Mehmet S. Copur, MD, FACP Medical Director

Transcription

1 Mehmet S. Copur, MD, FACP Medical Director CHI Health St. Francis Cancer Treatment Center, Grand Island, NE Professor, Department of Internal Medicine, Hematology/Oncology UNMC, Omaha, NE

2 CHI Health St. Francis Cancer Treatment Center Founded in 1887, CHI Health St. Francis is a regional referral center with more than 100 physicians and 1,100 employees who work together to build a healthier community by delivering high-quality care from maternity to cardiology to cancer close to home. The CHI Health St. Francis Cancer Treatment Center diagnoses and treats new cancer patients from across the state each year. Our affiliation with the National Cancer Institute and UNMC Eppley Cancer Center allows us to offer the latest cancer treatments, and the percentage of our patients enrolled in clinical trials is among the nation s highest. The Cancer Treatment Center is a three-time winner of the Outstanding Achievement Award from the American College of Surgeons Commission on Cancer.

3 E-Cigarettes Public Health Consequences

4 Cigarette Smoking-Preventable Health Problem Cigarette smoking the most preventable cause of death in the United States- 480,000 deaths annually 15.1 % of the U.S. adult population=36.5 million adults smoke cigarettes (CDC-estimate) Nicotine in inhaled tobacco smoke moves from the lungs into the bloodstream and to brain within seven to 10 seconds Once there, nicotine triggers a number of chemical reactions that create temporary short-lived feelings of pleasure subsiding within minutes As the nicotine level drops in the blood, smokers feel edgy and agitated the start of nicotine withdrawal Nicotine increases adrenaline which in turn heart rate, blood pressure, and restricts blood flow into the heart muscle Nicotine also inhibits the release of insulin leading hyperglycemia Nicotine activates the same reward pathways in the brain that other drugs of abuse such as cocaine or amphetamines do The acute effects of nicotine wear off within minutes so smokers must continue dosing themselves frequently throughout the day to maintain the effects and to prevent withdrawal symptoms

5 Nicotine-the Culprit Nicotine is one of the lesser harmful agents in a cigarette smoke but it is the addictive compound Nicotine can influence many biological processes; can suppress immune system which can be helpful for inflammatory bowel disease but harmful with other diseases by keeping immune system from doing necessary work Nicotine is neuroprotective-it keeps cells from dying which may sound beneficial but may promote certain forms of neoplastic growth Effects vary from person to person and depend on the genetics for the most part but for sure most negative side effects result from longterm exposure

6 Nicotine-the Culprit

7 How Addictive is Nicotine By Henningfield Criteria

8 How Addictive is Nicotine? By Benowitz Criteria

9 An electronic cigarette or e-cigarette is a handheld electronic device that simulates the feeling of tobacco smoking It works by heating a liquid to generate an aerosol, commonly called a "vapor" that the user inhales Using e-cigarettes is sometimes called vaping. The liquid in the e-cigarette, called e-liquid is usually made of nicotine, propylene glycol, glycerine, and flavorings

10 What is in E-cigarette Aerosol Scientists are still working to understand more fully the health effects and harmful doses of e-cigarette contents when they are heated and turned into an aerosol, both for active users who inhale from a device and for those who are exposed to the aerosol secondhand

11 What is in E-cigarette Aerosol The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including: Nicotine Ultrafine particles that can be inhaled deep into the lungs Flavoring such as diacetyl, a chemical linked to a serious lung disease Volatile organic compounds Cancer-causing chemicals Heavy metals such as nickel, tin, and lead It is difficult to know what e-cigarette products contain Some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine

12 Historical Perspective 2003 Headline: Invention of E-Cigarettes The first person on record to have the idea for an electronic nontobacco option is Herbert A. Gilbert who filed for a patent in 1963, in an era when tobacco smoking was widely accepted and the health risks were less apparent Three pack-a-day smoker Hon Lik, a 52-year old Beijing pharmacist, created the first successful electronic cigarette after his father, another heavy smoker, died of lung cancer By 2007, e-cigarettes were marketed in Europe and in the United States by the manufacturer Ruyan as a way to safely stop smoking tobacco

13 2008 Headline: WHO slams E-Cigarette Marketing In September 2008, the World Health Organization announces that marketers should immediately remove any claims that e- cigs are a "safe and effective smoking cessation aid" because there is no scientific evidence to confirm the product's safety and efficacy Soon after, a study funded by e-cigarette manufacturer Ruyan declares the product to be 100 to 1,000 times less dangerous than smoking tobacco, adding that when using their device, nicotine is "apparently not absorbed from the lung, but from the upper airways"

