APNA 30th Annual Conference Session 4024: October 22, 2016 Electronic Nicotine Delivery Systems Back Backgr grou ound (ENDS): Inf Information a rmation and D d Discussion on scussion on Early 2000’s by Chinese pharmacist Hon Lik El Electr ectronic Cig onic Cigare rett ttes a es and d “V “Vape P Pens” 460 brands 7,700+ flavor additives Carolyn Baird DNP , CARN-AP , FIAAN Carol Essenmacher DNP , CTTS October 22, 2016 (Brandon et al., 2015; Grana et al., 2014) Disclosure Discl re Descri Desc ripti ption Metal tube: heater/atomizer, battery, cartridge filled with liquid nicotine and other chemicals, light-emitting diode at The presenters have no conflict of interest to disclose end (mimic lit end of cigarette) Also known as: Vape pens, smokeless cigarettes, electronic nicotine delivery devices/systems (ENDD/ENDS) Objectiv Objectives es Type pes of END of ENDS The participant will be able to summarize key points on the safety and efficacy of ENDS. The participant will demonstrate the ability to provide peers and colleagues with clarifying information on the use of ENDS The participant will demonstrate the ability to provide patients with clarifying information on the use of ENDS CDC 2015 Essenmacher 1
APNA 30th Annual Conference Session 4024: October 22, 2016 Other Options: ENDS Other Options: ENDS Marketin Mark ing Alternative to conventional cigarettes Smoking cessation aid Less harmful / improved health Use nicotine in smoking-restricted areas CDC 2015 Clarification Clarific ion Marketing: Who Pr Mark ing: Who Prof ofits? its? Remember – 460+ manufacturers Not actually a vapor – is an aerosol (different sizes of particles) Between 2007 & 2013 ENDS businesses grew to $2 Billion /year industry Aerosol seen upon exhale is similar to “fog” machine Forecast: $10 Billion /year industry by 2017 (concerts) Research funded by tobacco companies: historical perspective Brandon et al, 2015; Shaw et al, 2015 Marketing Mar Chemi Chemicals F s Frequently ly Who Uses ENDS? Who Uses ENDS Found und in in ENDS (~42) ENDS (~42) Benzene (pesticides, gasoline) Cadmium (car batteries) Use of ENDS quadrupled in US between 2009 and 2010 Women more likely to try them; Men more likely to continue Formaldehyde (embalming use fluid) Lead 3x more likely to use if HS diploma or less Low income (<$15,000) more likely to try use Nicotine (pesticides/does not cause cancer) 6x more likely try ENDS and 3x more likely to continue use if Propylene Glycol (de-icing currently smoking solution) Toulene (industrial solvent) (CDC, 2015) (CDC, 2015; Group to Alleviate Smoking Pollution of Colorado) Essenmacher 2
APNA 30th Annual Conference Session 4024: October 22, 2016 ENDS & ENDS & Pa Patients w tients with th Percept eptions co ons conti ntinued… ued… Mental H ntal Health Is alth Issues es To not disturb others w/cig smoke (second-hand ENDS Prochaska & Grana (2014) found that 24% state they are exposure) using ENDS to quit, but there was no actual decrease in cigarettes smoked per day To use in smoking restricted areas (most ENDS restricted same places that cig smoking is banned) Dual Use (American Industrial Hygiene Association, 2014) No reduction in CPD with use of ENDS Patien Patient’ t’s P Perception of ENDS: eption of ENDS: Re Reporte ted P Pote tential B Benefits To quit smoking (Research does not support this) May decrease risks for adult patients who stop smoking and only To reduce cigarette consumption (Research does not support use ENDS, but no data to support that people are making total this) switch to only ENDS use To deal with nicotine withdrawal (Reduces cravings but not irritability, restlessness, poor concentration) (CDC, 2015) Percept eptions co ons conti ntinued… ued… Re Reporte ted P Pote tential & & Re Real H Harms Perceived safer than conventional cigarettes (no RCTs on Accidental poisonings ENDS users, no standardized dosing, types & concentrations of chemicals not studied, safety of flavor additives, sold to Nicotine can cause death in adults at 30-60mg and in children underage, etc.) at 10mg Cheaper than smoking (avg. costs to start ENDS kit = Refill bottles contain up to 1 GRAM of nicotine $120/per month vs 20cpd =$144/month) (CDC, 2015) Essenmacher 3
