A word from Big Tobacco

“If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle”

- Diane Burrows – R.J. Reynolds Tobacco Co – February 29,1984

“We at Philip Morris USA have long held the position that minors should not smoke and should not have access to cigarettes, and we have backed that commitment over the years with a series of concrete actions.”

-- James Morgan

President Philip Morris

1995

1981 – “[T]he success of Marlboro Red during its most rapid growth period was because it became the brand of choice among teenagers who then stuck with it as they grew older.”

1992 – “Thus, the ability to attract new smokers and develop them into a young adult franchise is key to brand development.”

Public Relations

1979 - “It seems to me our objective is…a ‘media event’ which in itself promises a lot but produces little.”

1995 – “If we don’t do something fast to project the sense of industry responsibility regarding the youth access issue, we are going to be looking at severe marketing restrictions in a very short time.”

Big Tobacco’s Global Reach on Social

Media• The tobacco industry says

it no longer tries to hook new generations of smokers. So what’s behind the legions of beautiful young people in smoking, vaping and partying posts with the same hashtags?

By Sheila Kaplan

Aug. 24, 2018

New York Times

Jon Oliver - Tobacco

https://www.youtube.com/watch?v=6UsHHOCH4q8

Big Tobacco’s Playbook?

• Enticing• Advertising

• Social Norm

• Flavors

• Addict• Hook ‘em Young, Hook ‘em For Life

• Spread Doubt• Question the data

• Distort Scientific probability

Greg Holzman, MD, MPH

State Medical Officer

The Tobacco Epidemic: Déjà vu all over again

Greg Holzman, MD MPH DOES NOT have any financial interest/arrangement or

affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the

subject of this presentation. He will not be discussing unlabeled or investigational

commercial products in the course of this presentation.

Disclosures

Learning Objectives• Participants will understand some of the major historical issues that

created the current health tragedies cause by tobacco products

• Participants will understand the current controversy over new tobacco products – such as e-cigarettes (vaping, juling), hookah, etc. – and why so many tobacco control advocates are concerned that we may be repeating history

• Describe the impact of nicotine and tobacco use on Montana residents

• Discuss the financial cost of tobacco use for the state, medical institution, and third-party payer

• Discuss the implementation of various evidence-based interventional techniques for the nicotine-dependent patient

High Personal and Societal Cost• Number one preventable cause of death in the US

• 1 in 5 deaths are attributed to tobacco1

• 480,000 deaths attributed to smoking, annually

• For every person who dies because of smoking, at least 30 people live with a serious smoking-related illness2

• Enormous health care cost: $170 billion3

• Direct medical cost

• Medicaid cost: around 39.6 billion3

• Medicare cost: around 45.0 billion3

• Productivity losses caused by smoking: $151 billion3

Sources:1) Centers for Disease Control and Prevention. Smoking & Tobacco Use: Tobacco-related Mortality.

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm. Accessed April, 2018.2) Centers for Disease Control and Prevention. Smoking & Tobacco Use: Fast Facts. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.

Accessed April, 2018.3) Campaign for Tobacco Free Kids. The Toll of Tobacco in Montana. http://www.tobaccofreekids.org/facts_issues/toll_us/montana. Accessed April, 2018.

High Personal & Societal Cost in Montana

• Annual adult deaths from smoking: 1,600

• Kids that will ultimately die prematurely from smoking: 19,000

• Annual health care costs: $440 million

• Medicaid costs: $81.1 million

• State and federal tax burden to Montanans: $779 per household

• Productivity losses: $368.9 million

Source:Campaign for Tobacco Free Kids. The Toll of Tobacco in Montana. http://www.tobaccofreekids.org/facts_issues/toll_us/montana. Accessed April, 2018.

