1 Cherylee Bridges RN Manager, Helpline Operations American Lung Association 3000 Kelly Lane| Springfield, IL 62711

2 New Landscape of Tobacco Products

3 Driven at least in part by the growth of smoke-free air laws and consequent search of smokers for alternative sources of nicotine, our tobacco house now has some new landscape.

4 Products in the New Landscape • Smokeless products • Pouches and Bandits • Snus • Dissolvables • Flavored Cigars • Electronic cigarettes—E-Cigs (ENDS) • Vape pens, e-vaporizers, hookah-pens, e-hookahs, e- cigars • Hookahs

5 6 Presentation Learning Objectives: • State what e-cigarettes/vaping and Hookah pipes are and how they are used.

• State the concerns about e-cigarettes/vaping and Hookah devices from a public health standpoint.

• Articulate how to discuss use/cessation and exposure to vapor with patients and families in a clinical setting.

7 What are electronic cigarettes?

3 Components 1. Power source 2. Heating element 3. Liquid-containing nicotine cartridge

• Electronic cigarettes, also known as e-cigarettes, or ENDS (Electronic Nicotine Delivery System) are battery- operated products designed to deliver nicotine, flavor and other chemicals. • Contain a heating element which turns chemicals, including highly addictive nicotine, into an aerosol that is inhaled by the user into the lungs.

8 • Most e-cigarettes are manufactured to look like conventional cigarettes, cigars, or pipes. • Available in US since 2007

Lorrilard--Blu ad found in the R.J. Reynolds, announced its own line of March 2014 Sport's Illustrated Altria-Marlboro maker electronic cigarettes, called VUSE. Swimsuit Issue advertising their boosts of e-cigarettes and (June 2013) product with an image of the has expanded the MarkTen mid-section of a thin women brand nationally (Feb 2014) wearing a bikini bottom with Blu's logo on it. Underneath the image is text: "Slim. Charged. Ready to Go. Available Nationwide!" and an image of Blu's classic tobacco e-cigarette products.

9 From cigarette to Vapor Pen, an evolution in technology

cigarette shisha pen

Rechargable e-hookah pen Vape pens, e-vaporizers, hookah-pens, Electronic Hookah Vaporizer Pen e-hookahs, e-cigars

10 Use of all E- devices • simulate the feeling of smoking a combustible tobacco product-nicotine effect. • user activates the device by taking slow puffs or pressing a button • User inhales an aerosol/vapor created from the e-juice containing nicotine • Absorbed through mucous membranes, lungs, nose • “hit” takes about 30 seconds compared to 8 seconds for regular smoking.

11 A Quickly changing product…… • First generation-poor battery life, very inconsistent • Second generation-present ones, many manufactured in China( >90%) with lithium ion battery but poor quality control. • Third generation-Vuse and MarkTen, processor controlled for temperature and puff typography. • ? Improved chemosensory effects • ? Improved deposition in the alveoli for arterial absorption

• Appears e-Hookah and vapor pens have gone through similar evolutions • There are currently more than 7,000 varieties of flavored ENDS/devices and e-juice (nicotine-containing liquid that is used in refillable devices) on the market.

12 Hookah

13 14 ENDS/Vaping/Hookah: Public Perceptions and Prevalence • Perceived to be safer than traditional cigarettes • Often used as a perceived cessation aid or used in places where combustible tobacco is not allowed. • Less social stigma associated with use

• Statistics from the CDC, HHS and NCHS report that e-cig use tripled from 2011- 2013 in US youth that have never smoked a cigarette. • CDC Adult Tobacco survey from 2010-2013 showed that % of adults who had ever used e-cig doubled. • CDC also found that vast majority of current e-cig users (76.8%) adult and (76.3%) youth are dual users.

15 What are the Public Health Harms? • Relative to smoked tobacco- • no tar • Relative to NO tobacco or medical NRT • Unclear but concern for decreased lung function • Quality control-adulterated products have been found. • Create new nicotine addiction. Dual use. • Safety of flavor and other e-juice agents when heated and inhaled is unknown. • Acute Nicotine Toxicity

16 17 All that Vapes is not Nicotine…. Constituents of e-juice?-not an easily answered question • Propylene glycol: in general recognized as safe • Acceptable in flavoring, drugs, cosmetics, food additive • Few human studies for inhalation but used as a tobacco humectant. • Can cause eye and respiratory irritation. • MSDS “ inhalation exposure to mists should be avoided.” • Formaldehyde: A probable carcinogen. • Acetaldehyde: Another probable carcinogen. • Nicotine-complex pharmacodynamics-neural stimulant at low doses-depressant at high doses. Doses vary from 1mg/ml up to 42mg/ml

