1. Shelia Evans L.P.N. Manager Community Health Program 353-5767
E-cigarettes
Shelia Evans L.P.N.
Manager Community Health Program

2. Objectives Understand what e-cigarettes are and how they work
How e-cigarettes are marketed and the laws regarding them
Know health implications of e-cigarettes
How to counsel patients on e-cigarettes

3. E-cigarette Defination & History
Electronic cigarettes (e-cigarettes) are products that deliver a nicotine-containing aerosol (commonly called vapor) to users by heat
It was invented in the current form by a Chinese pharmacist in the early 2000s
The US patent application describes the e-cigarette device as “an electronic atomization cigarette that functions as substitutes for cigarettes and quitting smoking”

4. Components

5. Available Products Disposable e-cigarette Rechargeable e-cigarette
Pen-sized Rechargeable e-cigarette
Tank-style, large size, rechargeable e-cigarette

6. Popular E-cigarettes on Market
They range in size from cigarette size, to compact flashlight size, and you can get one in almost any color and style.
Halo $44.99
V2 Cigs
$34.95+
blu $79.95
Green Smoke
$59.99+
$99.95
VaporFi™
$29.99

7. Additional Components
Every e-cigarette has at least three main components inside - the battery, the tank, and the atomizer.
Sometimes there is another component between the liquid and the atomizer. This can be either a clearomizer or a cartomizer.

8. E-cigs and E-liquid Comes in a variety of flavors and nicotine levels
Many of the products leak creating the potential for dermal nicotine exposure and potential nicotine poisoning
Many fluids are from China, but are now being made in United States, Germany, and Europe

9. Terminology
E-cigarettes - often called e-cigs, personal vaporizers, PVs, Electronic Nicotine Delivery Devices (ENDS)
Liquid nicotine - E-liquid, e-juice or smoke juice
Vaper - Person who uses electronic cigarettes
Vape or Vaping - the act of smoking an e-cig
Vape or Vapor Shops - Retail stores selling electronic cigarettes

10. Rationale for E-cigarettes
Traditional cigarette sales are declining
Tobacco industry needed alternative product to redefine itself
Designed to mimic cigarettes
Presented as a safe alternative
Avoids tobacco laws and taxation

11. Dangers of Liquid Nicotine
Poison Control Centers shows that poisoning incidents involving e-cigarettes and liquid nicotine jumped by 156% in the past year
More than half the calls involved a child under the age of six, and one child has died
A typical cigarette has approximately 9 mg of nicotine but we only consume about 2-3 mgs
Low strength = 4-8mg of nicotine per milliliter
Mid strength = 10-14mg nicotine per millimeter
High strength = 16-18mg per millimeter
Extra-high strength = 24-54mg per millimeter

12. Tobacco Free Campaign

13. Main Ingredients in Vapor
Basic ingredients (as listed by most e-cigarette manufacturers): propylene glycol or glycerin, nicotine, flavoring chemicals
Additional chemicals found through product testing:
Diethylene glycol
TSNAs (low levels)
Formaldehyde Carcinogens
Acetaldehyde
Acrolein

14. Propylene Glycol
The Dow Chemical Company, a major manufacturer of propylene glycol, states in its product safety materials that the “inhalation exposure to [propylene glycol] mists should be avoided” (Dow Chemical Company, 2013)
The American Chemistry Council warns against its use in theater fogs due to its potential to cause eye and respiratory irritation

15. Health Risks of E-cigs
There is little research on direct health effects
One study shows short-term pulmonary effects
There is evidence of cytotoxicity in animals and humans
No safety standards for e-cigarette components
A few of the additional toxins in vapor:
Ethylbenzene, Benzene, Toluene, Acetaldehyde, Naphthalene, Styrene, Acrolein, Nickel, Chromium, Cadmium, Selenium, Arsenic , Lead, Cobalt, Chlorobenzene, Crotonaldehyde, Chrysene, Retene FDA 2012, Harmful and Potentially Harmful Substances – Established List

16. Do E-cigarettes Reduce Harm?
There are still a lot of unknowns about e-cigarettes
The hope that they will reduce harm by delivering "clean" nicotine is debatable and will not be realized in continuing dual users including the cardiovascular risk
Cancer risk may only be modestly affected because smoking duration is more important than intensity

