@msdcenter

“E-Cigarettes: Panacea or Peril?” Special guest speaker: Michael P. Eriksen, ScD Dean, School of Public Health Georgia State University

Today’s Moderator

Cheryl L. Perry, PhD Professor & Regional Dean

The Rockwell Distinguished Chair in Society and Health The University of Texas School of Public Health

Austin Regional Campus

Today’s webinar will be recorded and available online next week at

msdcenter.org

Today’s Guest

Michael P. Eriksen, ScD Dean, School of Public Health

Georgia State University

E-Cigarettes: Panacea or Peril?

Michael&SusanDellCenterforHealthyLivingOctober28,2015MichaelP.Eriksen,ScDDean,SchoolofPublicHealthGeorgiaStateUniversity

Disclosures FundingSources

•  NIH/NIMHD(P20MD004806)•  NIDA(P50DA036128)•  Pfizer,Inc.(DiffusionofTobaccoControlFundamentalsinLargeChineseCiWes)

DisclaimerResearchreportedinthispresentaWonwassupportedbyNIDAandFDACenterforTobaccoProducts(CTP).ThecontentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsoftheNIHortheFoodandDrugAdministraWon.

AcknowledgementsCathyKemp,MHA;RachelLawley,MPHMBA;BanMajeed,PhD;PraWbhaNayak,PhD;AmyNyman,MA;TerryPechacek,PhD;PamRedmon,MPH;Sco`Weaver,PhD

Webinar Objectives

•  Recognizethattobaccouseistheworld’sleadingpreventablecauseofdeath.

•  UnderstandthatmostoftheharmcausedbytobaccoisduetocombusWon(smoke)

•  Realizethate-cigare`escouldplayanimportantrolebyincreasingcessaWonamongindividualsmokers.

•  DifferenWatebetweenthepossiblebenefitthate-cigare`esmayhavetoindividualsmokerscomparedtothepotenWalharmtopopulaWonhealth.

•  AcknowledgetheneedforeffecWveregulatoryacWontoopWmizeindividualbenefitandminimizepopulaWonharm.

•  Guidehealthprofessionalsonhowtodiscusse-cigare`eswithsmokers.

Globally, tobacco use is the largest preventable cause of death (6.3 million deaths annually)

The majority of harm from tobacco occurs as a result of smoke – a product of combustion

Current tobacco control strategies won’t result in single-digit smoking prevalence. We need to disrupt the status quo

Unpublished Data: Mendez and Warner, University of Michigan School of Public Health

Can novel nicotine products serve as a disruptive technology and advance public health?

Sources:MarkTen®Markten.com;VUSE®fromVusewapor.com;Blu®fromblucigs.com;Orbsfromtheevolvement.org;Hookahfromhookashisha.org;allotherimagesfromWkimediaCommons

E-cigs and tank systems (ENDS) heat liquid nicotine and create a vapor rather than burn tobacco and create smoke…Thus, fewer toxins

Will ENDS be a panacea or peril?

Fromanindividualperspec1ve…•  Smokingcombustedcigare`esisthesinglegreatestcauseofdeathintheworld.

•  CurrenttobaccocontrolmethodswillnotachievepublichealthobjecWves.

•  Properlyregulated,e-cigshavethepotenWalofprovidingnicoWneatamuchlowerlevelofharm.

Fromapopula1onperspec1ve…E-cigare`escould-

•  IncreaseyouthiniWaWon•  Promotedualuse

•  DelaycessaWon•  Providedifferenthealthrisks•  EnWceformersmokersbacktonicoWne

•  Re-normalizesmoking

•  ConWnueaddicWon•  SetbackprogressfromestablishinghealthpromoWngsocialnorms

Teens and E-cigarettes

Current e-cigarette use among high school students tripled between 2011 and 2013

*Currentuseisdefinedasuseononeormoredaysinthelast30daysSources:CentersforDiseaseControlandPrevenWon.NotesfromtheField:ElectronicCigare`eUseAmongMiddleandHighSchoolStudents—UnitedStates,2011–2012.Morbidity&MortalityWeeklyReport.2013;62(35):729-730andunpublisheddata.

1.5

0.6

2.8

1.1

4.5

1.1

0

1

2

3

4

5

HighSchool MiddleSchool

Percen

tageofR

espo

nden

ts

CurrentE-Cigare:eUse*Na>onalYouthTobaccoSurvey,UnitedStates

2011 2012 2013

E-cigarette use among never smoking youth •  From2011-2013,thenumberofneversmokingyouthwhousedane-cigsincreasedthree-fold

•  In2013,over250,000neversmokingyouthusede-cigare`es

•  IntenWontosmokecigare`eswashigheramonge-cigare`eusers

Source:Bunnell,Agaku,Arrazola,Apelberg,Caraballo,Corey,Coleman,Dube,andKing.IntenWonstosmokecigare`esamongnever-smokingU.S.middleandhighschoolelectroniccigare`eusers,NaWonalYouthTobaccoSurvey,2011-2013NicoWneTobRes.Epubaheadofprint.

