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Electronic Cigarettes: Hype Versus Science (an update)
Audrey Darville, PhD, APRN, CTTS, FAANPCertified Tobacco Treatment Specialist,
UK HealthCareCo-Director, Tobacco Prevention &
Treatment Division, BREATHEMarch 2, 2017
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Learning Objectives
• Describe the current state of electronic smoking products
• Identify current use patterns of electronic smoking products
• Explore cardiovascular concerns associated with the use of electronic smoking devices
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What is an Electronic Smoking Device?
Developed in China in 2003; introduced in Europe and the US in 2006-2007 and banned for sale/distribution in many countries; tested by the FDA in 2009 where inconsistencies were found in labeling versus actual ingredients and the product was refused
approval in the U.S.
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The Tobacco Control Act gives the FDA jurisdiction to regulate tobacco products (e-cigs,
cigars, pipe tobacco, and hookah), and as of August, 2016 they have been deemed tobacco
products
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Why the Initial Concern?• Cessation treatment claims led FDA to initially pursue regulation as a drug delivery device
• FDA testing found nicotine levels varied widely• Toxins (di-ethylene glycol=antifreeze) was found in one sample and ingredients were variable in others
• Early reports raised concern for potential harmful effects to the lungs
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Over 400 types of Devices• Range from “cig-alike” designs to large tank-style devices with adjustable voltage batteries
• Designed & marketed with youth appeal
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Heat Not Burn Devices• Initially developed in late 1980’s by tobacco companies;
use tobacco not e-juice• No real market appeal until recently• Provide “hit” effect of conventional cigarette that is lacking
in electronic cigarettes• Recent market expanding as e-cigarette market is slowing• Industry looking to have them regulated as “reduced-risk”
products
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From PMI: “These data alone do not imply or represent a claim of reduced risk or reduced exposure…”(pmiscience.com)
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Use Patterns• Primarily users are current or former smokers, many with
intent to reduce smoking• Experimentation in non-smokers• No current evidence that long term quit rates are
significantly higher than “cold turkey”• Dual/multiple product use is common• Devices are modified for use with substances/drugs other
than nicotine• Growing evidence that use may deter cessation
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Constituents• Nicotine: Concentrations can vary widely • Overall, significantly fewer chemicals than in combustible
cigarettes (40-60 versus 7000)• Propylene glycol: Principle ingredient in vapor; known
lung irritant• Some flavorings associated with known health risks• Formaldehyde: A by-product of heating and oxidation• Aerosolized Particulates: tin, silver, iron, and aluminum.
Concentrations of nickel are higher than conventional cigarettes
• Oxidizing chemicals
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Health Concerns• Lung Effects: Immediate effects on lung function and nitric oxide levels variable but somewhat consistent with conventional cigarettes. Lipoid pneumonia attributed to e-cig use in a young woman
• Cardiovascular Concerns: Arrhythmias and hypertension with e-cigarette use have been reported
• Cytotoxic/teratogenic Effects: Uncertain at this time but concerns have been raised
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Benowitz (2003) Progress in Cardiovascular Diseases 46 (1), 91-111.