14 2010 Headline: The Battle Heats Up In July, an FDA news release discourages the use of e- cigarettes, saying they contain carcinogens and an ingredient used in anti-freeze, diethylene glycol Vape supporters counter that diethylene glycol was found at a very low, non-toxic level of 1%, and that the carcinogens are at the same levels as other FDA-approved nicotine cessation products, like patches and gum Another concern arises as e-cigarettes are often marketed and sold to youngsters who, intrigued by the many flavors such as chocolate, bubble gum and mint, might easily adopt a smoking habit as a result of trying the devices By the end of the year, Amazon and Paypal restrict the sale of e-cigs on their websites

15 2012 Headline: E-Cigarette Use Doubles in Adolescents The Centers for Disease Control announces that e-cigarette use among U.S. middle and high school students doubles between 2011 and 2012, mirroring a similar increase in adult use Most alarming for policy makers: CDC concerns that vaping among adolescents may serve as a gateway to tobacco use To measure nicotine delivery, United Kingdom Researchers test 16 e-cigarettes with an automatic smoking machine and find wide variations in nicotine levels per puff, ranging from 0.5 to 15.4 mg In contrast, the typical level from a tobacco puff ranges only from 1.54 to 2.60 mg. The wide variation between e-cigarette brands leads researchers to question how well they can function as a nicotine replacement device

16 2013 Headline: Do E-Cigs Really Help Smokers Quit? Several 2013 publications show minimal evidence that e- cigarettes help smokers quit-a cross-sectional study of 1,836 tobacco smokers finds a significant association with e- cig use and "unsuccessful quitter" status but none with 'quitter" status Another study of callers to state tobacco quit lines finds e- cigarette users significantly less likely to be tobacco-free seven months after they first try vaping compared with participants who never try e-cigarettes A New Zealand Health Research Council Study of 657 smokers finds e-cigarettes modestly effective in helping smokers quit Researchers worry that e-cigarette use might distract smokers from proven safe and effective methods for kicking their tobacco habit- "It's filter tipped, low tar, déjà vu all over again: A Triumph of Wishful Thinking over Science."

17 2014 Headline: Poison Center Calls Skyrocket The Centers for Disease Control releases data showing that the number of calls about nicotine E-liquids to poison centers rose from a scant one call per month in 2010 to 215 calls per month in 2014 More than half of the calls involved children under the age of 5 ingesting, inhaling or getting the substance in their eyes or on the skin A study of over 75,000 Korean adolescents finds e-cigarette use to be strongly associated with current and heavy traditional cigarette smoking Data from the CDC find that the use of e-cigarettes among U.S. high school students grew from 4.5 % in 2013 to 13 % in 2014 In that same time period, use grew among middle-schoolers from 1 % to 4 % A study comparing the use of e-cigarette inhaler to the barely used FDA approved nicotine inhaler for smoking cessation finds the e-cig version a clear winner with users, providing more satisfaction and a better image

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19 2014 Headline: Poison Center Calls Skyrocket In 2014 more than half of reported exposures to e-cigarettes and liquid nicotine occurred in young children under the age of 6 Some children and toddlers who come in contact with e-cigarette devices or liquid nicotine have become very ill; some even requiring ER visits with nausea and vomiting being the most significant symptoms Adults should use care to protect their skin when handling the products, and they should be out of sight and out of the reach of children Additionally, those using these products should dispose of them properly to prevent exposure to pets and children from the residue or liquid left in the container

20 What is, and What Causes Popcorn Lung? In 2004, The US Centers for Disease Control and Prevention (CDC) reported several cases of bronchiolitis obliterans in workers in a microwave popcorn plant in Missouri Bronchiolitis obliterans is a serious and irreversible condition in which the tiny air sacs in the lungs become scarred After investigation by the NIOSH (National Institute of Occupation Safety and Health), it was discovered that a flavoring agent, diacetyl, was used to give the popcorn a buttery taste Inhalation of this flavoring likely contributed to the development of the illness The disease that results often is associated with cough and shortness of breath, similar to that seen in people with chronic obstructive pulmonary disease (COPD) This process is irreversible by current therapy.

