CADCA Mid-Year Training Institute

Whats Trending in
Tobacco: E-cigarettes
Wednesday, July 23, 2014 - Orlando, FL

Christine Cheng, Partner Relations Director

Overview
History: invented by a Chinese pharmacist
in 2003

Rapid evolution of devices: a moving target

Poll questions

YouTube videos:
from Consumer Reports, http://
www.youtube.com/watch?v=100b-l_0z9s
from CNN, http://
www.youtube.com/watch?v=EqvlxEQaQn 2
E
Poll Questions
1.Show of hands, how many have
tried an e-cigarette?

2.How open are you to discussing

the potential benefits and risks of
e-cigarettes as a smoking
cessation tool?

3.Are you willing to incorporate e-

cigarettes into a smoking 3
cessation treatment plan?
E-cigarette Devices
Currently Available

4
Components of E-
Cigarettes

Clearomiz
er
Battery 5
Battery
Fluids Contain
Many come premixed from China, but some
are now made in the US and Europe
Origins and quality of the ingredients are
generally not known
Fluids* may contain:
Nicotine (in varying concentrations 0-100 ml/mg)

Humectants: propylene glycol (or vegetable

glycerin) for vapor production

Flavorings (tobacco, menthol, coffee, vanilla, fruit,

cotton candy, etc.)

*Metals particle have also been found in the fluids 6

Harmless Vapor

7
 E-cigarette fluid and vapor contains toxic metals and
nanoparticles
Vapor contains tobacco-related toxins and chemicals
less than cigarettes, more than nicotine inhaler
Formaldehyde
Acrolein
Acetaldehyde
VOCs
NNN and NNK
Exposure studies - Puff Topography not
accounted for 8

Goniewicz et al, Tobacco Control

2013
9
E-cigarette Users Exhale

10
Look Familiar?

11

Videos from www.smokestik.com Image

from www.ecigaretteschoice.com;
www.v2cigs.com
12
What Attracts and
Sells

13
http://
www.npr.org/2014/03/03/284006424/e-cigarette-critics-wor
ry-new-ads-will-make-vaping-cool-for-kids
Cost Savings Claims

14
http://
tobacco.stanford.edu/tobacco_main/index.p
15
 Prevalence of E-cigarette Use:
Smokers and Recent Ex-smokers
50
45 Growth in prevalence of e-
40 cigarette use may have slowed
35 An
30 y
25
Percent
20of smokers and recent ex-smokers
15
10
5
0

N=11,666 adults who smoke or who stopped in the past year; increase p<0.001 16

www.smokinginengland.info/latest-statistics/
Clinical
Scenario #1
Im a heavy smoker and both
my parents were smokers who
died of lung cancer. Ive tried
all the meds but never quit for
more than a week. Ive heard
that e-cigarettes can help
smokers to quit and I really
want to give it a shot. What can
you tell me about them?
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 Clinical Scenario #1
Response
1. Support Quit Attempt
2. Assess motivation and
dependence
3. Assess prior quit attempts and
inform about all
treatment/support options
4. Inform on what we know and what
we dont know about e-cigarettes
5. Assist smoker to develop a plan to 18
quit smoking
6. Arrange a follow-up
 Clinical
Scenario #2
50 y.o. primary care patient with back pain,
hypertension, hyperlipidemia, depression
and PTSD, here for routine follow up,
incidentally noted she is still smoking 3 to
5 cpd, reduced from 10 cpd
She quit once cold turkey for 9 months 2
years ago
not interested in any medications,
counseling, or nicotine replacement
She is willing to set a quit date in the next
30 days (her sons birthday) and remarks, 19
Maybe Ill get one of those electric
cigarettes to quit, what do you think?
not interested
Ive tried everything
Frequently NRT misused or incorrectly used
Unassisted quit attempts
Correct misperceptions of approved
therapies
Correct misperceptions of e-
cigarettes
Treat Depression, PTSD
Shiffman S, Ferguson SG, Rohay J, Gitchell JG. Perceived safety and
efficacy of nicotine replacement therapies among US smokers and 20
ex-smokers: relationship with use and compliance. Addiction. 2008
Aug;103(8):1371-8
 Clinical Scenario #2
Response
1. Opportunity to engage patient in
counseling
2. This is a light smoker
3. Significant psychiatric history
4. ASK: why is she interested in e-
cigarette?
5. What does she think is different
from approved therapies?
6. History of past quit attempts and 21
assistance?
Clinical Scenario #2
Follow Up
This patient ended up with
Nicotine inhaler prescription (unfilled)
Quit with nicotine gum and
counseling on proper use
Saw a therapist to help manage
stress
Remains tobacco free today

22
 Clinical
Scenario #3
21 y.o. female presents for work physical
for restaurant job. Denies significant
past medical history except asthma,
treated with Albuterol (once or twice a
day)
Denies smoking. Drinks 4-5 alcoholic
drinks on weekends. Has been using a
vapor pen when out at parties
sometimes.
She lives with her mom and 5 siblings.
Mom (39) recently quit smoking using
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an e-cigarette, which she continues to
use.
 Clinical Scenario #3
Background
1. Screening challenges
2. Binge drinkers frequently smoke
3. May present themselves as
nonsmokers
4. Need to screen specifically (only
smokes when drinks)
5. Vapor pens = e-cigarettes
6. Also e-hookah, vapes, sticks, hookah
pens
7. Recreational use common 24

8. Young adults have highest rates of

25
23 million likes on FB
10 million Twitter
followers

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 Clinical Scenario #3
Asthma
1. Inadequately controlled
2. Personalized reason not to smoke
or be exposed to secondhand
smoke or aerosol
3. One study found acute pulmonary
effects
4. 5 minutes of e-cigarette use in
healthy smokers increased airway
resistance
27
5. Unknown clinical significance
6. May affect susceptible people
 Clinical Scenario #3
Response
1. Discourage recreational vapor
pen use
2. Personalize to patients medical
conditions
3. Fetal exposure to nicotine not
harmless
4. Support moms quit attempt!
5. Preserve smoke and vapor free
homes 28
6. E-cigarettes are not harmless toys
 Average 1 per month increased to 215/month
Most common adverse events were vomiting,
29
nausea, and eye irritation
Advice for Provider
Screen for poly tobacco use including e-
cigarettes
Field and devices are rapidly evolving
Engage with new opportunities to
discuss smoking cessation
Misinformation and false claims are
rampant
Data are scarce
Continue to recommend approved NRTs
30
and Rx
Monitor use in your clients, document
Advocacy and Coalition
Action
Include e-cigarettes in tobacco free
policies
Prohibit cessation and health claims
Apply cigarette advertising restrictions
to electronic cigarettes

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Last Words

32

www.blucigs.com,
 Contact SCLC for Technical
Assistance
Visit us online
http://smokingcessationleadership.ucsf
.edu

Call us toll-free
1-877-509-3786

Christine Cheng
email: ccheng@medicine.ucsf.edu
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