Cigarette smoking prevalence (%), by gender, U.S. adults >18, 1965-2012

Men

Women

MT Adult Smoking Prevalence, Special Populations, 2017

17%

46%

39%

25%

32%

39%

Montana Overall

American Indian

Income Less than

$15,000/yr LGBT

Adults w/ Less Than

H.S. Degree

Source: Montana Behavioral Risk Factor Surveillance System, 2017

Adults w/ Poor

Mental Health

• “Today tolerance for my smoking may be under attack. Tomorrow it may be tolerance for someone else’s right to pray or choose a place to live. So the real issues isn’t smoking against nonsmoking – it’s discrimination against tolerance.”

-- Hugh Cullman -

Gave Free Cigarettes to psychiatric facilities

Funded and coordinated research on mental health

“Scientific Research and Corporate Influence: Smoking, Mental Illness, and the Tobacco Industry”

Stress relief and relaxation

https://truthinitiative.org/news/how-tobacco-companies-linked-cigarettes-and-mental-health

Kill with Corporate Kindness

Give, give, give• National urban League

• Churches

• Political

• Social

• Artistic

• Banks and Insurance Co.

• Media Groups

• “Fast method of building image in the inner city black segment is exposure through involvement with the community”

-- R.J. Reynolds, Chicago Metro Marketing Plan for the Inner City Black Segment (1976)

How Did We Get Here

“Those who cannot learn from history are doomed to repeat it.”

--George Santayana

“How did I get here”

-- Talking Heads

Source: U.S. Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General.

The rise of the cigarette

• Bonsack cigarette rolling machine, 1884

• Era of modern advertising (Camels, 1913)

• World War I

Historical Review

• Lung cancer very rare early 20th century• 1914 – 0.6 per 100,000

• 1930 – 4.9 per 100,000

• 1990 – 75.6 per 100,000

Wayne “Marlboro Man” McLarenSept 12, 1940 -- July 22nd 1992

CAMELS, 1913

ARCHIVAL CIGARETTE DOCUMENTS

Honus Wagner

$2.8 million

http://www.mandatory.com/culture/961395-family-finds-hidden-stockpile-ty-cobb-baseball-cards-worth-1-million

War is harmful…but very good for cigarette manufacturers

Early interest in potential market of women smokers

• George Washington Hill, president of American Tobacco said in 1928, getting women to smoke “will be like opening a new gold mine in our front yard.”

• But tobacco companies did not advertise to women, for fear of sparking public outcry. Advertising was indirect.

Early interest in potential market of women smokers (cont’d.)

• 1920 Constitutional amendment gave women right to vote

• Edward Bernays, inventor of modern public relations, decided to sell cigarettes as “torches of freedom” for women (women’s liberation)

A special Va. Slims ad

Early ad campaign

Morphed into…

Why?

The Celebrities, The “Experts”, The Opinion Leaders

More health themes

And, would you believe…

Marlboros!

Of course, Marlboro was forever thereafter targeted at men

Wasn’t it?

Historical Review

• Major events • A prospective study by Drs. Doll and Hill “The mortality

of doctors in relation to their smoking habits: a preliminary report”

• Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service –1964 report

• Respiratory health effects of passive smoking lung cancer and other disorders – EPA 1992

Source: U.S. Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General.

“Scientific Facts”

• "AND NOW - CHESTERFIELD FIRST TO GIVE YOU SCIENTIFIC FACTS IN SUPPORT OF SMOKING."

"A responsible consulting organization reports a study by a competent medical specialist and staff on the effects of smoking Chesterfields...

'It is my opinion that the ears, nose, throat and accessory organs of all participating subjects examined by me were not adversely affected in the six-month period by smoking the cigarettes provided."

WARNING: There is no safe tobacco product. The use of any tobacco product — including cigarettes, cigars, pipes, and

spit tobacco; mentholated, "low-tar," "naturally grown," or "additive free" —

can cause cancer and other adverse health effects.

Smoking reduces life expectancy an average of about 10 years by

way of lung cancer, heart disease other illnesses, according to the

CDC.

