* * David S. Goya, DO, MBA, FCCP, FACP Kaiser Permanente Medical center Santa Clara, California
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Electric Cigarette was patented in 1965 by Herbert Gilbert First introduced into the marketplace in China in 2003 The sale of e-cigarettes sold have increased exponentially year by year Wells Fargo has predicted that sales margins for e-cigarettes could grow to 10 billion by 2017 Surpasses conventional cigarette sales margins 3 big tobacco companies have been purchasing independent e- cigarette companies & may share 75% of the profit within 10 years
IN THIS PRESENTATION E-Cigarette Basics Aerosol Contents Health Risks Marketing Tactics Image Credit: via thenounproject.com
E-Cigarette/Vape Pen Basics Image Credit: via thenounproject.com
What Are E-Cigarettes? Nicotine aerosol Battery Atomizer/coil Refillable Cartridge Nicotine Propylene glycol Vegetable glycerin Flavorants Image Credit: Dr. Gideon St. Helen
1st Generation Device Designed to look and feel like traditional cigarette Battery operated, initially composed of 3 components Battery Atomizer Cartridge Designed for single use Available in various nicotine concentration and flavoring
2 nd Generation Device Devices are larger and typically do not resemble cigarettes Sizes, shapes & colors vary widely Large, separate cartridges for liquids and flavorings Larger-capacity, rechargeable batteries, larger atomizers and more powerful electronic circuits Some allow manual control of both puff length and frequency
3 rd Generation Device Similar to the 2 nd generation, but are usually larger & more customizable Contain a range of different cartridge, atomizer and battery options Atomizers produce higher heating temperatures, generating more heat and affecting the amount & quantity of the aerosol Lithium batteries are known to ignite
E-Liquid Ingredients Propylene Glycol Vegetable Glycerin Nicotine Flavoring Image Credit: By TBEC Review via Wikimedia Commons
Propylene glycol Considered non toxic by the FDA. Found in flavorings, drugs, cosmetics and direct food additives 90% of the e-juice is propylene glycol Heating of propylene glycol can generate propylene oxide which is considered a carcinogen Decompose to form formaldehyde & acetaldehyde & levels will depend upon the voltage of the battery used Used in theater smoke and known to cause eye and lung irritation No long term human studies
Vegetable glycerin: FDA generally recognized it as safe Heating of glycerin can form acrolein which is an irritant and oxidizing agent & thought to contribute to adverse pulmonary and cardiovascular effects of cigarette smoking Long term inhalation of glycerin has led to the development of localized mild squamous metaplasia of the upper airways in rats No long term human studies
Nicotine Most e-juice contain either 6,12,18 or 24mg/ml of nicotine Total amount of nicotine in the e-juice will depend upon the size of refill vial 10ml bottle of 24mg/ml will contain 240mg of nicotine 1 regular cigarette will contain 10-15mg of nicotine and delivers a systemic dose of 1mg Difficult to determine the amount of nicotine delivered via e- cigarette Blood levels of nicotine are lower than e-cigarette, but users of some e- cigarettes use more powerful batteries and heaters & may achieve blood levels comparable to regular cigarettes Extent of nicotine absorption via e-cigarette has not been fully determined
Flavorings >7000 flavors available Some studies have found a link between cytotoxicity & certain flavorings used in e-cigarettes Sweet & cinnamon flavors Cherry flavor e-cigarettes have been found to contain benzaldehyde, a compound that has been associated with respiratory irritation Many flavorings contain aldehydes, tobacco-specific nitrosamines, nitrates and phenols which are in lower concentration that those found in conventional cigarettes Among US middle and high school students who currently use e- cigarettes, 63% have used flavored e-cigarettes
E-Cigarette Basics Aerosol Contents Image Credit: via thenounproject.com
E-Cigarettes: Just Water Vapor? NOPE!