Nearly half of U.S. students using tobacco use multiple products, especially e-cigarettes.

2014NaWonalYouthTobaccoSurvey,FDA.gov

Unintended consequences of ENDS: Youth use

The e-cigarette quandary: helping smokers quit while enticing new addicts. The e-cigarette dilemma “E-cigarettes pose a public policy conundrum. They are a gateway drug — but it’s not, or hasn’t been, entirely clear in which direction most traffic through that gateway flows.”

Ruth Marcus, September 5, 2014

U.S. Preventive Services Task Force Recommendation on ENDS for Smoking Cessation

•  Thusfar,theU.S.PrevenWveServicesTaskForce(USPSTF)hasmadethestrongeststanceaboutENDS

•  InSeptember2015,theUSPSTF“foundtheevidenceonENDSuseasasmokingcessaWontoolinadultsoradolescentstobeinsufficient.”

•  TheUSPSTFwasonlyabletoidenWfytworandomized,controlledtrialsthatevaluatedtheeffectofe-cigare`esonsmokingabsWnenceinadults.Thesetwostudiesfoundmixedresults.

U.S. Preventive Services Task Force, 2015

ENDS climate in UK: A strong stance has been taken

•  E-cigare`ecompaniesquicklycapitalizedonthisfinding,usingthestaWsWcinthefrontwindowofe-cigare`eshops.

•  SomecriWcizethatthereportisbasedonexpertopinion(mulW-criteriadecisionanalysis)ratherthanempiricalevidence.

Public Health England, 2015

• PublicHealthEnglandpublishedareportinAugust2015staWngthat“ThecurrentbestesWmateisthate-cigare`euseisaround95%lessharmfultohealththansmoking.”

30.4

11.1

1.8

56.7

33.828.3

2.8

35.1

0

10

20

30

40

50

60

LessHarmful AbouttheSame MoreHarmful IDon'tKnow

Percen

tageofR

espo

nden

ts

PercepWonofrelaWveharmofe-cigare`esamongUSadults,2012-2014

2012 2014

1.  Unpublishedresultsofdatafromthe2012HealthStylesurvey2.  Unpublishedresultsofdatafromthe2014TobaccoProductsandRiskPercepWonsSurveyconductedbytheGeorgiaStateUniversityTobaccoCenterofRegulatoryScience(TCORS)

Cigarette

E-Cigarette

Unintended consequences of ENDS: Vaping used for recreation, not cessation

•  E-cigare`esarethesourceofanewsport,calledCloudChasing,wherevaporstryandblowthemostvapor.

PhotoCredit:DavidBecker/Reuters

Public health concerns about ENDS marketing

•  E-cigare`eadverWsinggrewtwelve-foldintwoyears(from$6.4millionin2011toover$80millionin2013).

•  E-cigare`eadverWsingiscompletelyunregulatedand“anythinggoes.”• Muche-cigare`emarkeWngresemblestobaccoadverWsementsofthepast,andthisisaconcerntopublichealth.LiketradiWonalcigare`emarkeWng,e-cigare`emarkeWnguses:

•  RuggedmenandbeauWfulwomen

•  Sexappeal•  UnsubstanWatedhealthclaims•  Famousspokespersons

•  Cartoons•  Currente-cigmarkeWngisappealingtoyoungpeopleandhasthepotenWaltore-normalizesmoking.

No one under 42 years of age in the U.S. has ever seen an ad for a tobacco product on television… until now

blu E-Cigarettes Video with Jenny McCarthy (click for video)

"Responsible e-cigarette manufacturers, including blu ecigs, do not market to youth."

LorillardtoFDA(10/23/13)

Let’s see what “responsible” marketing really looks like to e-cig companies…

Examples of “responsible” marketing...

Sports Illustrated swim suit edition (February, 2014)

Some companies use e-cigs as “nutritional” supplements: Lose weight, have more energy and better sleep!

Unintended consequences of ENDS: Entice former smokers to return to nicotine

There are 53 million former smokers in the U.S. and they are being enticed to try e-cigs, as exemplified by FIN’s “Welcome Back” campaign.

Circumvent smokefree laws

Regulation can occur at each stage of the tobacco life-cycle and this regulation should include ENDS

Federal ENDS Regulation: Waiting for the FDA to act

•  In2009,PresidentObamasignedtheTobaccoControlAct.•  In2011,theFDAannounceditsintenWontoregulatealltobaccoproducts,includinge-cigare`es.