No Safe Exposure Level to Secondhand smoke

Classed by the EPA since 1992, as a Class A carcinogen along with only 15

other substances (asbestos, radon, benzene, arsenic and mustard gas)

“No one has ever become a cigarette smoker by smoking cigarettes without nicotine”

--W.L. Dunn (Phillip Morris), 1972

Tobacco Executives

Characteristics of an Addictive Drug

• The concentration of the drug achieved

• The rapidity with which that concentration is achieved

• The magnitude of the drugs effects• (How widespread the

effects of the drug are on the organism)

Nicotine is a Drug of Addiction

After inhaling, nicotine reaches the brain in

7-10 seconds• “Euphoria” without being “Stoned”

• Immediate REINFORCEMENT of drug-taking behavior

• Moment to moment titration of dose to achieve the desired effects

Nicotine’s Effect on the Brain

Mesolimbic Dopaminergic System

The “Pleasure-Reward System”

Nucleus Accumbens

Nicotine’s Effects on the Brain

The Reticular Activating System (RAS)

Locus CeruleusGeneralized

CorticalActivation/Arousal

Alertness

Concentration

Memory

Problem Solving

Nicotine is a Drug of Addiction

• Nicotine accumulates in the blood as cigarettes are smoked throughout the day => TOLERANCE

• Half-life (T 1/2) is 2-3 hours• Nicotine levels drop overnight => EUPHORIA and

STIMULATION with first cigarettes to maintain the addiction

Most Smokers want to quit

• Around 70% of smokers want to quit

• Half of smokers try to quit each year

• Only about 6% succeed*

Nicotine Addiction:“A Brain Disease”

• Physical Dependence• Increased numbers of Nicotine receptors• Increased intracellular gene expression with

protein and neurotransmitter synthesis => “MEMORY”

• Psychological Dependence• Cues trigger neurotransmitter release

• The Five Senses• Emotions (positive and negative)

• Results in “Euphoric Recall” (CRAVING)

It is a Disease“Not a Bad Person with a Bad Habit, but a Good Person with a Difficult Disease”

--Tom Gauvin, NDC Counselor

The 5 “A” Intervention

• ASK about Tobacco Use (Tobacco as a vital sign)

• ADVISE to stop

• ASSESS willingness to make an attempt

• ASSIST in the stop attempt

• ARRANGE for a follow-up visit

“Not since the polio vaccine has this nation had a better opportunity to make a significant impact in public health.”

-- David Satcher, MD,MPH US Surgeon General

Source

Most of the following slides are taken directly from two

documents

• Treating Tobacco Use and Dependence•Quick Reference Guide for clinicians• and•A How-To packet for implementing the

US Public Health Service Clinical Practice Guidelines

Ask

• Systematically identify all tobacco users at every visit

Advise• Strongly urge all tobacco users to quit

• In a clear, strong, and personalized manner, urge every tobacco user to quit.• Clear – Important, cutting down not

enough

• Strong – Most important thing you can do to protect your health

• Personalized – link to current healthy/illness, social and / or economic situations

Assess

•Determine willingness to make a quit attempt• Time• Participate in intensive treatment• Don’t want to quit? – provide

motivational intervention• Modify for special populations

Patients not ready to quit

• RELEVANCE: Tailor Advice and discussion to each patient

• RISKS: Outline risks of continued smoking

• REWARDS: Outline benefits of stopping

• ROAD BLOCKS: Identify barriers

• REPETITION: Reinforce the motivational message at each visit

Withdrawal Symptoms

• Insomnia

• Restlessness

• Anxiety, Irritability, Frustration, Anger

• Difficulty concentrating

• Sad, Depressed mood

• Increased appetite

Withdrawal Symptoms

• Headache

• Mouth ulcers

• Nausea

• Constipation

• Diarrhea

Assist

•Aid the patient in quitting• Pharmacological – if not contra-indicated• Counseling