Image Credit: via thenounproject.com
E-Cigarette/Vape Pen Aerosol Composition Propylene glycol Glycerin Flavorings (many) Nicotine NNN NNK NAB NAT Ethylbenzene Benzene Xylene Toluene Acetaldehyde Formaldehyde Naphthalene Styrene Benzo(b)fluoranthen e Chlorobenzene Crotonaldehyde Propionaldehyde Benzaldehyde Valeric acid Hexanal Fluorine Anthracene Pyrene Acenaphthylene Acenapthene Fluoranthene Benz(a)anthracene Chrysene Retene Benzo(a)pyrene Indeno(1,2,3- cd)pyrene Benzo(ghi)perylene Acetone Acrolein Silver Nickel Tin Sodium Strontium Barium Aluminum Chromium Boron Copper Selenium Arsenic Nitrosamines, Polycyclic aromatic hydrocarbons Cadmium Silicon Lithium Lead Magnesium Manganese Potassium Titanium Zinc Zirconium Calcium Iron Sulfur Vanadium Cobalt Rubidium
E-cigarettes generate an aerosol that consist of fine & ultra-fine particles in a gas phase The concentration of particles in e-cigarette averaged over different brands and types were similar to conventional cigarettes The number of particles will depend upon liquid nicotine concentration & puffing time It is not known whether the type of particles generated by e- cigarettes have the same toxicity as particles present generated by conventional cigarettes
Toxicant Content in nicotine inhaler mist per 15 puffs Range in content in aerosol from 12 EC samples per 15 puffs Range in content in conventional cigarette micrograms (μg) in mainstream smoke from 1 cigarette Formaldehyde (μg) 0.2 0.2-5.61 1.6-52 Acetaldehyde (μg) 0.11 0.11-1.36 52-140 Acrolein (μg) ND 0.07-4.19 2.4-62 o- Methylbenzaldeh 0.07 0.13-0.71 yde (μg) Toluene (μg) ND ND-0.63 8.3-70 p,m-xylene (μg) ND ND-0.2 NNN (ng) ND ND-0.00043 0.0005-0.19 NNK (ng) ND ND-0.00283 0.012-0.11 Cadmium (ng) 0.003 ND-0.022 Nickel (ng) 0.019 0.011-0.029 Lead (ng) 0.004 0.003-0.057
E-Cigarette Basics Aerosol Contents Health Risks Image Credit: via thenounproject.com
Health Risks to E-cigarette User Image Credit: via thenounproject.com
Limited data E-cigarettes contain chemicals that directly cause airway irritation when aerosolized Animal study showed increased airway inflammation in asthmatic mice when exposed to the vapors from e-cigarettes Small study of 30 healthy volunteers showed an increase in airway resistance when exposed to e-cigarette aerosols Increased evidence of chronic bronchitis among young e-cigarette users
E-cigarettes have been shown to increase the heart rate & blood pressure, but no increased risk of heart attack E-juice may have high cytotoxicity Human embryonic stem cells are the most sensitive when exposed to the aerosols Raises concerns for pregnant women who use e-cigarettes or 2 nd or 3 rd hand exposure Adverse effects of prenatal exposure to nicotine on lung development Nicotine is addictive. Nicotine exposure in adolescence may increase the susceptibility of the brain to dependence on cocaine & other illicit drugs
Nicotine in e-cigarette fluid poses potential for accidental ingestion Typical 5ml vial may contain a nicotine concentration of 20mg/ml Lethal dose of nicotine is 10mg in children and 60mg in adults Most common adverse health effects exposure calls were nausea, vomiting & eye irritation
Can you find the candy?
3rd Hand Smoke Nicotine & other chemicals
E-Cigarette Basics Aerosol Contents Marketing Tactics Health Risks Image Credit: via thenounproject.com
The Usual Suspects
In 2010, 1.8% of US adults reported having used an e-cigarette which rose to 13% by 2013 Current users (used at least once in 30 days) rose from 0.3% to 6.8% during the same period The prevalence of current e-cigarettes usage was highest among current cigarette smokers (16%) & former smokers who quit cigarette in the past year (22%)
Increased experimentation with e-cigarettes among children <18yrs CDC study revealed nearly 1.8 million young people tried e- cigarette and the number of US middle & high school students e-cigarette smokers doubled between 2011 and 2012 Studies have associated e-cigarette use with an increased risk of conventional cigarette smoking among youth E-cigarette use could lead to nicotine dependence
dg1 E-cigarettes surpasses conventional cigarettes in high school students The figure above is a bar chart showing the estimated percentage of high school students who used tobacco in the preceding 30 days, by tobacco product, in the United States during 2011 2014.
Slide 34 dg1 david goya, 5/15/2017
Who is going to replace the old smokers?
YOUNG PEOPLE 88% of adult smokers started before 18
How are e-cigarette manufactures reaching young people?
Trendy Products
Flavors
Targeted Marketing
U.K. Center for Tobacco & Alcohol Studies & University of Geneva s Institute of Social and Preventive Medicine have concluded that e- cigarettes are helpful in reducing or eliminating tobacco use British government s drug regulatory authority approved an e- cigarette as a quit smoking medicine There is no large randomized control studies to prove that e-cigarettes help reduce smoking Largest study of 657 New Zealander smokers were randomized to e- cigarettes (10-16mg nicotine), nicotine patches or non-nicotine e- cigarettes 6 months the quit rate was 7.3% with nicotine e-cigarettes 5.8% with nicotine patch 4.1% non-nicotine e-cigarettes Not statistically significant Dual usage of tobacco & e-cigarettes remained high at 6 months
E-cigarettes may contribute to a modest tobacco cessation effects E-cigarettes does not appear to effect pulmonary function compared to conventional cigarettes Increased in expired CO is found in conventional cigarette users but not in e-cigarette users Increase in WBC, lymphocytes & granulocyte count seen in smokers but not in e-smokers
E-cigarettes have second & third hand effects Components of aerosol can be different from those found in liquid due to heating Nicotine-free e-cigarettes may still contain nicotine Aerosols of e-cigarettes contains various toxic substances in low levels Depending on heating element, the toxic products can exceed the levels of conventional cigarettes Possible concerns of electronic cigarettes on fetal development during pregnancy Concern for potential accidental poisoning or suicide due to the ingestion of e-cigarette fluids
There is limited safety data Variability among different devices Lack of consistency among e-liquid products & product label Increasing in popularity Potential gateway to combustible cigarettes