Tobacco and Nicotine Products "The Times They are A'Changing" FOMA, 2019 NOVA SOUTHEASTERN UNIVERSITY AHEC Dr. Nevin Zablotsky 1
Cigarette Usage in U.S.A 1955 Ages Percentage 21-24 51.4% 25-34 63.4% 35-44 62.1% 45-54 56.9% 55-64 43.6% All ages 52.6% H.Wentzel.W,Green,D National Clearinghouse for Smoking (60,62,64)
Cigarette Usage in U.S.A 2018 Ages Percentage 21-24 13.1% 25-44 17.6% 45-64 18% >65 8.8% Total: 15.1% C.D.C 2018 5
Florida Tobacco Fast Facts 2,701,900 Adult Smokers 16.1% Tobacco Free Kids November 2018
Florida Tobacco Costs $8.64 billion dollars annual costs directly related to smoking $8.32 billion dollars lost in productivity
Tobacco History First Cultivated 5000-3000B.C in Peruvian/Ecuadorian Andes
Tobacco Total of 64 species of tobacco plant Two used by man Nicotiana rustica Nicotiana tabacum
Tobacco Nicotiana rustica Strong and harsh 20x more nicotine than tabacum Eastern Europe and Asia Used by S. American shamans
Tobacco Nicotiana tabacum Milder Multiple varieties Used in most cigarettes
History continued Tobacco shamans doctor-priests Use tobacco in religious rites and as medical treatment
Tobacco continued Usage Also used as mild analgesic and antiseptic Treated toothaches by wrapping leaves around tooth Leaves or juice applied to wounds
History continued Jean Nicot, 1559 French Ambassador to Portugal, distributes tobacco seeds throughout Europe Agrees with Dr. Monardes and extols its ability to cure cancer, bad breath, toothaches, migraines, kidney stones, dandruff, tapeworms Nicotine, the addictive drug in tobacco named in his honor
James Buck Duke 1889 Age 33 of North Carolina forms American Tobacco Company
Cigarette Production Skilled hand roller produced 200 cigarettes in one hour
We Can Now produce 20,000 Cigarettes a Minute
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Tobacco and Nicotine Products
Cigarettes It takes 5 seconds for a hit to reach the brain
Chemicals In Cigarette Smoke 7,000 chemicals, 80 Carcinogens Benzene Formaldehyde Strychnine Polonium 210
Tobacco Fast Facts: WHO 2017 1.2 billion people smoke cigarettes in the world
Prevalence C.D.C 2018 U.S Cigarette Adult Smoking Rates 37.8 million people 18 years or older 15.5% 16 million Americans live with a smoking-related illness 34
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Cigars - Prevalence In 2017, 12.3 million people aged 12 or over smoked cigars in the U.S 9% of high school boys used cigars 6.3% of high school girls used cigars 1.5% middle school students
Cigars All cigar smokers, whether they inhale or not are exposed to smoke and its toxic and cancer-causing chemicals affecting Lips Tongue Throat https://www.cancer.gov/about-cancer/causesprevention/risk/tobacco/cigars-fact-sheet National Cancer Institute
Smokeless Tobacco It takes 3-5 minutes for a hit to reach the brain
Smokeless Tobacco 3,000 Chemicals of which 28 are known carcinogens Arsenic Cyanide Polonium 210 (Nuclear Waste)
Snuff Tobacco Finely ground moist firecured tobacco Comes in pouch or can Tuck pouch or shreds between cheek and gums Buffered to alkaline ph that is easily absorbed
Smokeless Tobacco Comes in several forms Snuff or Snus Chewing(Dip,Pinch,Rub) Orbs, Sticks, Strips
SNUS Swedish word for snuff Scandanavian Snus is steampasteurized moist powdered tobacco Less nitrosamines Small bit placed in upper lip Not spit out
Chewing Tobacco Loose leaf Twist Plug
Smokeless Tobacco Dip or chewing 8 to 10 times per day equals the nicotine of smoking 30 to 40 cigarettes a day.
