Electronic Cigarettes AKA: ENDS, Vaping Products

Electronic Cigarettes AKA: ENDS, Vaping Products

Electronic Cigarettes AKA: E-cig, ENDs, Vaping Products, Mods, eGo Holly A. Tucker, DC Masters of Public Health Candidate University of Tennessee - Knoxville April 2015 About the Presenter BS Exercise Science BS Human Biology DC Doctor of Chiropractic

*MPH Masters of Public Health *Health Policy Certificate Anatomy of an e-cigarette Cartridge (nicotine and other liquids) Vaporizer, Atomizer or heating element Battery and electronics E-Liquid or Juice Contents Nicotine

Water Propylene glycol Glycerol Flavoring agents Examples of different electronic cigarette (e-cigarette) products. Grana R et al. Circulation. 2014;129:1972-1986 Copyright American Heart Association, Inc. All rights reserved. The Debate Research Agenda Research: Who uses e-cigarettes? 100.00% 90.00% 80.00%

70.00% 60.00% 50.00% 40.00% 2010 2013 30.00% 20.00% 10.00% 0.00% ul Ad 2013 se

tU r Cu m tS n re kr se -r U e Ev rm Fo

Sm er kr se -r U e Ev ul Ad ar w tA 2010

s es n e h ut o Y e Ev se -r U h ut o Y

se -U l a Du Research: Are they harmful to users? Published February 6, 2015 ENDs are hazardous to lung tissue Cause oxidative stress, inflammation Changes to lung cell morphology and affect viability Flavor agents (i.e., cinnamon) can cause damage in absence of nicotine

Research: Are they dangerous to children? Accidental Exposures Secondhand vapor Inhaling the byproducts Thirdhand vapor Skin exposure to vapor residue Poison Control Centers 1 215 September, 2010 February, 2014

1 Call to Poison Control per month 214 Calls to Poison Control per month Calls related to electronic cigarettes Over 50% of calls involved a child under 5 years Research: Are they dangerous to bystanders? Second-hand e-cigarette emissions contain cancer-causing chemicals, and could put children and others at risk if they are in proximity to users Kimberly Amazeen, VP of Public Policy and Advocacy, American Lung Assoc. Research: Whats in the e-liquid? No labeling laws

Amount of nicotine may vary Amount of other chemicals may vary Research: Are they safer than cigarettes? Conflicting reports Contain possible carcinogens, particulates Some sources imply safer option for those who have failed other methods Explosions and fires Less inflammatory response in tissues Research: Compare Cig vs. E-cig Smoking related diseases: oxidative stress, activation of inflammatory pathways and toxic effect of 4000 chemicals and carcinogens in tobacco smoke Nicotine: Literature shows it is not linked to cardiovascular disease. Other forms of nicotine

delivery useful in smoking cessation, Parkinsons, depression, dementia and UC. In vivo effects of e-cigarettes not studied (longitudinally) No more likely to have quit smoking at 1 year Research: Are they a Gateway Product? Children and non-smokers will initiate nicotine use greater with ENDS than expected when ENDS did not exist Renormalization making ENDs attractive may enhance smokings attractiveness due to similarity in product image The promotion of ENDs comes with at least one of the following messages or a combination of them: (a) try to quit smoking and if everything fails use ENDS as the last resort; (b) you do not need to quit nicotine addiction, just smoking; and (c) you do not need to quit smoking, use ENDs where you cannot smoke.

Research: Why are they flavored? Youth find flavors more attractive Marketed toward youth Use more flavors than adults Lead to dependence, lower intent to quit Create tolerance of harsh flavors Research: Who can buy them? Some states have not passed laws to prohibit minors from purchasing Internet/Non face-to-face sales Tax evasion No age verification (open to minors)

North Carolina Study Research: Who makes them? Conflicts of interest Tobacco companies own/buy e-cigs companies Pretending to be part of the solution of tobacco use Tobacco companies supporting government, opposing e-cigs Pharmaceutical companies GSK Nicoderm, Nicorette, Zyban feel heat from ecigs Research: How are they advertised? Following in Tobaccos path

2013 $82.1 million industry advertising Free samples Event sponsorships, recreation and youth-oriented NASCAR sponsors TV, Radio, Internet Celebrities selling masculinity, glamour, sex Conventional cigarette advertising has been banned from television since 1971. Website Ads: 59 brands 100% 95%

