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One Moment Please Today’s WebcastFriday, 12/20/19

E-Cigarettes

MuChun Joanna Tsai, MDGretchen Whitby, APRN-CNPMuChun Joanna Tsai, MDGretchen Whitby, APRN-CNP

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Webcast FeaturesWebcast Features

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© The Ohio State University Wexner Medical Center, 2019© The Ohio State University Wexner Medical Center, 2019

The following program is a Continuing Medical Education Activity sponsored by The Ohio State University Wexner Medical Center. The design and production of this CME Activity is the sole responsibility of the Center for Continuing Medical Education.

Accreditation Statement

The Ohio State University’s Center for Continuing Medical Education (CCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME®) to provide continuing medical education for physicians.

AMA Designation Statement

The Ohio State University’s Center for Continuing Medical Education designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

As an enduring material this CME Activity is approved for three years from original release. Original release 12/20/19. Termination date 12/20/22.

CCME Disclosure Statement

As a provider of AMA PRA Category 1 Continuing Medical Education, it is the policy of CCME to adhere to the ACCME Standards for Commercial Support to avoid any conflict of interest and/or commercial bias and must ensure balance, independence, objectivity and scientific rigor in all its sponsored educational activities. All individuals who are in a position to control content of an educational activity, including presenters, panel members and moderators, must to disclose any relevant financial relationships that create a conflict of interest.

Nothing in this program is intended to imply that any off-label or unapproved product use discussed is reimbursed by any government or private payor or that submission of a claim for such use is proper.

Presentation may include discussion of services and unapproved or off-label usage of commercial products or devices. Log on to ccme.osu.edu for more information.

The following program is a Continuing Medical Education Activity sponsored by The Ohio State University Wexner Medical Center. The design and production of this CME Activity is the sole responsibility of the Center for Continuing Medical Education.

Accreditation Statement

The Ohio State University’s Center for Continuing Medical Education (CCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME®) to provide continuing medical education for physicians.

AMA Designation Statement

The Ohio State University’s Center for Continuing Medical Education designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

As an enduring material this CME Activity is approved for three years from original release. Original release 12/20/19. Termination date 12/20/22.

CCME Disclosure Statement

As a provider of AMA PRA Category 1 Continuing Medical Education, it is the policy of CCME to adhere to the ACCME Standards for Commercial Support to avoid any conflict of interest and/or commercial bias and must ensure balance, independence, objectivity and scientific rigor in all its sponsored educational activities. All individuals who are in a position to control content of an educational activity, including presenters, panel members and moderators, must to disclose any relevant financial relationships that create a conflict of interest.

Nothing in this program is intended to imply that any off-label or unapproved product use discussed is reimbursed by any government or private payor or that submission of a claim for such use is proper.

Presentation may include discussion of services and unapproved or off-label usage of commercial products or devices. Log on to ccme.osu.edu for more information.

The following planning committee members have no relevant financial relationships with commercial interests to disclose:

James Allen, MD

Ruthann Kennedy, CNP

Barbara Berry

Derrick Freeman

The following planning committee members’ educational unit does not have a financial interest or affiliation with an organization that may receive direct benefit from the subject of the proposed CME activity, and they will not be personally compensated for their role in the planning or execution of this proposed CME activity by an organization other than The Ohio State University:

James Allen, MD

Ruthann Kennedy, CNP

Barbara Berry

Derrick Freeman

Planning Committee DisclosuresPlanning Committee Disclosures Speaker DisclosuresSpeaker DisclosuresThe following presenters for this educational activity disclose that they have no relevant relationships with commercial interests to disclose.

Their presentation will not include discussion of unapproved or “off-label” usage of commercial products and/or services.

MuChun (Joanna) Tsai, MD

Gretchen Whitby, APRN-CNP

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Agenda Disclaimer

CCME presents this activity for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of medicine. The content of the presentations is provided solely by presenters who have been selected for presentations of recognized expertise in their field.

No further reproduction or distribution is permitted by electronic transmission or any other means. The presentations during this webcast are the intellectual property of the presenter and require his/her permission for further use.

This activity will discuss E-Cigarettes.

Agenda Disclaimer

CCME presents this activity for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of medicine. The content of the presentations is provided solely by presenters who have been selected for presentations of recognized expertise in their field.

No further reproduction or distribution is permitted by electronic transmission or any other means. The presentations during this webcast are the intellectual property of the presenter and require his/her permission for further use.