• Problem solving

• Skills training

• Social Support• Intra-treatment social support

• Extra-treatment social support

Guidelines for pharmacotherapy

• Seven first line FDA approved pharmacotherapies• Bupropion SR• Chantix (Varenicline)• Nicotine Gum• Nicotine Inhaler• Nicotine Nasal Spray• Nicotine Patch• Nicotine Lozengers

Guidelines for pharmacotherapy

• Second line Pharmacotherapies• Clonidine

• Oral• Transdermal

• Nortriptyline

• Lighter smokers - lower NRT • 10-15 cigarettes/day• no adjustment for bupropion

Possible Side Effects for all Nicotine Replacement products

•Dizziness

•Nausea

•Headaches

Nicotine Patch

• Availability – Over the Counter

• Side Effects – Local skin reaction, mild gastric or sleep disturbances

• Dosing -- 5 mg, 7 mg, 10 mg, 14 mg, 15 mg, 21 mg, and 22 mg patches. (different brands); Also come in 24 and 16 hour delivery systems

• Duration – 8 weeks (weaning varies with brand)

• Cost (estimate) ~ 21 mg Nicotine Transdermal patches (14 each) ~ $39.99 {one patch per day ~ $2.85 per day}

• Remember: patches may not protect against acute cravings

• Quit Line Benefit: FREE 8 weeks

Nicotine Gum • Availability – Over the Counter

• Side Effects – Jaw soreness (make sure pt using medication correctly), dyspepsia, mild burning sensation in mouth and throat

• Dosing -- 2 mg and 4 mg dosages. Gum to be used Q 1 – 2 per awaken hour first 6 weeks, then one Q 2 to 4 awaken hours next 3 weeks, then one Q 4 to 8 awaken hours. (Max 30 per day)

• Duration – 12 weeks (longer as indicated by provider) Some use ad lib.

• Cost (estimate) ~ 2 mg (100 pieces) ~ $49.99; 4 mg (100 pieces) ~ $49.99 {Estimating 21 pieces per day ~ $10 per day};

• Remember: Chew, taste, and park. Do not use acidic beverages 15 minutes before and during use of gum

• Quit Line Benefit: FREE

Nicotine Lozenge• Availability – Over the Counter

• Side Effects – Hiccups, Heartburn

• Dosing -- 2 mg and 4 mg dosages. Lozenge to be used one Q 1 – 2 awaken hours first 6 weeks (around 8 to 9 lozenges per day), then wean as tolerated (Max 20 per day, 5 per six hour period)

• Duration – 12 weeks (longer as indicated by provider) Some use ad lib.

• Cost (estimate) ~ 2 mg (81 lozenge) ~ $49.99; 4 mg (81 lozenge) ~ $49.99 {Estimating 9 pieces per day ~ $5 per day}

• Remember: Do not chew; Do not eat or drink for 15 minutes before and during use of lozenge

• Quit Line Benefit: FREE

Nicotine Nasal Spray• Availability – prescription only

• Side Effects – Watering eyes and nose, Nasal and throat irritation, sneezing and coughing (usually dissipates with increase use), don’t use with active airway disease

• Dosing – 1 to 2 doses per hour (one dose = one spray in each nostril) {Min 8 doses per day, Max 40 doses per day} (average 14 to 15 doses per day)

• Duration – 6 - 8 weeks initial therapy then gradual taper over 4 to 6 weeks. Use up to 8 weeks

• Cost (estimate) ~ 10 mg/ml solution (120 ml) ~$ 359.10 {Estimating 15 doses per day ~ $4.50 per day}

• Remember: One dose equals one spray in each nostril

• Quit Line Benefit: Not available

Nicotine Inhaler• Availability – prescription only

• Side Effects – local irritation of throat and mouth, dry mouth

• Dosing -- 6 to 16 cartridges per day (max 20 cartridges, average 6 cartridges), continuous puffing over 20 minutes

• Duration – 3 months after which gradually reduce daily dose over next 6 to 12 weeks

