Emergi ging T ng Tobacco Produc ucts Luc ucinda Eng ngland nd M MD, M MSPH Office e on on S mok oking g an and d Heal alth Centers for or Disease Con ontrol ol an and d Prevention on Maryland S tate Council on Cancer Control Cancer Conference November 18, 2014 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the C enters for Disease C ontrol and P revention Centers for Disease Control and Prevention Office on Smoking and Health
Context: Burned Tobacco is is Still ill a P Proble lem “ The e burden en o of d dea eath an and diseas ease e from t tobac acco use e in the e United ed States es i is o over erwhel elmingly cau aused ed b by cigar aret ettes es and o d other combu busted t d toba bacco pr produ ducts; rapi pid e d elimination of their ir u use will d ill dramatic ically lly reduce this is b burden.” .” The health consequences of smoking – 50 years of progress: a report of the S urgeon General. – Atlanta, GA. : U.S . Department of Health and Human S ervices, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on S moking and Health, 2014.
Ov Overview 1 What are emerging tobacco products? 2 Who is using emerging products? 3 What are health risks of emerging products? Which policy approaches are appropriate for 4 emerging products?
What Are EN ENDS? Elect ectronic Cigar aret ettes es an and Vap aping D Devices es
EN ENDS Delivers nicotine-containing aerosol by heating a solution (typically propylene glycol or glycerol/ glycerin nicotine, and flavoring agents, and other additives) Long-term health effects of inhaled propylene glycol and glycerin are unknown Hutzler, Paschke, Kruschinski, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch T oxicol 2014
ENDS Aeros osol ol is not ot “Harmless ss Water er Vapor por “ Nicotine: 0-36 mg/ml Flavorings/additives often not disclosed S ome analyses show presence of potentially allergenic compounds such as cinnamic aldehyde (highly toxic to human embryonic stem cells) Overheating could lead to production of carcinogens, such as formaldehyde, acetaldehyde, acrolein Bhatnagar et al. E lectronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130:1418-36. Behar, Davis, Wang, et al. Identification of toxicants in cinnamon flavored electronic cigarette refill fluids. T oxicology in vitro 2014. Hutzler, Paschke, Kruschinski, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch T oxicol 2014
ENDS Other P Purpo rposes Some E e ENDS can an b be u e used ed t to del eliver er other er substan ances es, l like e mar arijuan ana an a and c caf affei eine
ENDS A As C s Cessa ssation Devices
Not Approved ed as as a a Ces essation Device Cen enter er f for D Drug E Eval aluation an and Res esear earch In 8 years companies have not approached FDA for approval Borderud, S . P., Li, Y., Burkhalter, J. E ., S heffer, C. E . and Ostroff, J. S . (2014), E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. doi: 10.1002/cncr.28811
ENDS and C Cessa ssation Grana, Benowitz, Glantz. E -cigarettes: a scientific review. Circulation 2014;129:1972-86.
Cessatio ion: Rando domiz ized T d Tria rials ls • 2 trials conducted with control arms – Caponnetto et al., 2013 (3 e-cigarette arms) • Participants not interested in quitting • All arms reduced cigs/day, no difference in quits – Bullen et al., 2013 • Participants wanted to quit • Nicotine e-cigarette, zero nicotine e-cigarette, NR T patch • 6 month follow-up • 50% reduction cigs/day (57%, 45%, 41%, p=0.08) • Quitting 7.3%, 4.1%, 5.8% (p=0.5)
Ces essation in c can ancer er patients Bo Borderud et al, 2014 2014 Patien ents pres esen enting t to Mem emorial al S Sloan an Ket etter ering C Can ancer er Cen enter er 2012 2012-2013 s screen eened ed f for tobac acco use, u user ers ref efer erred ed to Tobac acco Cessation P Program (n=4504) 4504) Tho hose w willing ng to enr nroll in t n treatment progr gram inc nclud uded i in s n stud udy (n=1074) 1074) • Asse ssesse ssed f for e-cigar aret ette u e use • Follo llow up at 6-12 months s for c cessa ssation st status ( s (n=414) Find ndings ngs: • 26% r rep eported ed pas ast 30 day use o e of e e-cigar aret ettes es at b bas asel eline; e; 92% 92% o of e e-cigar aret ette e user ers w wer ere e al also s smoking. • Quar arter erly p preval alen ence e increas eased ed f from 10.6% to 3 38.5% Borderud S P, Li Y, Burkhalter JE , S heffer CE , Ostroff JS .E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014 S ep 22.