This activity will discuss E-Cigarettes. Arthur G. James Cancer Hospital

and Solove Research Institute

The Ohio State UniversityWexner Medical Center

E-CigarettesE-Cigarettes

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MuChun (Joanna) Tsai, MDGretchen Whitby, APRN-CNP

Jim Allen, MDProfessor of Internal MedicineThe Ohio State University Wexner Medical Center

Jim Allen, MDProfessor of Internal MedicineThe Ohio State University Wexner Medical Center


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The average smoker loses 14 minutes of life for every

cigarette smoked

The average smoker loses 14 minutes of life for every

cigarette smoked


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MuChun (Joanna) Tsai, MDGretchen Whitby, APRN-CNPMuChun (Joanna) Tsai, MD

Gretchen Whitby, APRN-CNP

E-cigarettes and vaping

E-cigarettes and vaping

Are e-cigarettes the best way to stop

smoking?

Are e-cigarettes the best way to stop

smoking?

and email us with your questions.

and email us with your questions.

You are invited to participateYou are invited to participate

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MuChun (Joanna) Tsai, MDClinical Instructor

Division of Pulmonary, Critical Care, And Sleep Medicine

The Ohio State University Wexner Medical Center

Electronic cigarettesDecrease in Cigarette

Use in the USDecrease in Cigarette

Use in the US

Center for Disease Control and Prevention

E-cigarette Use on the Rise in Teens and Young Adults

E-cigarette Use on the Rise in Teens and Young Adults

Center for Disease Control and Prevention

Electronic cigarettesElectronic cigarettes• E-cigarette (e-cig)

• E-hookahs

• E-cigars

• Vape sticks

• Vape pens

• Vaping devices

• Electronic Nicotine Delivery System (ENDS)

https://www.fda.gov/tobacco-products/products-ingredients-components/vaporizers-e-cigarettes-and-other-electronic-nicotine-delivery-systems-ends

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E-cigarette ComponentsE-cigarette Components

• E-liquid or e-juice• Propylene glycol

• Vegetable glycerin

• Nicotine

• Flavoring

• Vaporizing chamber

• Power source/Battery


E-cigarette DevicesE-cigarette Devices

• First generation –“cig-alike”

• Second generation – “vape pens”

• Third generation –“mods”

• Fourth generation -JUUL


Is it Safe to Vape?Is it Safe to Vape?• E-cig aerosol generally contain fewer toxic

chemicals vs traditional smoking

• E-cigs contain nicotine and other harmful chemicals • Carcinogens

• Volatile organic compounds

• Diacetyl in flavoring – “popcorn lung”

• Propylene glycol and glycerin in many food products• Safety has not been established for aerosolizing or

inhaling them

Is it Safe to Vape?Is it Safe to Vape?• Nicotine use during pregnancy can affect

fetal development

• Nicotine exposure in adolescence can become an addiction• Younger the exposure, stronger the influence

• Impulse control problems

• Disruptive behaviors

• Early engagement with other substances

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Is it Safe to Vape?Is it Safe to Vape?• E-liquids are often custom-mixed at home or

vape shops• 1000s of unique flavoring

• Marijuana-related products

• No safety regulations• Some evidence e-cigarette aerosol toxicity- Direct toxicity to lung tissue- Impair host defense- Interfere normal lung development• Unknown long-term effects

E-cigarette or vaping associated lung injury (EVALI)

E-cigarette or vaping associated lung injury (EVALI)

EVALI SymptomsEVALI Symptoms

GI:- Abdominal Pain

- Nausea/vomiting

- Diarrhea

Constitutional:- Fever- Chills- Weight Loss

Respiratory:- Cough- Shortness of Breath- Chest Pain

Clinical EvaluationClinical Evaluation• Inquire about symptoms

• Thorough vaping history

- Substance used

- Brand

- Frequency

- Time of last use

- Method of use

• Physical Exam

• Laboratory Testing:

- CBC with diff

- Inflammatory markers

- Urine or serum toxicology screen

- Rule out infection

• CXR or CT chest

• Consider bronchoscopy

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Management/TreatmentManagement/Treatment

• Supportive care

• +/- Corticosteroids

• Antibiotics

Quit Smoking Using E-cigs?Quit Smoking Using E-cigs?

• Currently not approved by FDA as a smoking aid

• Mixed studies

- Some evidence e-cigs with nicotine can help smokers long-term compared to placebo

- Most adult users do not stop smoking and continue to use both

- Among quitters, majority were still vaping

The chemical culprit in EVALI

The chemical culprit in EVALI

Vaping products at greatest risk of EVALI

Vaping products at greatest risk of EVALI

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Gretchen Whitby, APRN-CNPDivision of Pulmonary, Critical Care,

and Sleep MedicineThe Ohio State University Wexner Medical Center

E-cigarette Friend or Foe plus Quit Tips

Case ReportCase Report• Rebecca is a 56 year old female who has a

40 py history of smoking.

• Quit using regular cigarettes 6 years ago using e-cigarette

• Has continued to use the e-cigarette since quitting.