APNA 30th Annual Conference Session 4024: October 22, 2016 Harms co s continued… ntinued… CDC CDC 18.4% report that nicotine leaks out of cartridge FINDI FI NDINGS GS POSIT SITION sometimes/often Dual use Not FDA approved, not harmless Exploding batteries/fires Possible benefit might be if Potential health risks for Increased respiratory resistance impedance, less exhaled carbon people who use ENDS adolescents, pregnant monoxide, Pneumonia completely quit tobacco women, non-smokers (CDC, 2015; Vardavas et al., 2012) FD FDA Youth and uth and ENDS ENDS FINDI FI NDINGS GS POSIT SITION Among high school youth, ENDS use tripled between 2013 (4.5%) and 2014 (13.4%) Require registration with FDA Growing health risks and report all product ingredients Middle school students increase ENDS use: 1.1% (2013) to Require childproof caps on Adolescents using 3.9% (2014) ENDS liquids Warning labels on products & advertisement Associated risks from liquid 13% high school students used ENDS compared to 9% cigarette Prohibit youth-oriented use) marketing and sales Prohibit child-friendly ENDS flavors “Enjoy the taste” “Sweet Tarts” and “Unicorn Puke” Prohibit ENDS where smoking prohibited. (CDC, 2015) Surgeo Surgeon Genera n General MAJOR STAKEHOLDERS FI FINDI NDINGS GS POSIT SITION No evidence that they Research Findings and Positions work Regulation Growing use by adolescents Public health concerns Essenmacher 4
APNA 30th Annual Conference Session 4024: October 22, 2016 American I erican Industrial H dustrial Hygiene ene Americ American L Lung Assoc ng Associat ation Asso Associati ation FI FINDI NDINGS GS POSIT SITION FINDI FI NDINGS GS POSIT SITION Nicotine not safe Additional chemicals Does not recommend Concerned about the delivered to lungs using until further research Increased use by impact of use, especially by adolescents who are at high adolescents risk Environmental pollution Ban use indoors due to Detectable levels of toxic occurs passive smoke exposure chemicals Diacetyl & lung disease Substances other than Second hand exposure nicotine are being smoked Attractive nuisance Ame American an Asso Associati ation f for Can r Cancer World Health Organization rld Health Organization Re Research & American S Society o of Clinic Cli ical Onco Oncology gy FI FINDI NDINGS GS POSIT SITION FINDI FI NDINGS GS POSIT SITION High level of dual use Recommends regulation Concerns for use by Support federal, state, and oncology patients local regulation of ENDS No evidence that people quit Dual use Less toxicants but still too much Need for research Passive smoke exposure American N Am erican Nonsmok nsmokers’ Rig rs’ Rights hts STAKEHOLDERS FINDINGS POSITIONS Foundation Fo CDC Potential health risks Not harmless FDA Growing use by vulnerable Regulation starts Fall 2016 population FINDI FI NDINGS GS POSIT SITION SURGEON GENERAL No evidence that they work, Research: regulation growing health concerns Confusion about right to ENDS should be regulated use ENDS in smoke free the same as smoked American Industrial Hygiene Source of environmental Ban from smoke free zones Association pollution areas tobacco American Association of Cancer Health concerns Local, state and federal Research & American Society of regulation Clinical Oncology Public health concerns from exposure to second American Nonsmokers’ Rights Significant public health Should be considered the same Foundation concern due to second hand as smoking tobacco & banned hand ENDS smoke smoke from smoke free zones American Lung Association Public health concerns Should be regulated Essenmacher 5
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