Emerging Issues in Tobacco Control: The Rise of Electronic Products and Implications for Policy, Planning, and Practice
BRIAN A. KING, PHD, MPH DEPUTY DIRECTOR FOR RESEARCH TRANSLATION OFFICE ON SMOKING AND HEALTH Wisconsin Department of Health Services ● January 15, 2019
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
The Bad News: The Landscape Is Evolving
Cigars, Cigarillos Cigarettes Little Cigars
Smokeless Pipes
Tobacco Snus Hookah
Bidis Dissolvables
Kreteks E-cigarettes
Heated Tobacco Products E-cigarettes: A Rapidly Diversifying Class The Rise of JUUL Additional USB-shaped e-cigarettes are increasingly available -- Brand examples
MarkTen Elite (Altria) myBlu (Imperial Tobacco) Vuse Alto (RJR) “Coming Soon”
Myle Phix SmokTech’s “Fit” Vapeccino’s MATE1 Coilart’s UME
Source: Campaign for Tobacco-Free Kids Additional E-cigarette Shapes
Suorin Drop Suorin KandyPens’ Daze Air Feather Mfg’s ZOOR
Source: Campaign for Tobacco-Free Kids What Are “Heat Not Burn” Products?
Contain Tobacco
Throat Hit Similar to Cigarettes Crosswalking Heated Tobacco Products, E-cigarettes, and Conventional Cigarettes
Characteristics* HTPs E-cigarettes Manufactured Cigarettes Electronic
Flame-activated
Contain tobacco leaf
Can deliver nicotine
Produce secondhand emissions Produce smoke
Can deliver marijuana
*Sometimes or always 10 HTPs Pending FDA Pre-Market Approval
A scientific advisory committee met to discuss the MRTP application in January 2018.
Philip Morris International submitted applications to FDA for approval to: • Market iQOS (“Premarket Tobacco Product Application” or PMTA) • Make health claims (“Modified Risk Tobacco Product” application or MRTP)
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
Youth E-cigarette Initiation and Use
Advertising Flavors Nicotine Youth Exposure to E-cigarette Advertising Use of Flavors is Prominent Among Youth
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
Ever Use of E-cigarettes Among Adults, by Cigarette Smoking Status—U.S., 2010-2017
60 Current Cigarette Smoker 53.5
50 Former Cigarette Smoker 50.3 44.9 46.7 Never Cigarette Smoker 40
36.5
30 31.2 Percentage (%) Percentage 21.2 17.8 20 16.3 19.3 14.7 9.6 10 9.8 7.4 5.7 6.7 5.9 4.7 6.1 2.5 1.3 2.3 1.2 1.3 0 2010 2011 2012 2013 2014 2015 2016 2017 Year
Source: CDC. Styles Survey. 2010-2017 A Majority of Adult E-cigarette Users Also Smoke Conventional Cigarettes Cigarette smoking status among current adult e-cigarette users, by age group
Source: QuickStats: Cigarette Smoking Status Among Current Adult E-cigarette Users, by Age Group — National Health Interview Survey, United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1177. Current Use of E-cigarettes and Any Tobacco Product Among Middle and High School Students— NYTS, US, 2011–2018
Source: Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018;67:1276–1277. JUUL use, access points, and misperceptions among young people
1 in 5 middle and high school students have seen JUUL used 11 at school 10
8
6 3 in 4 youth who used JUUL say they got the device from a physical retail location
15-17 18-21 63% of JUUL users ages 15-24 Ever Use Current Use did not know nicotine is always in the device
Source: Willett JG, Bennett M, Hair EC, et al Recognition, use and perceptions of JUUL among youth and young adults Tobacco Control Published Online First: 18 April 2018. Vallone DM, Bennett M, Xiao H, et al.Prevalence and correlates of JUUL use among a national sample of youth and young adults Tobacco Control Published Online First: 29 October 2018. doi: 10.1136/tobaccocontrol-2018-054693
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
Net Public Health Benefit or Harm?
Youth Initiation Adult Cessation E-Cigarette Use As A Smoking Cessation Tool in Adults
“Overall, the USPSTF found the evidence on the use of “The long-term safety of ENDS as a smoking cessation e-cigarettes is unknown.” tool in adults, including pregnant women, and adolescents to be insufficient.”
Conclusion 17-1. Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation.
Source: The National Academies of Science, Engineering, and Medicine. Public Health Consequences of E-cigarettes. 2018. www.uspreventiveservicestaskforce.org
Potential Health Risks of E-cigarettes
Leads to Exposes initiation of Leads to Diminishes Discourages children, Results in combustible relapse the chances smokers pregnant Glamorizes poisonings tobacco use among that a from using women, or among among non- and non- renormalizes smokers, former smoker will proven quit users to tobacco use users or particularly smokers quit methods secondhand non-users children aerosol Nicotine salts allow particularly high levels of nicotine to be inhaled more easilyJuul andContains with less irritationNicotine than Salts free base nicotine
Benzoic Acid
Nicotine Free00 Base Salts Nicotine
1 What Are They?
Why Are They 2 Popular?
Who’s Using 3 Them?
4 Are They Safe?
What Can We 5 Do About it?
Major Conclusion #7
“Action can be taken at the national, state, local, tribal, and territorial levels to address e-cigarette use among youth and young adults. Actions could include incorporating e-cigarettes into smoke- free policies, preventing access to e- cigarettes by youth, price and tax policies, retail licensure, regulation of e-cigarette marketing likely to attract youth, and educational initiatives targeting youth and young adults.” Public Health Actions to Address E-Cigarettes
Federal Regulation State, Local, Territory Family Smoking Prevention Potential Sub-National Action: and Tobacco Control Act
• Signed into law on June 22, 2009 • Including e-cigarettes in smokefree • Granted FDA the authority to indoor air policies regulate tobacco products • Restricting youth access to e-cigarette • Enhanced the ability to intensify in retail settings policy to reduce tobacco industry • Licensing retailers influence: • Establishing specific package • Manufacturing requirements • Marketing • Setting price policies • Sale
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Several factors have contributedWhy toAre the popularity They of e-cigarettes, including 2 advertisingPopular? and the vast array of available flavors.
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Youth use of e-cigarettes is unsafe. Adult smokers must completelyAre They quit to realize Safe? 4 benefits from e-cigarettes.
As the tobacco product landscape continuesWhat to diversify, Can it’s We important to modernize tobacco 5 controlDo strategies About to adapt. it?