• Cost (estimate) ~ 10 mg (168 each) ~ $125.97 {Estimating 8 cartridges per day ~ $6 per day}

• Remember: Nicotine absorbed through buccal mucous, cold temperatures decrease dosage delivery of nicotine

• Quit Line Benefit: Not available

Nicotine Replacement Therapy is Safe

• No exposure to carbon monoxide

• NRT has no effect on coagulation (clotting)

• Pharmacokinetics of nicotine from smoking is different than with NRT

• Levels of nicotine achieved with standard dosing of NRT is less than with usual tobacco use

Varenicline (Chantix)• Availability -- prescription only

• Contraindications – A reduced dose may be needed for those with a history of renal impairment, serious psychiatric illness or undergoing dialysis.

• Side Effects – Nausea, Vomiting, Gas, Constipation, Changes in Dreaming

• Dosing – 0.5 mg every day for 3 days, then 0.5 mg in the morning and again at night for 4 days, then 1 mg in the morning and again at night for remainder of treatment

• Duration – 12 weeks to 24 weeks

• Cost (estimate) ~ $13.00 per day

• Quit Line Benefit: Currently FREE

Bupropion SR

• Availability -- prescription only

• Contraindications -- History of Seizures; History of Eating Disorder

• Side Effects -- Insomnia, Dry Mouth

• Dosing -- 150 mg every morning for three days then 150 mg twice daily (Begin treatment 1-2 weeks pre-quit)

• Duration -- 7 to 12 weeks (longer as indicated by provider)

• Cost (estimate) ~ $ 1.16 per day

• Quit Line Benefit: Currently FREE

Nicotine Replacement TherapyUSPHS Guideline

No evidence of increased cardiovascular risk with NRT

Nicotine Patch TherapyInitial Dosing Based on Smoking Rate

Mayo Clinic Model

<10 cpd 7-14 mg/d

10-20 cpd 14-22 mg/d

21-40 cpd 22-44 mg/d

>40 cpd 44+ mg/d

E-cigarettes and Cessation

• E-cigarettes have the potential to benefit non-pregnant adult smokers if used as a complete substitute for all cigarettes

• However, e-cigarettes are not an approved FDA cessation product

• If someone uses e-cigarettes to quit conventional tobacco, they should be advised to quit e-cigarette use in the near future• Long-term health effects of e-cigarette use unknown

The least risk comes from cessation from all tobacco products.

Tobacco Dependence:A Chronic Disease

• There is a spectrum of disease severity

• Effective treatments are available

• High dose and multi-drug regimens may be necessary to achieve the target goals

• May require referral to specialists

• Individualized therapy is important

Individuals who may need more intensive therapy (more aggressive pharmacological therapy)

• Smoke more than a pack per day

• Smoke within 30 minutes of awakening

• Several withdrawal symptoms

• Early relapse

• History of psychiatric disorders

• Current or recovering dependence on alcohol or other drugs

• Presence of other smokers in the household

Assist: providing practical counseling

•Abstinence

•Review past quit experience• Success• Triggers for relapse

•Anticipate triggers, challenges

•Alcohol – can lead to relapse

•Other smokers – limit exposure

Arrange – schedule follow up

•Timing• Quit week• First 1 month

•Follow-up conversation

Montana Tobacco Quit Line• Available to all Montanans

• For all types of tobacco

• 5 coaching sessions

• Free personalized quit plans

• Free nicotine replacement therapy

• Reduced price prescription medication

(Chantix, Bupropion)

• Motivational interviewing

Fax and online provider referral available

4-7%

11-14% 12-16%

15-19%

22%

25-30%

34%

50%

0

10

20

30

40

50

60

Unaided Self-help Group Counseling Individual Counseling

Medication Alone Medication + Counseling

Montana Tobacco Quit Line

Montana Quit Line + Chantix

Tobacco Quit Rates by Type of Quit Attempt

National Jewish Health, Montana Tobacco Quit Line Data.Fiore, M.C.,Jaen, C.R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline, Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

Montana Tobacco Quit Line

• Hours of Operation• Staffed 7 days a week from 5am to 11pm• Except Thanksgiving and Christmas

• 24 hour voicemail, callers encouraged to leave a message and they will be called back

• Electronic, Web, and Fax referral system for health care providers

• Healthcare providers can also call for free information or assistance in helping their patients quit tobacco.

