Emerging Issues in Tobacco Control: The Rise of Electronic Products and Implications for Policy, Planning, and Practice B R I A N A. KING, PHD, MPH DEPUTY DIRECTOR FOR RESEARCH TRANSLATION OFFICE ON SMOKING AND HEALTH State of Alaska Tobacco Prevention and Control Grantee Training Meeting ● November 14, 2018 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 Good News: Cigarette Smoking Is Down 40 35 30 25 smoking prevalence smoking 20 15 Cigarette Cigarette 10 5 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Adults 18+ High School Students 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. 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 E-cigarette Landscape is Volatile Source: King, BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in the United States, 2013-2017. JAMA October 2018;Volume 320:Number 13. The Rise of JUUL What Are “Heat Not Burn” Products? Contain Tobacco Throat Hit Similar to Cigarettes 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? What Factors Lead to Youth Smoking? Source: DHHS. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA. 2012. Youth E-cigarette Initiation and Use Advertising Flavors Nicotine Youth Exposure to E-cigarette Advertising Evolution of E-cigarette Messaging 2015 2018 "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 Source:https://www.theverge.com/2015/4/21/8458629/pax https://www.theverge.com/2015/4/21/8458629/pax-labs-labs-e-cigarette-e-cigarette-juul-juul ; The Washington Post, July 19 2018 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 Former Cigarette Smoker 50 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 Current E-cigarette Use Among Adults, by Age, National Health Interview Survey, U.S., 2016 Source: QuickStats: Percentage of Adults Who Ever Used an E-cigarette and Percentage Who Currently Use E-cigarettes, by Age Group — National Health Interview Survey, United States, 2016. MMWR Morb Mortal Wkly Rep 2017;66:892. Current E-cigarette Use Among U.S. Adults BRFSS 2017 (January – September) D.C. 1.7% – 3.7% 3.8% – 4.2% 4.3% – 4.7% 4.8% – 6.5% Current e-cigarette users: Persons who reported using e-cigarettes or some other electronic “vaping” product “some days” or “every day” 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. Ever Use of Heated Tobacco Products Among U.S. Adults, 2017 Percentage (%) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Overall 0.7 Men 0.8 Women 0.6 <30 years 1.6 ≥30 years 0.5 Non-Hispanic, White 0.5 Other 1.0 Current smoker 2.7 Former smoker Relative standard error >40% Never smoker 0.5 Source: SummerStyles 2017. Marynak, K et al. Awareness and ever use of "heat-not-burn" tobacco products among U.S. adults, 2017. Accepted by AJPM. Current Tobacco Product Use Among U.S. High School Students by Tobacco Product – NYTS 2011-2017 Cigarette 15.8% Cigar 11.6% 11.7% Smokeless 7.9% 7.7% 7.6% 5.5% Hookah 4.1% Pipe 4.0% 3.3% Bidi 2.0% 1.5% 0.8% E-cigarette 0.7% 2011 2012 2013 2014 2015 2016 2017 YEAR Source: Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A. Tobacco Product Use Among Middle and High School Students — United States, 2011–2017. MMWR Morb Mortal Wkly Rep 2018;67:629–633. JUUL use at school, 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 Frequency of Youth E-cigarette Use 54.5 45.4 17.3 16.2 12 10.9 9.2 9.7 7.3 7.9 5.8 3.9 1-2 DAYS 3-5 DAYS 6-9 DAYS 10-19 DAYS 20-29 DAYS ALL 30 DAYS Middle School High School Source: Neff LJ, Arrazola RA, Caraballo RS, Corey CG, Cox S, King BA, Choiniere CJ, Husten CG.MMWR Morb Mortal Wkly Rep. 2015 Oct 2;64(38):1061-5. Frequency of Tobacco Use Among Middle and High School Students– U.S., 2014. 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 Is there a potential benefit for e-cigarettes? Answer: Under certain circumstances Complete long term substitution by established smokers Assist in rapid transition to a society with little or no use of combustible products Short-term use if shown to produce successful & permanent cessation of combustible products “Cutting back” is not enough—even a few cigarettes per day is dangerous 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 Conclusion 16-2. Among youth and young adult e-cigarette users who ever use combustible tobacco cigarettes, there is moderate evidence that e-cigarette use increases the frequency and intensity of subsequent combustible tobacco cigarette smoking. Leads to initiation of combustible tobacco use among non- smokers, particularly children Source: The National Academies of Science, Engineering, and Medicine. Public Health Consequences of E-cigarettes. 2018. Current Smokers ENDS use was associated with greater odds of quitting smoking 1.17 Leads to relapse Never Smokers Former Smokers among ENDS use was ENDS use was former associated with associated with smokers greater odds of greater odds of initiating smoking smoking relapse 7.41 1.53 Source: Kelly Young-Wolff et al. Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system. Prev Med. 2018. “The long-term safety of e-cigarettes is unknown.” Diminishes the “The small number of trials, low event rates and wide chances confidence intervals around the estimates mean that our that a confidence in the result is rated 'low' by GRADE standards.” smoker will quit “Overall, the USPSTF found the evidence on the use of ENDS as a smoking cessation tool in adults, including pregnant women, and adolescents to be insufficient.” Quit Methods Used Among U.S. Adult Cigarette Smokers Got help from a telephone quitline 5.4 Got help from a website such as 7.1 Smokefree.gov Used FDA-approved medications 12.2 such as Zyben or Chantix Got help from doctor or other health 15.2 professional Discourages Switched to "mild" cigarettes 20.4 smokers from using Switched completely to e-cigarettes 24.7 proven quit methods Used nicotine patch/gum 25.4 Substituted some regular cigarettes 35.3 with e-cigarettes Gradually cut back on cigarettes 82 Gave up cigarettes all at once 85.3 Mulitple quit methods 74.7 Source: Caraballo RS, Shafer PR, Patel D, Davis KC, McAfee TA.