E-CIGARETTES: IMPLICATIONS FOR PUBLIC HEALTH POLICY AND PRACTICE
Promoting a Healthier Wyoming ● September 19, 2019
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
MICHAEL A. TYNAN PUBLIC HEALTH ANALYST, OFFICE ON SMOKING AND HEALTH 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? GOOD NEWS: CIGARETTE SMOKING IS DOWN…
40
35 Adults 18+ High School Students 30
25
prevalence (%) prevalence 20
15 smoking
10 Cigarette Cigarette 5
0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: Adult cigarette smoking prevalence data are from the National Health Interview Survey (NHIS). High school cigarette smoking prevalence data are from the National Youth Risk Behavior Survey. …AND THE TOBACCO PRODUCT LANDSCAPE CONTINUES TO EVOLVE
Cigars, Cigarillos Cigarettes Little Cigars
Smokeless Pipes
Tobacco Products Snus Hookah
Bidis Dissolvables Kreteks E-cigarettes
Heated Tobacco Products THE EVOLUTION OF E-CIGARETTES E-CIGARETTE MARKET SHARE, BY DOLLAR SALES, US, 2013 - 2018
80%
70% JUUL Market Share rose to over 75% in 2019
60%
50% cigarette Dollar Sales Dollar cigarette - 40%
Total E Total 30%
20% Percent of Percent 10%
0% 2013 Population2014 Web2015-based cross-sectional2016 2017Retail Sales 2018 2019 Based surveyYear Altria British American Tobacco Imperial Tobacco Japan Tobacco DataJUUL Labs… Other Surveys
Source: King, Brian A, The Rise of the Pod Mod: Trends in E-Cigarette Sales in the US, 2013-2017. Paper presented at: 25th Annual Meeting of SRNT; February 2019; San Francisco, CA. CURRENT TOBACCO PRODUCT USE AMONG U.S. HIGH SCHOOL STUDENTS – (2011–2018)
20.8%
Cigarette 15.8%
Cigar 11.6%
Smokeless 7.9% 8.1% 7.6%
Hookah 4.1% 5.9% Pipe 4.0% 4.1%
E-cigarette 1.5% 1.1%
2011 2012 2013 2014 2015 2016 2017 2018 YEAR
Source: Gentzke AS et la.. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68(6):1-8. A VARIETY OF POD MODS CONTINUE TO ENTER THE U.S. MARKETPLACE
MarkTen Elite myBlu Vuse Alto Myle Phix (Altria) (Imperial Tobacco) (RJR)
Source: CampaignSuorin for TobaccoDrop-Free Kids Suorin Air KandyPens Feather Daze MFG ZOOR 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? WHAT CAUSES YOUTH E-CIGARETTE USE?
Advertising Flavors Nicotine YOUTH EXPOSURE TO E-CIGARETTE ADVERTISING EVOLUTION OF E-CIGARETTE MARKETING
"We don’t think a lot about addiction here because we’re not trying to design a cessation product at all…anything about health is not on our mind”
JUUL R&D Engineer, quoted in The Verge, April 2015
2015 2018
Source: https://www.theverge.com/2015/4/21/8458629/pax-labs-e-cigarette-juul; The Washington Post, July 19 2018 USE OF FLAVORS IS PROMINENT AMONG YOUTH
35 Unflavored or unknown Flavored 30
25
20 PERCENTAGE 15
10
5
0 2014 2015 2016 2017 2018
Source: Cullen et el. National Conference on Tobacco or Health. 2019. NICOTINE SALTS ALLOW HIGH LEVELS OF NICOTINE TO BE INHALED MORE EASILY
Free Nicotine 00 Benzoic Acid Base Salts Nicotine JUUL CONTAINS A HIGH AMOUNT OF 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? CURRENT E-CIGARETTE USE AMONG U.S. HIGH SCHOOL STUDENTS – BY SEX (2011–2018)
Female Male 25
20
15
PERCENTAGE 10
5
0 2011 2012 2013 2014 2015 2016 2017 2018
Source: Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019;68:157–164. CURRENT E-CIGARETTE USE AMONG U.S. HIGH SCHOOL STUDENTS – BY ETHNICITY (2011–2018)
30 White, non-Hispanic Black, non-Hispanic Hispanic Other race, non-Hispanic
25
20
15
PERCENTAGE 10
5
0 2011 2012 2013 2014 2015 2016 2017 2018
Source: Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco Product Use Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019;68:157–164. CURRENT ELECTRONIC TOBACCO PRODUCT USE AMONG U.S. HIGH SCHOOL STUDENTS – BY STATE, YRBS 2017 JUUL USE AMONG U.S. YOUNG PEOPLE (February – May, 2018)
12 11 10 10
8 8
6 6 5
4
3 3 PERCENTAGE 2 1
0 15-17 years 18-21 years 22-24 years 25-34 Ever Use Current (Past 30 Day) Use
Source: 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. FREQUENCY OF YOUTH E-CIGARETTE USE, 2015-2017
60 50.8 50 41.3 40
30
PERCENTAGE 20.1 20 17.6 12.1 9.9 10.7 10.5 8.9 10 8.6 4.2 5.3 0 1-2 days 3-5 days 6-9 days 10-19 days 20-29 days All 30 days Middle School High School
Source: Anic GM, Sawdey MD, Jamal A, Trivers KF. Frequency of Use Among Middle and High School Student Tobacco Product Users — United States, 2015–2017. MMWR Morb Mortal Wkly Rep 2018;67:1353–1357. EVER USE OF CANNABIS IN AN E-CIGARETTE AMONG YOUTH E-CIGARETTE USERS - NYTS, 2016
0 5 10 15 20 25 30 35
Overall Middle school High school Female Male White, non-Hispanic Other non-Hispanic Black, non-Hispanic Hispanic
Source: Trivers KF et al. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth. JAMA Pediatr. 2018;172(11):1097-1099. CURRENT E-CIGARETTE USE AMONG U.S. ADULTS, 2014-2018