93% 95% 88% 90% 80% 76% 71% 73% 70% 64% 60% 50%

40% 30% 20% 10% 0% ier la th He r pe a e Ch r ne a e

Cl e ok m S s e ok aw L m e S e Fr nd e ha

d ok m on tS ec S n ve No m u c r Cu re he w

y An n er od M on ati s s Ce ts en em at St

Internet Memes Position: Pro E-cigarette Jeff Stier, National Center for Public Policy Helps smokers quit: cleaner nicotine, realistic replication of habit No first or second hand smoke Doesnt normalize smoking Not a gateway Sin Taxes In fact, treating e-cigarettes like cigarettes would undermine a central tenet of the U.S. FDAs approach to securing the potentials benefit of e-cigarettes, while minimizing any potential harm. American Council of Science and Health, Dr. Ross Public Health message that e-cigarettes are bad keeps people smoking, keeps tax income going. E-cig alarmists keep cigarette business booming. Agencies dont want legislation as alternative to tobacco product/regulation. Pharmaceutical methods dont work but they make money

E-cigarette Legislation Types of Regulation Current FDA Regulation Current: FDA regulates cigarettes, cigarette tobacco, rollyour-own tobacco and smokeless tobacco Proposed rule: Deeming products such as hookah, electronic cigarettes, cigars, pipe tobacco, novel products and future tobacco products as tobacco products, subject to Food Drug & Cosmetic Act regulations (enabling regulation) Proposed April 25, 2014. Decision slated for June 2015 States can regulate in absence of federal preemption Only claims related to treat or cure disease subject to current FDA regulation Commentary: What should the FDA do? Mitch Zeller, FDA: comprehensive nicotine regulatory policy, continuum of risk needed

Interim Safety Guidelines Instill confidence for safer way to use tobacco, yet caution its use Establish Good Manufacturing practices in devices and liquids Limits on amounts of chemicals Nicotine levels Flavors Insurance Implications NOT covered as smoking cessation tools or preventative benefit If e-cigs are deemed tobacco products by FDA, they could be subject to: Taxes, Regulation, Age restriction Surcharges and higher premiums on insurance Legislation Attempt

Child Nicotine Poisoning Prevention Act of 2015 would direct the Consumer Product Safety Commission to issue rules requiring safer, childresistant packaging for any liquid nicotine sold to consumers Feb. 26, 2015 Committee ordered amendment in nature of substitute US Sen. Bill Nelson (D-FL) State Reports Action: Deemed same as tobacco 3 States (ND, NJ, and UT) 100% Smokefree with e-cig Pending in CA Minnesota: if liquid nicotine is tobacco derived

Air Force Surgeon General all AF Installations Action: Banning in public places or indoors 15 States: Limited Restrictions (i.e., schools, workplaces) AR, CO, DE, GA, HI, KS, KY, MD, NH, OK, OR, SD, VA, VT, WI California: pending SB 140 Prohibits Smoking of E-Cigarettes at Workplaces, Schools, Restaurants and Hospitals (supported by ACSCAN, AHA, ALA) Minnesota: 2014 Legislation banning indoor public buildings (with counter display and packaging restrictions) Local entities City/County Ordinances Various schools, universities, daycares, hospitals and prisons Blount County, Tennessee Health Board Action: Child-resistant packaging Minnesota: required packaging for e-liquids Illinois: Special packaging required for refillables

Action: Taxing Minnesota: 95% Tobacco Tax of whole sale cost of e-juice cartridges or starter kit North Carolina (2014): $0.05 tax per mL of liquid nicotine Utah: Looking to tax e-cigarettes, Gov. Gary Herbert estimates $10 million revenue Introduced 2014 /Failed: DE, HI, IN, KY, NJ, OK, OR, PA, RI, SC, VT, WA Action: No sale to minors 40 states prohibit sales to over 18 year olds North Carolina 2013 Few states age 19 years to purchase New York City age 21 years to

purchase New York City Mayor Bloomberg bans e-cig use wherever smoking is banned (public places since 2011) Legal age to purchase tobacco products (including e-cig) to 21 years Minimum price per pack of cigarettes $10.50 Action: Inaction Michigan: Vetoed bill to restrict sales to 18+ year olds because language also excluded them from the definition of tobacco products Action: Public Health Education California What Could Go Wrong Other Countries European Union: Dec. 18, 2013 deemed as

tobacco products. If 3 countries pull the products for safety issues, all countries can vote to ban. Mayor of Normandy, France local ban (France has 1.5 million users) Winning vs. Losing Arguments Addictive to minors Data on teen use, compared to cigarettes, in lieu of tobacco products, etc. Poison Control Calls Target minors sensationalizing smoking image Not a proven cessation tool Not enough research to restrict use

Not Big Tobacco, propaganda Public Health responsibility to allow cigarette alternative on market without sin taxes or restriction (harm reduction) #vapingsavedmylife Government relies on tobacco tax Tennessee HB309/SB411 Tobacco products, restricts under age 18, adds: Store owners/managers train employees on sale of vapor products Child-resistant safety standards for liquid nicotine Exempts definition of smoking//allows for use where smoking current prohibited Status: Passed the Senate Committee April 6th