18 • Vegetable glycerin/Acrolein: Formed from heated glycerin, acrolein can damage the lungs and contribute to heart disease in smokers. • All three are released in increasing amounts as the temperature of the e-liquid rises. • Unfortunately, the higher you heat the liquid, the more nicotine you get from it. People who want to get a big dose of nicotine may use really high voltage batteries. • The flavorings mask the unpleasant taste that results when users heat their e-cigarettes to the point at which formaldehyde is made. • For all: Unknown long-term health impacts from repeated inhalation.

19 Other Constituents of e-juice & beyond

• Flavorings and chemosensory agents • Wax/hashish • Wax/cannabis • Oils • Whole Tobacco, Herbs, Cannabis

20 Documented cases of Lipoid pneumonia from glycerin based oils found in e-cig Nicotine vapor. Documented cases of “Popcorn Lung”

21 CDC-Using a hookah to smoke tobacco poses serious health risks to smokers and others exposed to the smoke from the hookah. Hookah Smoke and Cancer •The charcoal used to heat the tobacco can raise health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals.1,4 •Even after it has passed through water, the smoke from a hookah has high levels of these toxic agents.4 •Hookah tobacco and smoke contain several toxic agents known to cause lung, bladder, and oral cancers.1,4 •Tobacco juices from hookahs irritate the mouth and increase the risk of developing oral cancers.4,7

Other Health Effects of Hookah Smoke •Hookah tobacco and smoke contain many toxic agents that can cause clogged arteries and heart disease.1,4 •Infections may be passed to other smokers by sharing a hookah.2 •Babies born to women who smoked water pipes every day while pregnant weigh less at birth (at least 3½ ounces less) than babies born to nonsmokers.5,8 •Babies born to hookah smokers are also at increased risk for respiratory diseases.8

22 The practice of smoking tobacco from hookahs has been on the rise, especially among youth, over the past decade. It's no secret that hookah smoking has many of the same health risks as cigarette smoking. Now, a new meta-analysis led by the University Of Pittsburgh School Of Medicine has found that one hookah session delivers roughly 125 times the smoke, 25 times the tar, 2.5 times the nicotine and 10 times the carbon monoxide of a single cigarette. Given the fact that hookah smoking is becoming more popular among teens, the latest findings should be cause for concern. The lead author Brian Primack, assistant vice chancellor for health and society in Pitt's Schools of the Health Sciences, said, "Our results show that hookah tobacco smoking poses real health concerns and that it should be monitored more closely than it is currently".

The findings are published online and in the January/February print issue of the journal Public Health Reports. 1/13/2016 6:24 AM

23 E-Cigarettes, vaping, hookah: What to Tell Patients 1) ASK about tobacco use (of all kinds and forms) Don’t start if never used. 2) ADVISE and counsel to quit all forms of tobacco. 3) REFER to Quit Line for free support (1-800-QUITNOW)

Talking points:  Is it safer over many years? Likely to be less toxic than cigarettes. Not harmless water vapor-concern over secondhand particulates. Unknown long term .  Quantify the known hazards of: propylene glycol, Battery vapor, Particulate matter, solvents, flavoring, preservatives.  Concern over NEW ITERATIONS OF ECIGS as still unregulated  Concern over AMOUNT AND HAZARD OF DUAL USE

24  Preclinical data predictive of clinical hazards: Immunocompromise for pulmonary infection Inflammation triggered by nanoparticles- show less levels of most toxicants, but not particles. Solvent transforms to carcinogens Impact on stem cells? Pregnancy? UNKNOWN

NOT proven as a cessation aid- most remain dual users.

14 January 2016-Lancet-meta-analysis of 38 studies--As currently being used, e-cigarettes are associated with significantly less quitting among smokers.

25 1) Dual user: • pharmacotherapy-stop use of all tobacco products • pharmacotherapy-Plan to wean off ENDS

26 2) Quit combustible tobacco but using ENDS: • Congratulate on quitting smoking. • Monitor for relapse. • Offer pharmacotherapy and plan to wean off ENDS.

27 3) ENDS user only-never smoker: • Offer pharmacotherapy and plan to wean off ENDS.

28 QUESTIONS?

29 30