Free Nicotine Replacement Therapy• Three types of NRT are available:

• Nicotine patch• Nicotine gum• Nicotine lozenges

• Up to 8 weeks

• Physician authorization may be needed for:• Patients with high blood pressure, cardiovascular disease, or

complex medical conditions• Pregnant women

• Each caller is eligible for medication and NRT’s once first coaching call is complete

• All NRT’s and prescriptions are shipped directly to the caller

Prescription

Chantix

• 1 month free

• Increasing costs?

Bupropion

• $5 co-pay per month

• For three months

Quitline Programs

• Phone Only• Coaching over the phone, plus materials, and quit

planning

• Access to NRT’s

• Online Only• Materials, quit planning, and quit progress tracking

through our website

• Phone + Online• Coaching over the phone, plus email, text, chat, web-

based materials, and quit progress tracking though our website

• Access to NRT’s

American Indian Commercial Tobacco Quit Line

• American Indian coaches

• Culturally sensitive coaching that distinguishes between traditional tobacco and commercial tobacco

• Additional counseling support (10 coaching sessions)

Quit Now Montana Pregnancy ProgramPregnancy and Postpartum

• Dedicated female coaches

• Cash incentives for completed

coaching calls

• Extended coaching calls (9 during

pregnancy and postpartum)

• Free NRT before and after the baby is

born, with doctors approval

Promotional Materials

• Items available

• Pamphlets

• Posters

• Magnets

• Stickers

• Signs

• Fax referral forms

• Available at no cost to you on MTUPP’s website

http://mtupp.allegrahelena.com/

Contact Information

Jennifer Floch, MPHTobacco Cessation Health Educator

Chronic Disease Prevention and Health

Promotion Bureau

PO Box 202951 | 1400 Broadway | Helena

MT 59620-2952

406.444.5687 | fax 406.444.5900 jennifer.floch@mt.gov

E-cigarettes

What are E-cigarettes?

Image source: vapor4life.com

Nicotine Content: Cigarettes vs. E-cigarettes

Cigarette

• 1.1mg-1.7mg per cigarette or

• 22mg-34mg per pack

E-cigarette

• Most vary from 0-36mg

• High potency brands JUUL: 59mg/mL or 40mg in one pod

Image source: vapor4life.comSources: National Cancer Institute, ‘‘Cigars: Health Effects and Trends,’’ NCI Smoking and Tobacco Control

Monograph 9, 1998.Public Health Law Center. JUUL & the Guinea Pig Generation.

http://www.publichealthlawcenter.org/sites/default/files/resources/JUUL-and-the-Guinea-Pig-Generation-2018.pdf

What do we know about E-cigarettes?

• Long-term health effects unknown

• 99% of e-cigarettes sold contain nicotine

• E-cigarettes are not fully regulated by the FDA• We don’t know what’s in there

• Studies have found harmful and potentially harmful chemicals:*

Source: Cheng T. Chemical evaluation of electronic cigarettes. Tob Control 2014;23(Suppl2): ii11–17

Carcinogens Metals, toxins, stimulants & irritants

• Acetaldehyde • Diacetyl (popcorn lung)

• Benzene • Diethylene Glycol

• Formaldehyde • Cadmium

• Nickel • Lead

• Nitrosamines • Silver

• Tin

• Toluene

Challenge: E-cigarettes

“Aerosol from e-cigarettes is not harmless.” - 2016 Report of the Surgeon General

Source: Centers for Disease Control and Prevention

Big Tobacco’s Playbook

•Entice• Advertisements• Social Norming• Flavors• Etc.