Tennessee Department of Health February 11, 2014 Advisory urges caution: Inadequate research on health effects No regulation on manufacture Levels of nicotine or contaminants vary Untested as smoking cessation devices Health threats to children (battery, liquid) Dual users of cigarettes, cumulative health impact Pregnant warning, effects of nicotine Update December 11, 2014: Use at Own Risk Tennessee Health Dept. Survey County Health Dept. and Regional Office Directors (54 contacts) 72 responses County/Metro or Region 57 of 95 counties represented, including 5 Metros

7 of 7 regions represented Survey Results: Policy Landscape To your knowledge, have any of the following local entities banned the use of tobacco (100% Smoke Free) from their property? T=172 Other Unsure Local City Government Other: Health Departments Local County Government Hospital Private business Higher Education Institution Public School Survey Results: Policy Landscape

To your knowledge, has a local (city/county) public policy on e-cigarette use or sales been established? T=72 15.28% 23.61% Yes No Unsure 61.11% What governing body established the local e-cigarette polcy? T=21 6 4 2 0 ty ali p i ic

un /M ty Ci Co v Go y t un t. lth ea H ty

un o C d ar Bo P ol ho c S lic ub u Ed r e

gh Hi n tio ca te tu ti s In l ta pi s Ho r

he t O ro et :M . pt De Survey Results: E-cig Prevalence To your knowledge, has any level of staff encountered the use of e-cigarette devices in your facility? T=72 To your knowledge, how often are clinical staff interacting with e-cigarette users? T=68 35 30

Unsure; 2.78% 25 No; 23.61% 20 Yes No 15 Yes; 73.61% 10 Unsure 5

0 Daily Weekly Monthly Never Unsure Are patients being asked their e-cigarette status during encounters at this facility? T=70 How are clinical staff counseling patients on e-cig use? T=79 35 30 25 Responses

20 15 10 5 0 Every Visit Some Visits First Visit Only Never Unsure 45 40 35 30 25 20 15 10 5 0

Encouraging use Not counseling Unsure Cautioning use Discouraging use Survey Results: Education Resources Which of the following entities have requested information from your health department on e-cigarettes? T=135 None requested 29 Health Board or Health Council 25 Individuals/Patients 21

Public School or School Board 17 Local County Government 13 Private Businesses Higher Education Institution 6 Hospitals or Physicians 5 Local City/Municipality Government

5 Other Health Department E-cigarette educational materials T=72 8 60 50 40 30 20 10 0 4 Other: Media 1

Other: TSF Planning 1 W Yes No Unsure av eh s ial er t a em W

s ial er t a em s eu What format do you prefer for educational materials on e-cigarettes? T=200 Other: PSAs, Online CEU, Targeted materials Webinars On-site Training Presentations Pamphlets Flyer/Handout/Fact Sheet 0 10

20 30 40 50 60 r sa ir al e at M ve

cti e ff ee W an or m t ls ria e at em Survey Results: Community Beliefs

What do you think the beliefs are about e-cigarettes in your community? T=113 1.77% 1.77% Safer than cigarettes Cessation Tool Public Unsure/Unaware Harmless vapor/No adverse health 2.65% 2.65% effects 3.54% 4.42% Unsafe44.25% or Health Threat 10.62% Other Youth Appeal/Coolness 13.27% Unsure Safer around children 15.04%

Not addictive Survey Results: Community Attitudes What do you think the attitudes are about e-cigarettes in your community? T=101 1.98% Acceptance/Positive/Safe Varied, Indifferent, Ignoring No health threat/Not 2.97% 2.97% 5.94% 5.94% 51.49%

7.92% 9.90% 10.89% Unsure Absence of Regulation=Acceptance Unsure Opposition/Negative Youth Appeal, coolness, status symbol Other Survey Results: Other Comments

Lack of resources for tobacco education in schools Combination of ground/media campaigns Ban does not educate about dangers E-cigs in PHN protocols TDH needs to advocate and support FDA regulation Need for more, fact-based information Clarify pre-emption status and definitions Notable Quotes Interviewees were unaware even that the devices contained nicotine, for example. Anecdotally, we have heard people refer to them as a healthier NRT for smokers. It seems likely, given the history of such things, that the community's initial beliefs will be formed largely by the propaganda of advertisement, which, in the absence of some governmental regulation, will almost certainly be better financed

and more prevalent than any factual counterargument derived from research and evidence. Success Stories Blount County Other Counties with information: Montgomery Carroll Knox Giles Greene Sumner Bedford Questions

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