21 Do E-Cigarettes Cause Popcorn Lung? It is not only microwave popcorn that contains dangerous chemical flavorings such as diacetyl A study published in 2015 in the journal Environmental Health Perspectives showed that harmful chemicals associated with "popcorn lung" are present in many types of flavored e-cigarettes, particularly those with flavors like fruit and candy that may appeal to young smokers Of the 51 flavored e-cigarettes tested, flavoring chemicals were found in 47 and diacetyl specifically in 39 samples This suggests a potentially dangerous level of exposure via e-cigarettes to chemicals that can cause severe lung damage

22 2014 Headline: Poison Center Calls Skyrocket The Centers for Disease Control releases data showing that the number of calls about nicotine E-liquids to poison centers rose from a scant one call per month in 2010 to 215 calls per month in 2014 More than half of the calls involved children under the age of 5 ingesting, inhaling or getting the substance in their eyes or on the skin A study of over 75,000 Korean adolescents finds e-cigarette use to be strongly associated with current and heavy traditional cigarette smoking Data from the CDC find that the use of e-cigarettes among U.S. high school students grew from 4.5 % in 2013 to 13 % in 2014 In that same time period, use grew among middle-schoolers from 1 % to 4 % A study comparing the use of e-cigarette inhaler to the barely used FDA approved nicotine inhaler for smoking cessation finds the e-cig version a clear winner with users, providing more satisfaction and a better image

23 Nicotine Inhalers Devices similar to electronic cigarettes, have existed for years, but they were just not cool enough to catch on Listed among the treatments used for helping smokers quit, nicotine inhalers were approved by the Food and Drug Administration (FDA) in 1997 The devices deliver nicotine to the mouth when the smoker puffs at the plastic mouthpiece that looks like an oldfashioned cigarette holder These products have been around for over 15 years now, and physicians and consumers are not aware of them

24 Nicotine Inhalers The nicotine inhaler is a form of nicotine replacement therapy (NRT) consists of a plastic cigarette-like tube that houses a replaceable nicotine cartridge and a mouthpiece When a person draws on the mouthpiece nicotine is released and absorbed through the membranes in the mouth and throat with less than 5 percent of the inhaled nicotine reaching the respiratory tract Of the 10 mg of nicotine in a cartridge, 4 mg can be inhaled and 2 mg absorbed into the body, each cartridge lasts about 20 minutes and delivers approximately the same amount of nicotine as one regular cigarette Typically recommended amount for ex-smokers is to start with a minimum of 6 nicotine cartridges a day for 3 to 6 weeks up to 16 cartridges a day up to 12 weeks After that, it should be tapered down with the help of doctor until weaned off of it completely The nicotine inhaler is one of two types of nicotine replacement therapy that require a doctor's prescription(the other is nicotine nasal spray)

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26 2015 Headline: Vaping Could be Dangerous, but perhaps a Quitting Aid A New England Journal of Medicine study sets off alarm bells by reporting that some e-cigarettes release formaldehyde, a probable carcinogen, when heated by high-voltage batteries A Cleveland Clinic clinical review restates ongoing concerns about propylene glycol and the various food flavorings that are part of e-juice-while considered safe to eat in food in small quantities, researchers say PGs have not been studied when "inhaled deeply and repeatedly Another study looks at 51 of the nearly 7,000 e-cigarette flavors currently marketed to check for a flavoring chemical called diacetyl that has been shown to be associated with a disease called popcorn lung The study finds diacetyl at higher than laboratory normal levels in 39 of the tested flavors-researchers call for "urgent action" to evaluate the "potentially widespread exposure"

27 2016 Headline: Vaping a Gateway to Tobacco Use... and No Better for Your Heart In late January, BMJ published a study that quizzed more than 2,000 Hawaiian ninth- and 10th-graders about their e-cigarette and traditional cigarette use, then followed up a year later-nearly all of the teens (98%) knew about vaping, and 68% considered e-cigarettes to be healthier than smoking They found that vapers were more than three times as likely to have begun smoking cigarettes by the next year compared with "never smokers The study also found the effect of e-cigarettes was independent of other factors that encourage teens to pick up the habit, such as rebelliousness and lack of parental support While the study showed any level of vaping led to some cigarette use, it was the heavy vapers who were more likely to become regular cigarette smokers

28 2017 Headline: E-Cigarettes are Safer than Conventional Cigarettes Former smokers who replaced standard cigarettes with e-cigarettes substantially reduced their intake of cancer-causing chemicals, according to a study published in Annals of Internal Medicine in February Although it's clear that vaping is not a healthy behavior, many people argue that it is at least better than smoking, Yet scientific evidence of how these two behaviors compare has been sorely lacking One study, published in Pediatrics showed teens using these flavored versions were less likely to see tobacco smoking as dangerous, and therefore more likely to take up cigarette smoking The Food and Drug Administration recently announced that it will regulate all tobacco products, including e-cigarettes, cigars, hookah tobacco and pipe tobacco, and will prohibit the sale to youths under the age of 18 But the regulations stopped short of regulating flavorings, which leaves these alluring flavors on the market to entice kids to try e-cigarettes

