Background. Description. Disclosure. Objectives. Types of ENDS. APNA 30th Annual Conference Session 4024: October 22, 2016.

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1 Electronic Nicotine Delivery Systems (ENDS): Information and Discussion on Electronic Cigarettes and Vape Pens Carolyn Baird DNP, CARN-AP, FIAAN Carol Essenmacher DNP, CTTS October 22, 2016 Background Early 2000 s by Chinese pharmacist Hon Lik 460 brands 7,700+ flavor additives (Brandon et al., 2015; Grana et al., 2014) Disclosure The presenters have no conflict of interest to disclose Description Metal tube: heater/atomizer, battery, cartridge filled with liquid nicotine and other chemicals, light-emitting diode at end (mimic lit end of cigarette) Also known as: Vape pens, smokeless cigarettes, electronic nicotine delivery devices/systems (ENDD/ENDS) Objectives The participant will be able to summarize key points on the safety and efficacy of ENDS. Types of ENDS The participant will demonstrate the ability to provide peers and colleagues with clarifying information on the use of ENDS The participant will demonstrate the ability to provide patients with clarifying information on the use of ENDS CDC 2015 Essenmacher 1

2 Other Options: ENDS Marketing Alternative to conventional cigarettes Smoking cessation aid Less harmful / improved health Use nicotine in smoking-restricted areas CDC 2015 Clarification Marketing: Who Profits? Not actually a vapor is an aerosol (different sizes of particles) Aerosol seen upon exhale is similar to fog machine (concerts) Remember 460+ manufacturers Between 2007 & 2013 ENDS businesses grew to $2 Billion/year industry Forecast: $10 Billion/year industry by 2017 Research funded by tobacco companies: historical perspective Brandon et al, 2015; Shaw et al, 2015 Chemicals Frequently Found in ENDS (~42) Benzene (pesticides, gasoline) Formaldehyde (embalming fluid) Nicotine (pesticides/does not cause cancer) Toulene (industrial solvent) Cadmium (car batteries) Lead Propylene Glycol (de-icing solution) (CDC, 2015; Group to Alleviate Smoking Pollution of Colorado) Marketing Who Uses ENDS? Use of ENDS quadrupled in US between 2009 and 2010 Women more likely to try them; Men more likely to continue use 3x more likely to use if HS diploma or less Low income (<$15,000) more likely to try use 6x more likely try ENDS and 3x more likely to continue use if currently smoking Essenmacher 2

3 ENDS & Patients with Mental Health Issues Prochaska & Grana (2014) found that 24% state they are using ENDS to quit, but there was no actual decrease in cigarettes smoked per day Dual Use No reduction in CPD with use of ENDS Perceptions continued To not disturb others w/cig smoke (second-hand ENDS exposure) To use in smoking restricted areas (most ENDS restricted same places that cig smoking is banned) (American Industrial Hygiene Association, 2014) Patient s Perception of ENDS: To quit smoking (Research does not support this) To reduce cigarette consumption (Research does not support this) Reported Potential Benefits May decrease risks for adult patients who stop smoking and only use ENDS, but no data to support that people are making total switch to only ENDS use To deal with nicotine withdrawal (Reduces cravings but not irritability, restlessness, poor concentration) Perceptions continued Perceived safer than conventional cigarettes (no RCTs on ENDS users, no standardized dosing, types & concentrations of chemicals not studied, safety of flavor additives, sold to underage, etc.) Cheaper than smoking (avg. costs to start ENDS kit = $120/per month vs 20cpd =$144/month) Reported Potential & Real Harms Accidental poisonings Nicotine can cause death in adults at 30-60mg and in children at 10mg Refill bottles contain up to 1 GRAM of nicotine Essenmacher 3

4 Harms continued 18.4% report that nicotine leaks out of cartridge sometimes/often Exploding batteries/fires Increased respiratory resistance impedance, less exhaled carbon monoxide, Pneumonia CDC Dual use Potential health risks for adolescents, pregnant women, non-smokers Not FDA approved, not harmless Possible benefit might be if people who use ENDS completely quit tobacco (CDC, 2015; Vardavas et al., 2012) Youth and ENDS Among high school youth, ENDS use tripled between 2013 (4.5%) and 2014 (13.4%) Middle school students increase ENDS use: 1.1% (2013) to 3.9% (2014) 13% high school students used ENDS compared to 9% cigarette use) Enjoy the taste Sweet Tarts and Unicorn Puke FDA Growing health risks Adolescents using Associated risks from liquid Require registration with FDA and report all product ingredients Require childproof caps on ENDS liquids Warning labels on products & advertisement Prohibit youth-oriented marketing and sales Prohibit child-friendly ENDS flavors Prohibit ENDS where smoking prohibited. MAJOR STAKEHOLDERS Findings and Positions Surgeon General No evidence that they work Growing use by adolescents Research Regulation Public health concerns Essenmacher 4