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Cardiovascular Effect “Red Flags”• Oxidative stress markers are elevated with even short
term use (Carnevale, et al, 2016, Chest DOI: http://dx.doi.org/10.1016/j.chest.2016.04.012)
• Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in young, healthy subjects (Moheimani, et al, 2017; JAMA Cardiol. doi:10.1001/jamacardio.2016.5303)
• Particulates and carbonyls such as formaldehyde, acetaldehyde, acetone, acrolein, and butanol in e-cigarettes are associated with impaired regulation of blood pressure, increased clotting, and accelerated formation of atherosclerotic lesions (Bhatnagar, 2016, doi:10.1007/s12170-016-0505-6)
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The Harm Reduction Debate
• Current controversy in tobacco control and public health communities
• Perceived as less harmful, but harms are largely untested with controlled studies
• Multiple studies are ongoing• Many devices developed/marketed by the tobacco industry
• Long range impact on tobacco prevalence & cessation rates is debated and largely unknown
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Impact on Youth Initiation• 5.6 million Americans aged <18 years who are alive
today are projected to die prematurely from smoking-related disease
• Are e-cigarettes a “gateway product”?Estimated percentage of high school students who currently use (past 30 day) any tobacco products, ≥2 tobacco products, and select tobacco products— National Youth Tobacco Survey 2011–2015
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In Summary• Safety regulations and standards regarding electronic
cigarettes and vaping devices are pending: Product use is not “risk free” but “risk unknown” at this time
• Nicotine is highly addictive and has been found in e-juices claiming to be nicotine free
• There is increasing concern that e-cigarettes are a gateway to other forms of tobacco use in youth
• There is no solid evidence that e-cigarettes help people quit smoking and growing evidence that they may be deterring cessation in certain cases
• The tobacco industry is investing heavily in “Reduced-Risk Products”
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Association for the Treatment of Tobacco Use and Dependence
An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for
the tobacco user.www.attud.org
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BREATHE Tobacco Treatment Specialist Training Program: An Intensive Evidence-Based Training Program for Health Professionals
• Teaches the core competencies for tobacco treatment specialists developed by the Association for the Treatment of Tobacco Use and Dependence
• The online course with approximately twenty-five hours of instruction time, which is broken down into five sequential modules
• Currently piloting/applying for accreditation but will re-open registration in late spring/early summer
• Contact Audrey Darville ([email protected]) for more information
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If interested in clinical case studies see:
Clinical Case Conference Electronic cigarettes: a review of safety and clinical issuesMichael Weaver, MD, FASAM, Alison Breland, PhD, Tory Spindle, BS, & Thomas Eissenberg, PhD
NIH Public Access Manuscript:
J Addict Med. 2014; 8(4): 234–240. doi:10.1097/ADM.0000000000000043.
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Selected References:
Bhatnagar A. E-cigarettes and cardiovascular disease risk: evaluation of evidence, policy implications, and recommendations. Curr Cardiovasc Risk Rep. 2016;10:1-10.
Benowitz, N. L., & Goniewicz, M. L. (2013). The Regulatory Challenge of Electronic Cigarettes. JAMA. doi: 10.1001/jama.2013.109501
Bullen, C., et al. (2013). Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. doi: 10.1016/S0140-6736(13)61842-5Carnevale R, Sciarretta S, Violi F, Nocella C, Loffredo L, Perri L, Peruzzi M, Marullo AGM, De Falco E, Chimenti I, Valenti V, Biondi-Zoccai G, Frati G, Acute impact of tobacco versus electronic cigarette smoking on oxidative stress and vascular function, CHEST (2016), doi: 10.1016/j.chest.2016.04.012.
England LJ, et al. (2015) Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J Prev Med. 2015;doi 10.1016/j.amepre.2015.01.015
Goniewicz, M. L., et al. (2013). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. doi: 10.1136/tobaccocontrol-2012-050859Grana R, et al. (2014) E-Cigarettes: A Scientific Review. Circulation;129(19):1972-1986.
Hajek P, et al. (2014) Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction;109(11):1801-1810.
McRobbie H, et al. (2015). Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2015;12:CD010216.
Moheimani RS, Bhetraratana M, Yin F, et al. Increased cardiac sympathetic activity and oxidative stres in habitual electronic cigarette users: implications for cardiovascular risk [published online February 1, 2017]. JAMA Cardiol. doi:10.1001/jamacardio.2016.5303.
Vardavas CI, et al. Acute pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance and exhaled nitric oxide. Chest. 2012;141(6):1400-1406.
Williams, M., et al. (2013). Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol. PLoS One, 8(3), e57987. doi: 10.1371/journal.pone.0057987
Zarwertailo, L., Pavlov, D., Ivanova, A., Ng, G., Baliunas, D., Selby, P., (2017). Concurrent e-cigarette use during tobacco
dependence treatment in primary care settings: Association with smoking cessation at 3- and 6-months.NTR19(2):183-189.
Zhu SH, et al. (2014). Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control;23(Suppl 3):iii3-9.