• She is worried if she quits “vaping”, she will return to smoking regular cigarettes

• Has she gained anything by her switch?

E-cigarettesE-cigarettes• E-cigarettes heat a liquid

into an aerosol for inhalation

• Usually comprise propylene glycol and glycerol, with or without flavors and nicotine

• First, second, third, or fourth generation devices are now available

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/OSH-E-Cigarettes-and-Youth-What-HCPs-Need-to-Know-20190327-508.pdf

Source: Centers for Disease Control and Prevention

What is in E-cigarette aerosol?What is in E-cigarette aerosol?

• Nicotine• Ultrafine

particles• Flavorings

• Dactyl• Vitamin E acetate• THC• Cannabinoid (CBD)• Volatile organic

compounds• Cancer-causing

chemicals• Heavy metals

Graphic from the January 2015 California Department of Public Health’s State Health Officer’s Report on E-Cigarettes warning about harmful substances in e-cigarettes.

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Who is using E-cigarettes?Who is using E-cigarettes?

• Middle school students

• High School Students

• Adults

• Current regular cigarette smokers

• Former smokers

• Never regular smokers

Office on Smoking and Health, National Center for Chronic Disease Prevention and Health. MMWR. DEC 6, 2019/vol. 68/ SS-12BMJ 2018;360:j5543 . 1 Action on Smoking and He(ASH). Use of e-cigarettes (vapourisers) among adults in Great Britain 2017. http://ash.org.uk/download/use-of-e-cigarettes-among-adults-in-greatbritain-2017. 2 West R, Beard B, Brown J. Trends in electronic cigarette use in England: Smoking Toolkit Study. www.smokinginengland.info/latest-statistics.

Source: Fair Expert

Risks of E-cigarettes for Kids, Teenagers, and Young Adults?Risks of E-cigarettes for Kids, Teenagers, and Young Adults?

• Most e-cigarettes contain nicotine.

• Can contain other harmful substances besides nicotine.

• Young people who use e-cigarettes may be more likely to smoke cigarettes in the future

• Increase risk for future addiction to other drugs.


Dangers of e-cigarettesDangers of e-cigarettes• Can deliver high levels of nicotine –

highly addictive

• Health danger to pregnant women and their developing fetuses

• Ingestion has poisoned children and adults

• Difficult for consumers to know what e-cigarette products contain

• Long-term effects on health are still being studied


Are E-cigarettes less harmful than regular cigarettes? Yes, but…

Are E-cigarettes less harmful than regular cigarettes? Yes, but…

Benefits

• Lower exposure to carcinogens

• Second hand smoke exposure

• May help smokers to quit smoking.

Concerns• No evidence of safety of long term

use• No convincing evidence of efficacy

as aid to quitting over approved methods

• Inconsistent levels of nicotine aerosol delivery and nicotine blood levels

• Impurities in solutions

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E-cigarette as quitting aid?E-cigarette as quitting aid?• Currently insufficient evidence to make

recommendation

• Not approved by the FDA

• Use of currently FDA approved methods have a proven track record of success

• Safety concerns

• Most e-cigarette users don’t stop but become “dual” users.

RECOMMENDATIONS FOR

E-CIGARETTE USAGE?

RECOMMENDATIONS FOR

E-CIGARETTE USAGE?

Tips by BMJTips by BMJ• Quitting smoking improves your health and extends your

life• The harm from smoking comes from burning the tobacco,

not from the nicotine.• Currently approved smoking cessation methods are

useful and safe• Behavorial• NRT, Varenicline and Bupropion

• No evaluations of cost effectiveness of e-cigarettes for quitting.

• Less evidence on usefulness and safety of e-cigarettes• 2nd generation devices (vape pens) – best to try• 1st generation devices delivered less nicotine, not as

reliable• 3rd and 4th generation devices are more complicated.

BMJ 2018;360:j5543

CDC Public Health RecommendationsCDC Public Health Recommendations

Do not:

• Use an e-cigarette, or vaping product that contains THC

• Buy any type of e-cigarette, or vaping products, particularly those containing THC, from informal sources (such as family, friends, or in-person or online dealers)

• Modify or add any substances to e-cigarette, or vaping, products that are not recommended by the manufacturer

AAFP Pharmacologic Product Guide of FDA-Approved Medications for Smoking Cessation

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CDC Public Health Recommendations CDC Public Health Recommendations

• E-cigarette, or vaping products should never be used by youth, young adults, or pregnant women

• If not currently smoking, do not start using e-cigarette, or vaping

• If using e-cigarettes to quit smoking, consider changing to an FDA-approved nicotine replacement therapy