5 American Industrial Hygiene Association American Lung Association Additional chemicals delivered to lungs Environmental pollution occurs Substances other than nicotine are being smoked Does not recommend using until further research Ban use indoors due to passive smoke exposure Nicotine not safe Increased use by adolescents who are at high risk Detectable levels of toxic chemicals Diacetyl & lung disease Second hand exposure Attractive nuisance Concerned about the impact of use, especially by adolescents World Health Organization High level of dual use No evidence that people quit Less toxicants but still too much Recommends regulation American Association for Cancer Research & American Society of Clinical Oncology Concerns for use by oncology patients Dual use Need for research Support federal, state, and local regulation of ENDS Passive smoke exposure American Nonsmokers Rights Foundation Confusion about right to use ENDS in smoke free areas Public health concerns from exposure to second hand ENDS smoke ENDS should be regulated the same as smoked tobacco STAKEHOLDERS S CDC Potential health risks Not harmless FDA Growing use by vulnerable population Regulation starts Fall 2016 SURGEON GENERAL American Industrial Hygiene Association American Association of Cancer Research & American Society of Clinical Oncology American Nonsmokers Rights Foundation No evidence that they work, growing health concerns Source of environmental pollution Health concerns Significant public health concern due to second hand smoke Research: regulation Ban from smoke free zones Local, state and federal regulation Should be considered the same as smoking tobacco & banned from smoke free zones American Lung Association Public health concerns Should be regulated Essenmacher 5

6 Nursing Implications: What to Tell Patients Because clinical studies about the safety and effectiveness of these products have not been well studied, we have no way of knowing: Whether e-cigarettes are safe for their intended use What types of concentrations of potentially harmful chemicals are found in these products TDB ENDS Outcomes & Next Steps Summary of Evidence Position Paper Publication ENDS information handouts for nurses Suggestions How much nicotine they are inhaling when they use these products (emphasize advertised content vs. fact) Nursing Implications: What to Tell Peers (suggestion ) Questions? (In addition to previous slide): I can t vouch for their safety. I am not in the habit of recommending devices when there is still so much unknown about them. Nicotine is very clearly harmful to the developing human brain and is not recommended for use in persons under the age of 18 (ideally 25). Therefore it is also harmful to a pregnant women s fetus. 35 APNA Tobacco Dependence Branch (TDB) ENDS Committee Members Lisa Atwa Carolyn Baird Patricia Black Leigh Powers Rhonda Schwindt Marie Smith Contact Information Carol Essenmacher DNP, PMHCNS-BC, CTTS quittobaccorn@gmail.com carolessenmac@gmail.com Sonia Duffy Carol Essenmacher Madeline Naegle Matthew Tierney Dorothy Valin Bridgette Vest Carolyn Baird, DNP, RN-BC, CARN-AP, CCDPD, FIAAN cb@counselingandtraumaservices.com Essenmacher 6

7 References American Industrial Hygiene Association. (2014). White paper: Electronic cigarettes in the indoor environment. Available at: Brandon, T. H., Goniewicz, J. J., Hanna, N. H., Hatsukami, D. K., Herbst, R. S., Hobin, J. A., & Warren, G. W. (2015). Electronic nicotine delivery systems: A policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology. Clinical Cancer Research. 21(3), CDC. (2015). E-Cigarette use among teens tripled from 2013 to Available at: CDC Office on Smoking and Health. (2015). E-cigarettes: An emerging public health challenge. Available at: Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-Cigarettes: A scientific review. Circulation, 129, Prochaska, J. J., & Grana, R. (2014). Tobacco use among middle and high school students: U.S., MMWR Weekly Report, 65(14), Shaw, D. M. Etter, J., & Elgar, B. (2015). Should academic journals publish e-cigarette research linked to tobacco companies? Addiction, 111, Vardavas, C., Anagnostopoulos, N., Kougias, M., Evangelopolou, V., Connollly, G., & Behrakis, P. (2012). Short-term pulmonary effects of using an electronic cigarette: Impact on respiratory flow resistance, impedence, and exhaled nitric oxide. Chest, 141(6), Williams, R. S., Derrick, J., & Ribisi, K. M. (2015). Electronic cigarette sales to minors via the internet. JAMA Pediatrics, 169(3), e1563. doi: /jamapediatrics Images Slides 6 & 7, From public domain: CDC Public Health Grand Rounds: Essenmacher 7