use Results in poisonings among users or non-users

17 Conclusion 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 and intensity of subsequent combustible tobacco cigarette smoking. Leads to initiation of combustible tobacco use among nonsmokers, particularly children Source: The National Academies of Science, Engineering, and Medicine. Public Health Consequences of E- cigarettes

18 Current Smokers ENDS use was associated with greater odds of quitting smoking 1.17 Leads to relapse among former smokers Never Smokers ENDS use was associated with greater odds of initiating smoking 7.41 Former Smokers ENDS use was associated with greater odds of smoking relapse 1.53 Source: Kelly Young-Wolff et al. Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system. Prev Med

19 The long-term safety of e-cigarettes is unknown. Diminishes the chances that a smoker will quit The small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards. Overall, the USPSTF found the evidence on the use of ENDS as a smoking cessation tool in adults, including pregnant women, and adolescents to be insufficient.

20 Quit Methods Used Among U.S. Adult Cigarette Smokers Discourages smokers from using proven quit methods Got help from a telephone quitline Got help from a website such as Smokefree.gov Used FDA-approved medications such as Zyben or Chantix Got help from doctor or other health professional Switched to "mild" cigarettes Switched completely to e-cigarettes Used nicotine patch/gum Substituted some regular cigarettes with e-cigarettes Gradually cut back on cigarettes 82 Gave up cigarettes all at once 85.3 Mulitple quit methods 74.7 Source: Caraballo RS, Shafer PR, Patel D, Davis KC, McAfee TA. Quit Methods Used by US Adult Cigarette Smokers, Prev Chronic Dis 2017; 14:

21 Exposes children, pregnant women, and nonusers to secondhand aerosol Conclusion 5: E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful constituents, including nicotine

22 Glamorizes or renormalizes tobacco use

23 Youth Exposure to E-cigarette Advertising

24 Unintended Injuries: Poison Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid. Results in poisonings among users or non-users

25 Nicotine Poses Unique Dangers to Young People Chapter 3 Conclusion 1, 2, & 5

26 Are Youth Using E-cigarettes with Nicotine? Self-reported nicotine consumption among youth may be subject to bias: Youth may not know what nicotine is, let alone whether it is in their e-cigarette. Youth who access e-cigarettes from peers may not see packaging. Some e-cigarette labels obscure nicotine content. Question asked respondents to choose only one response option. Source for infographic:

27 Sales Data Tell Another Story Percentage of products that contained nicotine 99.6% of disposable e-cigarette sales 100% of rechargeable sales 99.5% of refill sales Percentage that contained nicotine by product type 99.6% of all e-cigarette products sold 99.4% of flavored e-cigarette products 99.9% of non-flavored e-cigarette products Source: Marynak, K.L.; Gammon, D.G.; Rogers, T.; Coats, E.M.; Singh, T.; King, B.A., "Sales of nicotine-containing electronic cigarette products: United States, 2015," American Journal of Public Health 107(5): , May 2017.

28 Your Gut Can Handle More Than Your Lungs Some e-cigarette manufacturers claim flavorings are safe because they meet the FDA definition of Generally Recognized as Safe ( GRAS ) GRAS does not apply to products that are not food

29 E-cigarettes and Cannabinoids Conclusion: E-cigarette products can be used as a delivery system for cannabinoids and potentially for other illicit drugs. Sources: Singh T, Kennedy S, Marynak K, Persoskie A, Melstrom P, King BA. Characteristics of Electronic Cigarette Use Among Middle and High School Students United States, MMWR Morb Mortal Wkly Rep 2016;65: DOI:

30 1 Patterns of Use 2 Health Effects 3 Hot Topics 4 Policy Options

31 The Rise of JUUL

32 The E-cigarette Landscape is Volatile Source: King, BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in the United States, JAMA October 2018;Volume 320:Number 13.

33 Recognition, Use and Perceptions of JUUL Among Youth and Young Adults 29 25% of respondents reported recognition of the device 10% reported both recognizing and having ever used a JUUL 8% reported recognition and past 30- day use of JUUL YEARS YEARS Recognize Juul Ever use MALES Recognize Juul Past 30-day use Ever use FEMALES Source: Willett JG, Bennett M, Hair EC, et al Recognition, use and perceptions of JUUL among youth and young adults Tobacco Control Published Online First: 18 April 2018.