Ces essation in c can ancer er patients Cont ontinued E-cigar aret ette u e user ers : S moked more cigarettes/day R eported higher nicotine dependence scores Had more frequent and longer duration of prior quit attempts No difference in quitting motivation or confidence At f follo llow up: 7-day point prevalence of smoking abstinence was no different in e-cigarette users and non-users (44.4% vs. 43.1%). E -cigarette users were less likely to have been abstinent for > 24 hrs After adjustment, e-cigarette users as likely to be smoking at follow up as non-users. Borderud S P, Li Y, Burkhalter JE , S heffer CE , Ostroff JS .E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014 S ep 22.
Market eting
ENDS A Advertising ng Expend nditur ures ac across m med edia a mar arket ets 2011: 2011: $6. $6.4 m 4 million 2012: 2012: $18. $18.3 m 3 million 2013: 2013: >$80 m millio illion
Cel eleb ebrity spo pokespe peopl ple Glamor orou ous w wom omen
Hundr dreds ds o of flavors
Sports s and musi sic e events sp s sponso sorsh ship
Use se i in sm smoke-free ee ar areas eas
Cheape per pri price S lide courtesy Pam Ling, UCS F
Socia ial l network rkin ing
Plac acem emen ent Next to Can andy http://www.countertobacco.org/n ews/2014/09/12/njoy-brags-about- e-cigarette-placement-among- candy
Heal ealth Clai aims S lide courtesy Pam Ling, UCS F
Physician an Endorsem emen ent
Wha hat tactics lead to yout uth h smoking? ng? • Ex Exposure to o ads s • Them emes es in a n advertising ng tha hat resona nate w with h yout uth h • Lo Low pric rices a and pric rice-reduc ucing ng prom omot otions • Eas ase e of ac acces ess to a a product • Cand ndy a and nd frui uit-flav avored pr produ ducts • Heal ealth c clai aims • Pr Products that ar are eas e easier er to u use se
E-cigar aret ette e ever er u use m e more t e than an d doubled ed* b bet etween een 2011 2011 and 2012 2012 among students Y out uth h E -cigaret ette e E E ver U v Use, Nat ation onal Y Y outh T ou obac ob acco o S urvey, Unite ted S tate ta tes 2011 2012 10. 10.0% 0% 1.78 1. 78 >300, 300,000 000 millio illion stud udent nts stud udent nts 6.8% 6. 8% 4. 4.7% 7% 3.3% 3. 3% 2. 2.7% 7% 1.4% 1. 4% All Students High School Middle School *S tatistically different (p<0.05) Centers for Disease Control and Prevention (2013). "Notes from the Field: E lectronic Cigarette Use Among Middle and High S chool S tudents — United S tates, 2011–2012." Morbidity and Mortality Weekly R eport 62 62(35): 729-730.
Trends s in Use se
E-cigar aret ette e ever er u use m e more t e than an d doubled ed* b bet etween een 2011 2011 and 2012 2012 among students Y out uth h E -cigaret ette e E E ver U v Use, Nat ation onal Y Y outh T ou obac ob acco o S urvey, Unite ted S tate ta tes 2011 2012 10. 10.0% 0% 1.78 1. 78 >300, 300,000 000 millio illion stud udent nts stud udent nts 6.8% 6. 8% 4. 4.7% 7% 3.3% 3. 3% 2. 2.7% 7% 1.4% 1. 4% All Students High School Middle School *S tatistically different (p<0.05) Centers for Disease Control and Prevention (2013). "Notes from the Field: E lectronic Cigarette Use Among Middle and High S chool S tudents — United S tates, 2011–2012." Morbidity and Mortality Weekly R eport 62 62(35): 729-730.
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