Smokeless Tobacco Camel Orbs Camel Sticks Camel Strips 0.6-3.1mg nicotine
Electronic Nicotine Delivery Systems
E-Cigarettes
E-Cigarettes First developed in China in 2003 by Hon Lik, Chinese pharmacist In response to losing his father to lung cancer Look for safer way to get nicotine
What Are They? Battery-powered nicotine delivery systems that produce heated aerosol instead of smoke 59
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Usage Slow steady draw to fill mouth and hold for 3-5 seconds Inhale in lungs and exhale through nose and mouth Will feel hit in about 30 seconds After 3-7 draws take a short break
The Hype Are E-Cigarettes Safer To Use Than Cigarettes?
The Hype Are E-cigarettes Effective Smoking Cessation Aids?
So They Promote Them
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N.Y Times: April 14, 2014 Major producers targeting young people Giving away free samples at music events and sporting events Running advertisements on radio and television on youth oriented programs 73
CDC / E-Cigarette and Vaping It is estimated that 10.8 million adults in the U.S are vaping
Noncigarette Tobacco Products and Future Use of Cigarettes in Youth JAMA 1/2/18 Use of e-cigarette,hookah,non-cigarette combustible tobacco, or smokeless tobacco Youth using any of these producets are more likely to use cigarettes one year later Using more than one of these products even more likely to use cigarettes
Flavoring Chemicals in E- Cigarettes 7,000 e-cig flavorings presently on the market Harmful chemicals now being detected Diacetyl 2,3-Pentanedione Acetoin 83
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E-Cigs F.D.A has analyzed samples Some contain propylene glycol Nitrosamines Toxic chemicals Carcinogens Tobacco
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Death of First Child From Liquid Nicotine McClatchy Washington Bureau January 13,2015 BY LINDSAY WISE The 1-year-old boy died in Fort Plain, NY, on December 9 after ingesting liquid nicotine. Local police said the death appeared to be a accident. Child s death revives call for federal government to regulate liquid nicotine for e-cigarettes 88
Int J Environ Res Public Health. 2018 Jan; 15(1): 75. "At present, the research on E- cigarettes is fragmentary and incomplete, and there has been no systematic review of its safety "
Feb. 6th 2019 American Stroke Association International Stroke Conference Survey finds compared to non-users E-cigarette users had a 71 percent higher risk of stroke 59 percent higher risk of heart attack 40 percent higher risk of heart disease.
E-Cigs No Scientific Proof Yet of Their Safety
Are E -Cigarettes a Real Tobacco Cessation Aid? 95
Dual Use A 2018 report from the National Academies of Sciences, Engineering, and Medicine showed Among adults in, 58.8 percent of e- cigarette users also smoked cigarettes. Among young adults in, 40 percent of e- cigarette users also smoked cigarettes 96
American Lung Association 2019 The FDA has not found any e-cigarette to be safe and effective in helping smokers quit. If smokers are ready to quit smoking for good, they should call 1-800- QUITNOW or talk with their doctor about finding the best way to quit using proven methods and FDA-approved treatments and counseling.
2019 NEJM: E-Cigarettes Vs. Traditional NRT as Effective Cessation Aids A year long, randomized trial in England with 885 subjects used either e-cigarettes or traditional nicotine replacement therapies. Both groups also participated in at least four weekly counseling sessions They noted that 80 percent of the study participants who had quit by using e-cigarettes were still vaping at one year, while only 9 percent of the NRT group was still using nicotine products.
Positive Cessation Aid? Both groups also participated in at least four weekly counseling sessions, an element regarded as critical for success. They noted that 80 percent of the study participants who had quit by using e- cigarettes were still vaping at one year, while only 9 percent of the NRT group was still using nicotine products.
Big Tobacco Enters the Scene
E-Cigarette Finances Blu Ecigs founded in 2009 Blu Ecigs sold to Lorillard in 2012 for $135 million dollars Becomes first big tobacco company to enter the e- cigarette market
E-Cigarette Finances R.J Reynolds buys Lorillard in 2015 for $29.5 billion dollars includes Blucigs, Kool, Winston, Salem and Maverick brands
JUUL JUUL's hardware is made in Shenzhen, China The JUUL pods are made in the United States Highly concenterated nicotine vaporizer User inserts flavored pod into stick
Nicotine/Nicotinic Salts
Nicotine First isolated in 1828 in Heidelberg Clear liquid, poisonous alkaloid Natural insecticide Found in tobacco,also in tomatoes, potatoes, eggplants in insignificant concentrations
Nicotine Nicotine naturally occurs in tobacco as a base In 1960s Phillip Morris scientists added ammonia and created unprotonated (Freebased) nicotine Making it more basic and lipid soluble and easier for it to be absorbed into the lungs
Nicotine Cigarettes and most e-liquids use freebase nicotine Freebase nicotine easily passes through the blood brain barrier Inhaling freebase nicotine is harsh to the mouth and throat
Side Effects of Nicotine
So What are JUULs?