3.7 3.5 3.2 3.2
2.8 Percentage
2014 2015 2016 2017 2018
Source: National Health Interview Survey 2014-2018 EVER USE OF E-CIGARETTES AMONG CURRENT, FORMER, AND NEVER ADULT CIGARETTE SMOKERS — 2010-2018
60 Current Cigarette 53.5 Smoker 50 50.3 46.7 Former Cigarette 44.9 Smoker 45.2 40 36.5 30 31.2 24.7 21.2 19.3 20 16.3 17.8
Percentage (%) Percentage 14.7 9.6 10 9.8 6.1 7.4 5.7 5.9 6.7 8.6 2.5 4.7 1.3 2.3 1.2 0 1.3 2010 2011 2012 2013 2014 2015 2016 2017 2018
Source: CDC licensed data fielded by Porter Novelli Services. Summer Styles Survey. 2010-2018 USE OF E-CIGARETTES SHAPED LIKE USB FLASH DRIVES AMONG U.S. ADULTS, 2018
50 45.9 45 Ever Use Current (Past 30 Day) Use 40 35.6 34.3 35 30 25.7 25 20 15 10.3 10 7.9 8.3 7.5 6.8 3.4 5 2.0 2.2 1.8 2.4 2.4 3.0 1.0 0.2 0
Source: Marynak K, Ali FR, Schauer G, Tynan M, King B. Ever Use, Current Use, and Reasons for Use of Electronic Cigarettes Shaped Like USB Flash Drives among US Adults, 2018. Poster presented at: 25th Annual Meeting of the Society for Research on Nicotine and Tobacco; February 2019; San Francisco, CA. RELATIONSHIP BETWEEN CIGARETTE SMOKING AND E-CIGARETTE USE
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. 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 AMONG ADULTS
“Overall, the USPSTF found the evidence on Conclusion 17-1. Overall, the use of ENDS as a there is limited evidence “The long-term safety of smoking cessation tool in that e-cigarettes may be e-cigarettes is unknown.” adults, including effective aids to promote pregnant women, and smoking cessation. adolescents to be insufficient.”
Source: Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010216. www.uspreventiveservicestaskforce.org. Final Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. U.S. Preventive Services Task Force. September 2015.. The National Academies of Science, Engineering, and Medicine. Public Health Consequences of E-cigarettes. 2018. E-CIGARETTES MAKE AEROSOL, NOT VAPOR
E-CIGARETTES MAKE AEROSOL, NOT VAPOR E-CIGARETTE POISONINGS
Source: American Association of Poison Control Centers YOUR GUT CAN HANDLE MORE THAN YOUR LUNGS
Some e-cigarette manufacturers claim flavorings are safe because they meet the FDA definition of “Generally Recognized as Safe” (“GRAS”)
GRAS does not apply to products that are not food NICOTINE POSES UNIQUE DANGERS TO YOUNG PEOPLE
Chapter 3 Conclusion 1, 2, & 5 SURGEON GENERAL’S ADVISORY ON E-CIGARETTE USE AMONG YOUTH (2018)
https://e-cigarettes.surgeongeneral.gov/ POTENTIAL HEALTH RISKS OF E-CIGARETTES
Leads to Exposes initiation of children, Leads to Diminishes Discourages Results in combustible pregnant Glamorizes relapse the chances smokers poisonings tobacco use women, or among that a from using among among non- and non- renormalizes former smoker will proven quit users or smokers, users to tobacco use smokers quit methods non-users particularly secondhand children aerosol 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? 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 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.”
Source: US Department of Health and Human Services. The health consequences of smoking–50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. EVERYONE HAS A ROLE IN ADDRESSING YOUTH E-CIGARETTE USE
States, communities, tribes, Teachers Health professionals Parents and territories
• Implement evidence-based population-level strategies to reduce e-cigarette use among young people, such as including e-cigarettes in smoke-free indoor air policies, restricting young peoples’ access to e-cigarettes in retail settings, licensing retailers, implementing price policies, and developing educational initiatives targeting young people. • Implement strategies to curb e-cigarette advertising and marketing that are appealing to young people. • Implement strategies to reduce access to flavored tobacco products by young people. E-cigarettes are a tobacco product that produces an aerosol Whatby heating aAre liquid thatThey? typically 1 contains nicotine, flavorings, and other chemicals.
Several factors have contributedWhy toAre the popularity They of e-cigarettes, including 2 advertising and the vast array of availablePopular? flavors.
E-cigarette use is higher among young people than adults. As of 2014,Who’s e-cigarettes Using were the most 3 commonly used tobacco product among U.S.Them? youth.
Youth use of e-cigarettes is unsafe. Adult smokers must 4 completelyAre They quit to realize Safe? 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? Michael A. Tynan Office on Smoking and Health [email protected]
www.cdc.gov/tobacco
For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.