•Addiction• Nicotine content

•Obscuring the facts, question the science

Seen This Show Before

•Filtered

•Low Tar

Is History Repeating Itself?OLD TOBACCO AD CURRENT E-CIG AD

LOOK FAMILIAR?

The authors of the study had connectionswith and received funding from the

tobacco industry

May be safer than combustible tobacco (less toxins)1) Complete substitute2) Wean off e-cigs

Or a way for quitting1) Not FDA approved2) Plan for weaning off e-cigs

And it works…

• One of the top 3 reasons youth use e-cigarettes = belief they are less harmful

• Perception of e-cigarettes as less harmful than conventional cigarettes = increased e-cigarette use

Sources: Amrock SM, Zakhar J, Zhou S, Weitzman M. Perception of e-cigarettes’ harm and its correlation with use among U.S. adolescents. Nicotine Tob Res. 2014;17(3):330–336. https://doi.org/10.1093/ntr/ntu156;

Morbidity and Mortality Weekly Report. Reasons for Electronic Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2016

Is History Repeating Itself?OLD TOBACCO AD CURRENT E-CIG AD

LOOK FAMILIAR?

Is History Repeating Itself?OLD TOBACCO AD CURRENT E-CIG AD

LOOK FAMILIAR?

Photo Source: http://choices.scholastic.com/story/e-cigarettes-can-they-kill-you-too

Is History Repeating Itself?1930 Even doctors vouch for cigarettes

Is History Repeating Itself?OLD TOBACCO AD CURRENT E-CIG AD

LOOK FAMILIAR?

Source: U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

E-cigarettes are NOT safe for youth

• Nicotine is harmful to the developing brain

• Youth who use e-cigarettes are 4 times more likely to use conventional tobacco in the future

Big Tobacco’s Playbook?

• Enticing• Advertising

• Social Norm

• Flavors

• Addict• Hook ‘em Young, Hook ‘em For Life

• Spread Doubt• Question the data

• Distort Scientific probability

Web Resources• http://www.cdc.gov/cancer/

• http://www.ahrq.gov/

• http://www.surgeongeneral.gov/tobacco/(also includes Spanish language handouts-can download and print USPHS guidelines)

• www.justquit.org(National Jewish - tobacco cessation resources)

• http://www.mayoclinic.org/ndc-rst/(Nicotine Dependence Center-includes links to publications by Mayo staff)

• www.quitnet.com(an internet site that can be given to all your patients)

Big Tobacco’s Saying Sorry (Because They Legally Have To)

References

• Annual smoking-attributable mortality, years of potential life lost, and economic costs 1995-1999. MMWR, 2002

• Tobacco Use – United States, 1900-1999, MMWR, 1999 Nov 5;48(43):986-93.

• Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.

• CDC, Cigarette smoking among adults – United States, 2000, MMWR, 2002:51:642-5

• CDC, Cigarette smoking among adults – United States, 2004, MMWR, 2005:54:1121 – 4

• Henning field JE, Reginald FV, Buchhalter AR, Stitzer, ML Pharmacotherapy for Nicotine Dependence, CA Cancer J Clin. 2005:55;281 – 299

References

• Zevin S, Jacob III P, Benowitz NI. Dose-related cardiovascular and endocrine effects of transdermal nicotine. Clin. Pharmacol Ther 1998;64;87-95

• Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs –United States, 1995 – 1999. Morb Mortal Wkly Rep 2002;51:300-303

• US. Department of Health and Human Services. The health consequences of using smokeless tobacco: Report of the Advisory Committee to the Surgeon General. NIH Publication No. 85-2874. Bethesda, MD: US Department of Health and Human Services, Public Health Service. 1986

• Critchley JA, Unal B. Health effects associated with smokeless tobacco- a systematic review. Thorax 2003;58: 435-443