JUUL 2007 Adam Bowen and James Monsees found Ploom Labs They create the PAX vaporizer and introduce JUUL e-cigs in 2015 at PAX Labs and spin off in 2017 to JUUL Labs
Nicotine In 2007 JUUL labs mixes freebase nicotine with benzoic acid creating nicotinic salt in a biologically accepted liquid 112
JUUL/Nicotinic Salts This combination can be absorbed readily and is inhaled smoothly Delivers 2x concentration of nicotine as other e-cigs Speed of "hit" mimics cigarettes
JUUL - Highly Addictive 114 Campaign for Tobacco-Free Kids www.tobaccofreekids.org
JUUL/ CNN Feb.7th 2019 BMJ Journal Tobacco Control: Dr. Robert Jackler Stanford Research In 2015 the majority of companies had 1%-2% nicotine concentration JUUL released it 5% nicotine pods In 2019 competing brands reach into the 5% to 7% range of nicotine concentration "This makes it potently addictive to nicotine-naive teenagers" 115
JUUL In September of 2018 JUULs has a 72% market share of the e- cigarett market
JUUL USA Today Oct. 2017 New vaping has "gone viral" on middle and high school, college campuses Flavors like creme brulee, mango and fruit medley
JUUL Can fill with THC Can be mistaken for a USB stick Can be charged in computer
E-Cigarettes and Vaping September 2018 JUUL labs valued at $15 billion dollars December 2018 Altria purchases a 35% stake in JUUL labs for $12.8 billion dollars JUUL's value equals $38 billion dollars
Nobody is quite sure what to do with those wanting to quit, as this is all so new, said Ira Sachnoff, president of Peer Resource Training and Consulting in San Francisco
E-Cigarette and Vaping
E-cigarette and Vaping
Heat Not Burn Products
History of Heat-Not-Burn Products All of These Products Attempt to Simulate Smoking Cigarettes
History of Heat-Not-Burn Products These systems use heated tobacco not burning tobacco Constituents are heated to 350 degrees fahrenheit and aerosolized Device then removed and smoked like a real cigarette
History of Heat-Not-Burn Products Iqos Glo Ifuse Ploom
Iqos Iqos marketed by Philip Morris International PMI has spent $3 billion dollars developing these types of products
Iqos 1994 launched in Japan and Italy 2016 available in 20 countries As of March, 2017 3 million devices sold in Japan Demand has outstripped supply
January 25th, 2018 FDA advisory panel said PMI should not be able to claim IQOS is safer than smoking PMI still awaiting FDA final decision
Please Don't Forget About the Impact of Cigarettes 136
7 million people in the world die from tobacco related illness per year Every 6 sec. someone dies in the world from tobacco-related use
One Billion People Will Die in This Century From Tobacco Use
Tobacco is the single greatest cause of disease in the U.S and is responsible for 480,000 deaths annually Centers for Disease Control and Prevention
16 Million Americans Live With a Smoking-related Illness
Florida Tobacco Mortality Rates 32,300 deaths directly related to smoking per year 2,960 deaths from 2 nd hand smoke per year Tobacco Free Kids 2018
You Can Make A Difference A brief 3 minute conversation with a health care provider followed by a referral to cessation services can more than double the chances of quitting. Ask every patient about their tobacco use Advise patients of the benefits of quitting Refer to tobacco cessation services Source: Treating Tobacco Use and Dependence Clinical Practice Guideline, 2008 Update USDHHS Public Health Service
Where can you refer patients? Local Group Cessation Programs offered FREE in every county in Florida Group Quit programs offered through your local AHEC and Tobacco Free Florida 877-848-6696, ahectobacco.com Free NRT Patches, Gum, Lozenges Groups facilitated by Tobacco Treatment Specialists Statewide: Tobacco Free Florida s Phone Quit (over the phone counseling) and Web Quit (online cessation program)