•  In2014,theFDAissuedaproposedruleforextendingtheirregulatoryauthorityoveralltobaccoproducts(deeming).

•  InApril2015,HealthandHumanServicesSecretarysetagoalofJune2015forissuingafinalruling.

•  OnOctober19,2015,FDAsubmi`edthefinalruletoOMBforapproval

E-cigare`esareunregulatedintheU.S.andareasourceofconfusionamonghealthprofessionals,healtheducators,publichealth,researchers,governmentofficials,andconsumersalike.

Campaign for Tobacco-Free Kids, September 22, 2015 Press Release

Role of state and local laws in regulating e-cigarettes

•  SincetheFDAhasnotactedone-cigare`es,statesandlocalgovernmentshaveimposedtheirownregulaWons,insomeinstances.

• AsofJuly2015,atleast170municipaliWesandthreestatesstatedthate-cigare`escannotbeusedinsmokefreeenvironments.

• HealthprofessionalshavethepotenWaltoplayastrongroleinadvocaWngthate-cigare`eusetobebannedinsmokefreeareas.ThiscanbedoneatthelocallevelandwilllikelybemoreeffecWvethanfocusingexclusivelyonfederalpolicychange.

American Nonsmokers’ Rights Foundation, 2015

Action Steps: What needs to happen?

• Createaregulatoryschemethatfavorsexclusiveuseofnon-combustednicoWneproductsovertradiWonalcigare`es.

• GraduallyreducenicoWnelevelsincigare`estonon-addicWvelevels.• Avoidunintendedconsequences

•  YouthiniWaWon •  Dualuse(unlesslimiteddualusehelpswithcessaWon)•  FormersmokersreturningtonicoWne•  Re-normalizaWonofsmoking•  Useofe-cigsfordeliveryofillicitdrugs

• WorktoeliminateanytypeofaddicWon,includingaddicWontonicoWne.•  IncludeaspartofbroaderhealthpromoWonstrategy.

Establish strategic nicotine regulatory framework focused on complete transition from combustion

Useallpolicyleverstoachievetransi>onfromcombus>on,including:

•  Provideevidence-basedandaffordablecessaWonservices•  AllowresponsibleENDSmarkeWngconsistentwithevidence(aswithNRT)•  EstablishdifferenWaltaxpolicytodiscouragecombustedproducts(NEJM)•  Allownon-harmfulflavorsasnecessary•  LimitnicoWnecontentandotherproductstandardsthatwouldmakecombusWblecigare`eslessaddicWnganda`racWve

•  EstablishprogressivelymorerestricWveWme,place,andmannerofsalesofcombusWblecigare`es,parWcularlyatthestateandlocallevel

•  Assurepolicyleversdonoterodesuccessfultobaccocontrolstrategies,parWcularlycleanindoorairlaws.

Potential Health Impact of ENDS

Source:Thehealthconsequencesofsmoking–50yearsofprogress:areportoftheSurgeonGeneral.–Atlanta,GA.:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevenWon,NaWonalCenterforChronicDiseasePrevenWonandHealthPromoWon,OfficeonSmokingandHealth,2014.

“Thepromo7onofelectroniccigare<esandotherinnova7vetobaccoproductsismuchmorelikelytobebeneficialinanenvironmentwheretheappeal,accessibility,promo7on,anduseofcigare<esarebeingrapidlyreduced”

Health education efforts directed toward smokers

AsthepopularityofENDSincreases,moresmokersarethinkingaboutquiIng:•  CapitalizeonthisunprecedentedinterestinquivngandcommunicatethebestinformaWonavailabletoguideinformeddecisionmaking.

•  CommunicatethatthereareprovenandeffecWvemethodstostopsmoking(e.g.,NRT,counseling,ChanWx).Ifthesemethodshaven’tworkedforaparWcularsmoker,he/shemaywanttoconsiderENDS.

•  Emphasizethatthereisli`leevidenceabouttheefficacyorunintendedconsequencesofENDS.And,whiletheremaybeunknownharmsfromENDS,itiscertainlylessharmfulthanconWnuedsmoking.

•  AdvisesmokerstoavoiddualuseandthatENDSshouldonlybeusedforafiniteperiodofWme,ratherthanasapermanentreplacementproductforsmoking.

•  Striketheproperbalancebetweenpossibleindividualbenefit(smokersquivng),againstpossiblepopulaWonharm(kidsstarWng&dualuse).

•  UsethepublicdiscourseonENDStofurtherdiscouragesmokingandadvanceothertobaccocontrolpolicies.

Thank You! Questions?

www.publichealth.gsu.edu