29 Are E-cigarettes less Harmful than Regular Cigarettes? E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes However, e-cigarette aerosol is not harmless It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents

30 Can E-cigarettes Help Adults Quit Smoking Cigarettes The U.S. Preventive Services Task Force, a group of health experts that makes recommendations about preventive health care, has concluded that evidence is insufficient to recommend e-cigarettes for smoking cessation in adults, including pregnant women To date, the few studies on the issue are mixed A Cochrane Review found evidence from two randomized controlled trials that e-cigarettes with nicotine can help smokers stop smoking compared with placebo (non-nicotine) e-cigarettes However, there are some limitations to the existing research, including the small number of trials, small sample sizes, and wide margins of error around the estimates A recent CDC study found that many adults are using e- cigarettes in an attempt to quit smoking yet most end up continuing to use both products known as dual use

31 Who is Using E-cigarettes? In the United States, youth are more likely than adults to use e-cigarettes In 2015, among adult e-cigarette users overall, 58.8% also were current regular cigarette smokers, 29.8% were former regular cigarette smokers, and 11.4% had never been regular cigarette smokers In 2016, more than 2 million U.S. middle and high school students used e-cigarettes in the past 30 days- 4.3% of middle school students and 11.3% of high school students Among current e-cigarette users aged years, 40.0% had never been regular cigarette smokers In 2016, 3.2% of U.S. adults were current e-cigarette users

32 E-Cigarette Use Among Youth and Young Adults Brain Risks The part of the brain that's responsible for decision making and impulse control is not yet fully developed during adolescence. Youth and young adults are also uniquely at risk for long-term, long-lasting effects of exposing their developing brains to nicotine including nicotine addiction, mood disorders, and permanent lowering of impulse control. Nicotine also changes the way synapses are formed, which can harm the parts of the brain that control attention and learning. Addiction Until about age 25, the brain is still growing. Each time a new memory is created or a new skill is learned, stronger connections or synapses are built between brain cells. Young people's brains build synapses faster than adult brains. Because addiction is a form of learning, adolescents can get addicted more easily than adults. The nicotine in e-cigarettes and other tobacco products can also prime the adolescent brain for addiction to other drugs such as cocaine. Behavior Risks E-cigarette use among youth and young adults is strongly linked to the use of other tobacco products, such as regular cigarettes, cigars, hookah, and smokeless tobacco

33 JUUL Came out 2 years ago Has already amassed nearly half of the e- cigarette market share Every month the JUUL Labs produce 20 million products (devices and cartridges) JUUL Device cost $34.99 Four-pack of pods costs $15.99 Nicotine in each pod=1 pack of cigarettes (200 puffs)

34 How do JUULs work? JUUL devices heat up a cartridge containing oils to create vapor Vapor quickly dissolves into the air Small and sleek tech inspired design that was inspired by a USB flash drive Charges by plugging into laptop

35 Ingredients in JUL Vapor Glycerol colorless, sweet liquid formed as a byproduct in soap manufacture-used as an emollient and laxative and for making explosives and anti-freeze Benzoic Acid colorless crystalline solid. Combine with other acids to treat skin irritation and inflammation caused by burns, insect bites, fungal infections and eczema Propylene Glycol synthetic liquid substance that absorbs water- Used as an antifreeze, a solvent for food colors and flavors, and in the paint and plastic industry Nicotine Does not contain Diacetyl (which some e-cigarettes do). Natural Oils Extracts and Flavor

36 Majority of youth e-cigarette users think that the last time they used a product they vaped only the flavoring, not nicotine According to University of Michigan 2016 Study Nicotine is known to cause long-term impacts on brain development in youth Centers for Disease Control and Prevention reported that 99% of e-cigarettes sold in the U.S. stores in 2015 contained nicotine Flavoring to target youth examples: Peach, Mango, Mint Four times more likely to start smoking combustible tobacco University of Pittsburgh Schools of Health Sciences (December, 2017)

37 Started August 23, 2017 JUULvapor.com requires you to be 21 & Over to purchase 21 & Over only for online but can purchase JUUL device in a store at the states law for tobacco & nicotine products JUUL uses a system at checkout that does a public records search to find age If they can t find information may be required to upload a picture of I.D.