• People who continue using e-cigarette, or vaping products:• Carefully monitor themselves for symptoms • See a health care provider immediately, if

symptoms develop

AAFP Pharmacologic Product Guide of FDA-Approved Medications for Smoking Cessation

RECOMMENDATIONS FOR

HELPING SMOKERS QUIT

RECOMMENDATIONS FOR

HELPING SMOKERS QUIT

The 5 A’s of Treating Tobacco UseThe 5 A’s of Treating Tobacco Use

Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158–176. doi:10.1016/j.amepre.2008.04.009

FTNDFTND• How soon after you wake up do you smoke your first

cigarette?• After 60 minutes (0), 31-60 minutes (1), 6-30 minutes

(2), Within 5 minutes (3)

• Do you find it difficult to refrain from smoking in places where it is forbidden?• No (0) Yes (1)

• Which cigarette would you hate most to give up?• The first in the AM (1) Any other (0)

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FTNDFTND• How many cigarettes per day do you smoke?

• 10 or less (0), 11-20 (1), 21-30 (2), 31 or more (3)

• Do you smoke more frequently during the first hours after awakening than during the rest of the day?• No (0) Yes (1)

• Do you smoke even if you are so ill that you are in bed most of the day?• No (0) Yes (1)

Readiness to Quit LadderReadiness to Quit LadderCircle the one number that shows what you think about

quitting. Please read each sentence carefully before deciding.

• 10 I have quit smoking. • 9 I have quit smoking, but I still worry about slipping

back, so I need to keep working on living smoke free. • 8 I still smoke, but I have begun to change, like cutting

back on the number of cigarettes I smoke. I am readyto set a quit date.

• 7 I definitely plan to quit smoking in the next 30 days. • 6 I definitely plan to quit smoking in the next 6 months. • 5 I often think about quitting smoking, but I have no

plans to quit.

Readiness to Quit LadderReadiness to Quit LadderCircle the one number that shows what you think about

quitting. Please read each sentence carefully before deciding.

• 4 I sometimes think about quitting smoking, but Ihave no plans to quit.

• 3 I rarely think about quitting smoking, and I have noplans to quit.

• 2 I never think about quitting smoking, and I have noplans to quit.

• 1 I have decided not to quit smoking for my lifetime. I have no interest in quitting.

Stages of changeStages of change

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• Chemical

• Medications

• Psychological

• Develop new coping mechanisms

• Habit or conditioned behavior

• New habit

Process of Nicotine addictionProcess of Nicotine addiction Triggers and Action PlanTriggers and Action Plan

Trigger

Strength

(0-4)

When do

I smoke

What is my

routine

New strategies for

dealing with each trigger

3 During

Breakfast

Wake up, drink coffee, smoke

1. Switch to drinking tea.

2. Eat in different room.

3. Water flowers

Self Monitoring Log

• Set a quit date• Start daily medication 1-2 weeks before

your quit date• Start as needed medication on your quit

date• Cut back on a regular basis

• Eq. cut out 2 cigarettes per week.• Use as needed medication to help you

cut back• Start daily medication 1-2 weeks before

you are scheduled to be quit. (if needed)

Quit PlanQuit Plan

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Managing CravingsManaging Cravings• Avoid triggers• Get support• List reasons for

quitting• Stay busy

• Smoke Free Zone.• Use approved

medications.• Take it one day at a

time.

Supporting your QuitterSupporting your Quitter

Emphasize positive outcomes of stopping tobacco, not on just the costs of continued use.Do not nag or criticize If you are a smoker, do not smoke around themGet rid of items that could be a trigger, lighters,

ash trays or spit cups.Make your home and car a “smoke free” zone.

The Ohio State University Wexner Medical Center, Thinking about Quitting. May 30, 2012.

Has Rebecca gained anything by switching?

Has Rebecca gained anything by switching?

What's the bottom line?What's the bottom line?• E-cigarettes have the potential to benefit adult smokers who

are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.

• E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.

• While e-cigarettes have the potential to benefit some people and harm others, scientists still have a lot to learn about whether e-cigarettes are effective for quitting smoking.

• If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start.

• Additional research can help understand long-term health effects.

“Source: CDC”; “Materials developed by CDC”);

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Nicotine and breast milkNicotine and breast milk Nicotine poisoningNicotine poisoning

E-cigarettes and home oxygen use

E-cigarettes and home oxygen use

E-cigarette use in public areas

E-cigarette use in public areas

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Diacetyl and e-cigarettesDiacetyl and e-cigarettes Medications used in tobacco treatment

Medications used in tobacco treatment

© The Ohio State University Wexner Medical Center, 2019© The Ohio State University Wexner Medical Center, 2019

Remember to e-mail us your questions.Remember to e-mail us your questions.

Our doctors will respond to your emailed questions.

Our doctors will respond to your emailed questions.

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