18. Can be Used for Other Drugs
E-cigarettes can be altered by users and be used to deliver other drugs

19. Second-Hand Smoke
E-cigarettes pollute the air less than conventional cigarettes, but they pollute the air
They do not just emit "harmless water vapor"
People passively exposed to e-cigarettes aerosol absorb nicotine (measured as cotinine), with one study showing levels comparable to passive smokers

20. Cessation
Marketed as healthier alternative to tobacco smoking and as useful for quitting
The temporal and causal relationships between e-cigarette use and smoking have not been determined
There is a high level of dual use of e-cigarettes and conventional cigarettes among adults
Used as a way to circumvent smoke-free laws by enabling users to “smoke anywhere”

21. Do They Help People Quit
E-cigarettes have not been proven to help people quit smoking
Longitudinal population studies show that e-cigarette use is associated with a lower odds of quitting
The randomized trial comparing e-cigarettes to nicotine patch shows that in the context of low level behavioral support, the quit rate for those using e-cigarettes is low

22. The Rise of E-cigarettes
Retail sales of over 1 billion
U.S. comprises 30% of the 6 billion global market
Could surpass consumption of traditional cigarettes in the next decade
Youth use rose from 4% in 2011 to 10% in 2012
In 2012 over 1.78 million middle and high school students used them

23. Marketing
E-cigarettes are evolving rapidly and being marketed like cigarettes were in the 1950s and 1960s
Aggressive placement in convenience stores (next to candy or medications)
E-cigarettes are marketed via television, the Internet, and print advertisements (that often feature celebrities)

24. Youth Youth are rapidly adopting e-cigarettes
E-cigarettes contain candy flavors (e.g., cherry, chocolate, turkish delight)
Youth who use e-cigarettes are heavier smokers
Youth who use e-cigarettes are much less likely to have stopped smoking
There are high levels of dual use

25. Promotion of E-cigarettes
Jenny McCarthy promoting blu
e-cigarettes.
Logo: Take Back Your Freedom

26. Marketing Sponsorships
Blu E-Cigs was the primary sponsor of an Indy car at the Toyota Grand Prix of Long Beach Race Event
(April 2013)

27. Tobacco Industry
E-cigarette companies were competing with conventional cigarette companies, but now all the major cigarette companies are in the e-cigarette business
E-cigarette companies are using the same political and public relations strategies as cigarette companies (most notably organizing users, similar to how the cigarette companies organized smokers)

29. Transform Tobacco: Issues in Indiana
Higher Taxes Affect You. State legislators can push for higher cigarette taxes at any time. That’s why it’s important for you to make your voice heard on this important issue by contacting your elected officials today.
Call your elected officials: (toll-free)
The excise tax on one pack of cigarettes in Indiana is currently $0.995.
Take a closer look at the cigarette tax dollars being collected in Indiana in FY2013.​
$434,473,203 Cigarette Excise Taxes
$31,159,532 Other Tobacco Products Taxes
$161,866,120 Cigarette Sales Taxes
$129,467,003 Tobacco Settlement
$756,965,858 Total Smoker Payments FY2013 ​

30. Policy Making
At a minimum, these policies should be implemented immediately:
Prohibit the use of e-cigarettes anywhere where the use of conventional cigarettes is prohibited
Apply the same restrictions on e-cigarette advertising and promotion that apply to conventional cigarettes
Ban the use of characterizing flavors in e-cigarettes

31. Policy Making Continued
Prohibit claims that e-cigarettes are effective smoking cessation aids until such time as there is convincing scientific evidence that such claims are true for e-cigarettes as they are actually used in the general population.
Regulate e-cigarettes to set standards for product performance in order to minimize risks to users and bystanders
Tax them like cigarettes

32. What to Tell Your Patient
Be sure the advice you are giving doesn’t undermine their motivation to quit
Follow the 5 As of evidence-based treatment:
ask, advise, assess, assist, and arrange
Refer to the Quit line (1-800-QUIT-NOW)
If previous failure and wants to try e-cigarettes, support them but
Inform patients that products are unregulated, contain toxic chemicals, and are not proven cessation devices

33. Cessation Interventions
Key recommendations:
Clinicians should prescribe the first-line medications that reliably increase long-term smoking abstinence
Chantix
Zyban
NRT
classes

34. Three Phases of Nicotine Addiction
Physical addiction – when your body and brain feel different from lack of tobacco.
Psychological addiction – when you need tobacco to feel normal or deal with stress.
Social addiction – when you see one of your smoking friends and it triggers you to want to use tobacco.
In order to quit, you must approach all three aspects of the addiction.

35. Questions
What questions do you have?