38 Expert Committee of the National Academies of Sciences, Engineering, and Medicine

39 National Academies of Sciences, Engineering, and Medicine

40 Conclusive Evidence by National Academies of Sciences, Engineering, and Medicine

41 Substantial Evidence by National Academies of Sciences, Engineering, and Medicine

42 National Academies of Sciences, Engineering, and Medicine Conclusions Organized by Outcome Exposure to nicotine and toxic substances There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on the characteristics of the device and the e-liquid, as well as on how the device is operated. There is conclusive evidence that in addition to nicotine, most e- cigarettes contain and emit numerous potentially toxic substances. There is substantial evidence that except for nicotine, exposure to potentially toxic substances from e-cigarettes (under typical conditions of use) is significantly lower compared with conventional cigarettes. There is substantial evidence that nicotine intake from e-cigarettes among experienced adult e-cigarette users can be comparable to that from conventional cigarettes.

43 National Academies of Sciences, Engineering, and Medicine Conclusions Organized by Outcome Dependence and abuse liability There is substantial evidence that e-cigarette use results in symptoms of dependence on e-cigarettes. There is moderate evidence that risk and severity of dependence is lower for e- cigarettes than for conventional cigarettes. There is moderate evidence that variability in the characteristics of e-cigarette products (nicotine concentration, flavoring, device type, and brand) is an important determinant of the risk and severity of dependence on e-cigarettes. Harm reduction There is conclusive evidence that completely substituting e-cigarettes for conventional cigarettes reduces users exposure to many toxicants and carcinogens present in conventional cigarettes. There is substantial evidence that completely switching from regular use of conventional cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.

44 National Academies of Sciences, Engineering, and Medicine Conclusions Organized by Outcome Injuries and poisonings There is conclusive evidence that e-cigarettes can explode and cause burns and projectile injuries. Such risk is significantly increased when batteries are of poor quality, stored improperly, or are being modified by users. There is conclusive evidence that intentional or accidental exposure to e- liquids (from drinking, eye contact, or skin contact) can result in adverse health effects such as seizures, anoxic brain injury, vomiting, and lactic acidosis. There is conclusive evidence that intentionally or accidentally drinking or injecting e-liquids can be fatal. Respiratory effects There is no available evidence whether or not e-cigarettes cause respiratory diseases in humans. There is moderate evidence or increased cough and wheeze in adolescents who use e-cigarettes, and an increase in asthma exacerbations. Reproductive and developmental effects There is no available evidence whether or not e-cigarettes affect pregnancy outcomes. There is insufficient evidence whether or not maternal e-cigarette use affects fetal development.

45 National Academies of Sciences, Engineering, and Medicine Conclusions Organized by Outcome Use by youth and young adults There is substantial evidence that e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes. Secondhand exposure There is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels. There is moderate evidence that second-hand exposure to nicotine and particulates is lower from e-cigarettes compared with conventional cigarettes. Cancer There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. (An intermediate cancer endpoint is a precursor to the possible development of cancer; for example, polyps are lesions that are intermediate cancer endpoints for colon cancer.) There is limited evidence from animal studies using intermediate biomarkers of cancer to support the hypothesis that long-term e- cigarette use could increase the risk of cancer.

46 American Cancer Society Position Statement February-2018 Scientific Summary: Based on currently available evidence, using current generation e-cigarettes is less harmful than smoking cigarettes, but the health effects of long-term use are not known As new evidence emerges, the ACS will promptly report these findings to policy makers, the public and clinicians Clinical Recommendations: The ACS recommends that clinicians advise their patients to use FDA-approved cessation aids that have been proven to support successful quit attempts Many smokers choose to quit smoking without the assistance of a clinician and some opt to use e-cigarettes to accomplish this goal The ACS recommends that clinicians support all attempts to quit the use of combustible tobacco and work with smokers to eventually stop using any tobacco product, including e-cigarettes The ACS strongly discourages the concurrent (or dual ) use of e-cigarettes and combustible cigarettes

47 What s the bottom line? If you're a long-term cigarette smoker and haven t been able to cut back or stop smoking using approved cessation methods, e-cigarettes and other vaping devices products appear to be a safer alternative than continuing cigarette smoking, even if they do not help you reduce your nicotine intake. However, if you do not smoke or use other forms of tobacco or nicotine, steer clear of e-cigarettes and other vaping devices. The potential risks to your long-term health outweigh any enjoyment in the moment.

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