34 JUUL Contains Nicotine Salts Nicotine for e-liquid begins as free base nicotine To change to a nicotine salt, an e-liquid maker adds an acid to lower the ph usually benzoic acid Initial patent for JUUL nicotine salt technology obtained in 2015

35 What Are Heat Not Burn Products? Contain Tobacco Throat-Hit similar to cigarettes Positioned to appeal to smokers who have tried and rejected e-cigarettes

36 Pending FDA Pre-Market Approval A scientific advisory committee met to discuss the MRTP application in January Philip Morris International submitted applications to FDA for approval to: Market iqos ( Premarket Tobacco Product Application or PMTA) Make health claims ( Modified Risk Tobacco Product application or MRTP)

37 Ever Use of Heat-Not-Burn Products Among U.S. Adults, OVERALL 0.7 MALE 0.8 FEMALE YEARS 0.5 <30 YEARS 1.6 NON-HISPANIC, WHITE 0.5 OTHER 1 Source: Marynak et al. Awareness and Ever Use of Heat-Not-Burn Tobacco Products Among U.S. Adults, Am J Prev Med, 2018 [in press]

38 Net Public Health Benefit or Harm? Youth Initiation Adult Cessation

39 Protecting Youth From the Harms of E-Cigarettes Chapter 5 Conclusion 3. The adoption of public health strategies that are precautionary to protect youth and young adults from adverse effects related to e-cigarettes is justified.

40 Youth Knowledge of Absolute Risks of E-cigarette Use MIDDLE SCHOOL HIGH SCHOOL No harm Little harm Some harm A lot of harm Source: Wang, Teresa W., Trivers, Katrina F., Marynak, Kristy, O Brien, Erin Keely, Persoskie, Alexander, Liu, Sherry T., King, Brian A. Harm Perceptions of Intermittent Tobacco Product Use Among U.S. Youth, J Adolesc Health Jun; 62(6): Published online 2018 Mar 2.

41 Tobacco Harm Reduction: A proposed strategy to lower the health risks to individuals and society by transitioning combustible tobacco users to products with relatively lower health risks. Combustible Tobacco Products Noncombustible Tobacco Products Electronic Tobacco Products

42 Perceived Harm of E-cigarettes Relative to Cigarettes Among U.S. Adults: LESS HARMFUL ABOUT THE SAME MORE HARMFUL I DON'T KNOW Source: Ban A. Majeed, Scott R. Weaver, Kyle R. Gregory, Carrie F. Whitney, Paul Slovic, Terry F. Pechacek, Michael P. Eriksen. Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, American Journal of Preventive Medicine, 2016.

43 1 Patterns of Use 2 Health Effects 3 Hot Topics 4 Policy Options

44 Tobacco Control Vaccine Source: King BA, Graffunder C. The Tobacco Control Vaccine: a population-based framework for preventing tobacco-related disease and death. Tobacco Control 2018;27:

45 Major Conclusion #7 Action can be taken at the national, state, local, tribal, and territorial levels to address e-cigarette use among youth and young adults. Actions could include incorporating e-cigarettes into smokefree policies, preventing access to e- cigarettes by youth, price and tax policies, retail licensure, regulation of e-cigarette marketing likely to attract youth, and educational initiatives targeting youth and young adults.

46 Public Health Actions to Address E-Cigarettes Federal Regulation Family Smoking Prevention and Tobacco Control Act Signed into law on June 22, 2009 Granted FDA the authority to regulate tobacco products Enhances the ability to intensify policy to reduce tobacco industry influence Manufacturing Marketing Sale State, Local, Territory Potential Sub-National Action: Including e-cigarettes in smokefree indoor air policies Restricting youth access to e-cigarettes in retail settings Licensing retailers Establishing specific package requirements Setting price policies

47 New FDA Manufacturer Requirements: Registering manufacturing establishments and providing product listings to the FDA Requiring premarket review and authorization of new tobacco products by the FDA Reporting ingredients, and harmful and potentially harmful constituents Placing health warnings on product packages and advertisements Not marketing newly deemed tobacco products (including e-cigarettes)with modified risk claims unless authorized by the FDA.

48 States With & Without Laws Prohibiting Smoking & Use of E-cigarettes in Indoor Areas of Private Worksites, Restaurants, & Bars U.S., September 2018 D.C No Comprehensive Smoke- Free Law or Prohibition on Indoor E-cigarette Use Source: Centers for Disease Control and Prevention. STATE System Prohibits Indoor Smoking Only Prohibits Indoor Smoking and Indoor E- cigarette Use

49 Source: Preventing Tobacco Addiction Foundation. Accessed September 27, Including 6 with Statewide T-21 laws

50 Tobacco Control Hurdles Evolving Landscape Disparities Limited Resources Industry Influence

51 Takeaways Youth use of tobacco products in any form, including electronic tobacco products, is unsafe. 1 2 Adult smokers must completely quit to realize benefits from e-cigarettes. E-cigarettes are not currently an FDA approved quit aid. 3 Recently, the electronic product landscape 4 has diversified to include new products, including JUUL and heated tobacco products. The tobacco product landscape continues to diversify, and it s critical to modernize tobacco control strategies to adapt to these changes.

52 Questions? 52

53 Contact Information Brenda Jenkins, RN, D.Ay., CDOE, CPEHR, PCMH CCE Senior Program Administrator

54 Connect with the New England QIN-QIO on Social Media! This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINB