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Vaping & the Use of E-Cigarettes in
Our Community
Kern County Network for Children
Larry E. Reider Education Ctr.
2000 K Street, Room 101
Bakersfield, CA 93301
November 5, 2014
Presentation materials borrowed from Dr. Phil Gardiner and authorized to be used for public education only.
From Whence E-cigarettes
• 2003: Chinese pharmacist, Hon Lik, is credited
with conceptualizing and producing the first
modern Electronic Cigarette
E-Cigarettes
• Nicotine Addiction: The Next Generation
–
–
–
–
–
Vaporizes liquid nicotine among other chemicals
Varying degrees of nicotine potency delivered
Long term health Impact still to be determined
Potential Life Saving Cessation Device
Explosion in popularity; emergence of a subculture;
the new “in thing” in Hollywood
– The Tobacco Vapor Electronic Cigarette Association
estimates that there are more than 3.5 million ecigarette users in the United States alone.
Component Parts
E-Cigs
Nicotine Inhaler
Hookah and E-Hookah
• Hookah and E-Hookah
E-Pens; E-Hookah Pens
• Cherry, Chocolate,
• Vanilla, Bubblegum
E-Cigars
• Swisher Sweets E-cigars (Swisher
International)
Westenberger, 2009; Goniewicz et al 2013)
E-Cigars
Vaporizers
E-Cig Style
New Bluetooth E-Cigarette Lets You Vape AND
Receive Calls, Listen to Music
Stanford Research into the Impact of
Tobacco Advertising
The Stanford School of Medicine has developed
an online compendium of some 2000 e-cigarette
ads, including a comparison of e-cig vs. cigarette
ads highlighting the revival of long-banned
advertising methods.
http://tobacco.stanford.edu/tobacco_main/ecigs.php
http://tobacco.stanford.edu/tobacco_main/subtheme_
ecigs.php?token=fm_ecigs_mt036.php
The E-Cigarette Explosion
• Market Size Continues to Increase
– retail sales are over $1B currently;
– ~$1.8B by the end of 2013;
– $10B by 2017.
– U.S. comprises 30% of the $6B global market
• E-cigs could surpass consumption of
conventional cigs within the next decade (by
2023).
(Herzog, 2013)
E-Cigarette Explosion: Youth Uptake
Case in Point
• Among Middle and High School Students:
– E-cigarette use rose from 4.7 percent in 2011 to
10.0 percent in 2012 (ever used)
– E-cigarette use rose from 1.5 percent to 2.8
percent (past 30 days)
– In 2012 more than 1.78 million middle and high
school students nationwide had tried e-cigarettes
– 76.3 percent of who used e-cigarettes within the
past 30 days also smoked conventional cigarettes
in the same period.
(MMWR,CDC, 2013)
Enter the tobacco industry
•
Lorillard (LO)
– Acquired the blu e-cigs in April 2012 for $135M.
•
Reynolds American (RAI)
– Vuse supposedly has technology that improves the consistency of vaping
experience, unique design features and will be manufactured in the U.S.
•
Altria Group (MO)
– Launched MarkTen this year.
– May acquire an existing e-cig company such as NJOY.
•
NJOY (privately held)
– One of the first retail entrants to the e-cig market; personnel includes several exAltria execs.
– #2 brand in the c-store channel in terms of dollar sales and #4 in the take-home
channel
(Adapted from Herzog, 2013)
Lorillard Jumps Out First
• Lorillard in 2012 acquired E-Cigarette
Company Blu- Blu ad
• > 40% E-Cig Market (non-internet)
Reynolds: Technologically Superior
• R.J. Reynolds has test marketing Vuse since
2011; purported to be technological advanced
• Vuse ad
• Reynolds
Vapor Co.
Altria Joins the Fray
• Altria Group
– Test Marketing now in
Arizona
– Altria still may acquire an
existing company
– Altria first-quarter U.S. sales
volume fell by 5.2%
– Marlboro sales fell by 5.5%
loomberg.com, 2013)
NJOY: Hanging Tough
• NJOY
– One of the first retail entrants to the e-cig market; personnel includes
several ex-Altria execs.
– #2 brand in the e-cigarette market behind Blu
– Ex-Surgeon General Carmona; PM, Altria Executives
– Feels Like the First Time
NJOY: A Healthier (sic) Product?
• “Friends Don’t Let Friends Smoke”
• NJOY
E-Cigarette Liquid
E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Nicotine, extracted from tobacco leaves
• Large variation in content between and within brands
(Cheah et al 2012; Trtchounian et al 2011; Goniewicz et al 2013)
• Lethal if ingested; 60 mg Adult; 6 mg Children
• Detrimental to fetuses (Martz, 2009)
• Tobacco specific nitrosamines (TSNAs) (Laugesen, 2008;
Westenberger, 2009; Goniewicz et al 2013)
E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Propylene Glycol - the vapor; the fog
• FDA approved food additive (humectant, solvent for
colors and flavors), cosmetics, and medicines.
• Short term exposure causes eye, throat, and airway
irritation (Wieslander et al 2001; Vardavas et al 2012,)
• Long term exposure can result in children developing
asthma. (Choi et al 2010)
• Chemical composition changes when heated (Henderson
et al, 1981)
E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Glycerin: A humectant used instead of or in
combination with propylene glycol in EC fluids for
aerosol production.
– FDA Approved for ingestion.
– Slightly hazardous in case of skin and eye contact,
ingestion, and inhalation; prolonged exposure
may cause organ damage.
– Metals
– Tin Particles found in E-liquid (Williams et al., 2013)
E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Flavorants. Key one Menthol; Candy flavoring
• Anesthetic effects, mimics bronchial dilatation, increases salivary
flow; transbuccal absorption; greater cell permeability
• Allows the poison to go down easier!
– 100s of candy flavors; appeals to kids (bubblegum,
strawberry, gummy bears, etc.)
– Exotic for adults (Sex on the Beach, Aces and 8’s)
• Mix your Own (ala roll your own)
Combustion; Heating; Aerosolizing
• Cigarettes burn tobacco at ~ 900˚ Celsius
• Heated Tobacco Products
• E-Cigarettes aerosolize nicotine laced
propylene glycol at 40 – 65˚ Celsius
The Aerosol: Its not just Water Vapor
• E-Cigarette Aerosol Vapor Contains:
– Propylene glycol, glycerol, flavorings, and nicotine, which
are found in the e-liquid, are also found in the e-vapor
– Volatile Organic Compounds: Benzene and Toluene
– Carbonyl Compounds: Formaldehyde, acetaldehyde, and
acrolein
– Metals: tin, silver, iron, nickel aluminum, sodium, chromium,
copper, magnesium, manganese, lead, potassium and silicate
nanoparticles
– Tobacco specific nitrosamines (TSNAs) carcinogenic
compounds found in tobacco and tobacco smoke.
• (Schripp et al, 2012: Westenberger 2009; Goniewicz et al, 2013; Williams et al,
2013)
Aerosol composition
•
Propylene glycol
•
Chlorobenzene
•
Benzo(ghi)perylene •
•
glycerin
•
Crotonaldehyde
•
Acetone
•
Silicon
•
Flavorings (many)
•
Propionaldehyde
•
Acrolein
•
Lithium
•
Nicotine
•
Benzaldehyde
•
Silver
•
Lead
•
NNN
•
Valeric acid
Nickel
•
Magnesium
•
NNK
•
•
Hexanal
Manganese
NAB
•
Tin
•
•
•
Fluorine
Potassium
NAT
•
Sodium
•
•
Anthracene
•
Titanium
Ethylbenzene
•
Pyrene
Strontium
•
•
•
Zinc
Benzene
•
Acenaphthylene
Barium
•
•
•
•
•
Zirconium
Aluminum
•
•
Calcium
Chromium
•
Iron
Cadmium
•
P,m, xylene
•
Acenapthene
•
Toluene
•
Fluoranthene
•
Acetaldehyde
•
Benz(a)anthracene
•
Boron
•
Sulfur
•
Formaldehyde
•
Chrysene
•
Copper
•
Vanadium
•
Naphthalene
•
Retene
•
Selenium
•
Cobalt
•
Styrene
•
Benzo(a)pyrene
•
Arsenic
•
Rhubidium
•
Benzo(b)fluoranthene
•
Indeno(1,2,3cd)pyrene
Compounds in yellow are from FDA 2012,
Harmful and Potentially Harmful
Substances – Established List
The Aerosol: Its not just Water Vapor
• E-Cigarette Vapor
– Concentrations of pollutants less than in cigarettes
– Carcinogens, less than in cigarettes
– Great variation across products; no product
standards
– Intermediate and long term health effects
unknown
– Maybe safer, but this doesn’t mean safe
Peering Through the Mist . . .
(Burstyn, 2013)
• “an analysis of current state of knowledge
about chemistry of liquids and aerosols
associated with electronic cigarettes indicates
that there is no evidence that vaping
produces inhalable exposures to
contaminants of the aerosol that would
warrant health concerns by the standards
that are used to ensure safety of workplaces.
Peering Through the Mist . . .
(Glantz Blog, 2013 on Threshold Limit Values, TLVs)
• “TLVs are for occupational exposures; occupational
exposures are generally much higher than levels
considered acceptable for ambient or population-level
exposures
• Same approach to risk assessment as those conducted
for secondhand smoke by those affiliated with the
tobacco industry decades ago
• Occupational exposures also do not consider exposure
to sensitive subgroups, such as people with medical
conditions, children and infants, who might be exposed
to secondhand e-cigarette emissions.”
Secondhand Exposure to Vapors From
Electronic Cigarettes (Czogala et al, 2013)
• The average concentration of nicotine
resulting from smoking tobacco cigarettes was
10 times higher than from e-cigarettes
(31.60±6.91 vs. 3.32±2.49 µg/m
• 7xs more Particulate matter
• Still, in a room of 5 to or more e-cigarette
users, nicotine and particulate matter levels
are above healthy levels
Second Hand Vaping:
The Take Home Message
“Overall, the e-cigarette is a new source of
VOCs and ultrafine/fine particles in the indoor
environment. Therefore, the question of
“passive vaping” can be answered in the
affirmative. However, with regard to a healthrelated evaluation of e-cigarette consumption,
the impact of vapor inhalation into the human
lung should be of primary concern” (Schripp,
et al., 2012).
Short Term Pulmonary Effects
A team of scientists found that only after 5
minutes of use, e-cigarettes had immediate
adverse physiologic effects, similar to some of
the effects seen with tobacco smoking,
including decreased FeNO. FeNo, or Fractional
exhaled Nitric Oxide, shows the retardation of
lung function; this measure is often used in
assessing persons with asthma (Vardavas, et.
al., 2012)
E-Cigs and Cessation:
The Promise vs. The Reality: Dual Use
• Proof of concept study in 40 smokers not
wanting to quit; Followed up at 24 weeks
– 33% sustained a 50% reduction in cigarette
consumption
– 13% sustained an 80% reduction in cigarette
consumption
– 23% sustained complete abstinence
Polosa et al 2011 BMC Public Health, 11(1): 786
E-Cigs and Cessation:
The Promise vs. The Reality: Dual Use
• In another study comparing three different
groups, 2 using different strengths of ecigarette “juice” and one group not receiving
nicotine cartridges, found that “there were
significant reductions in Cigs/day comparing
baseline to week 52:
– Group A: 19 to 11
– Group B: 21 to 10
– Group C : 22 to 12
(Caponnette, et al., 2013).
E-Cigs and Cessation:
The Promise vs. The Reality: Dual Use
• Four Country Survey Comparing Wave 7 and Wave 8
– 85% (n=146) of current ENDS users stated that they used
ENDS as a tool to help them quit smoking, although only
11% of current ENDS users report having quit since Wave
7.
– Quitting did not differ between users and non-users of ecigarettes
– After a year of using e-cigarettes as a cessation devise,
the vast majority, 89%, had not quit and were still using
regular cigarettes.
(Atkison, et al., 2013).
E-Cigs and Cessation:
The Promise vs. The Reality: Dual Use
• A 6-state Quitline survey collected data on 2758
treatment seekers at baseline and then again a 7
moths. The authors found that:
– E-cigarette user groups were significantly less likely to
be tobacco abstinent at the 7-month survey compared
with participants who had never tried e-cigarettes.
– The bottom line is that e-cigarette users, while using
these products to quit, were not any more likely to
have been successful if that had used them at all.
– (Vickermann, et al., 2013)
From De-normalization to
Renormalization
• From the 21st Century to the 1950’s: Vaping is
not only technologically up to date, it is
everything a “girl” could want!
– Vuse Ad
– Blu ad
The Downside of Dual Use
• In a study of of 23 521 men and 19 201
women, aged 35–49 years, screened for
cardiovascular disease risk factors in the mid
1970s and followed throughout 2002.
• “smoking 1–4 cigarettes per day was
associated with a significantly higher risk of
dying from ischemic heart disease and from all
causes, and from lung cancer in women”
(Bjartveit and Tverdal, 2005).
Renormalization
Renormalization
Need We Say More
Renormalization
Electronic Nicotine Delivery Device
& Other Drugs
• Poisonings from E-Cigarettes and Synthetic
Pot Are Surging (Spice, Black Mamba, K2, MOJO, White Widow,
Hash Oil…)
Seizures
Hallucinations
Vomiting
Psychosis
Extreme anxiety
Permanent brain damage
Suicidality
Severe kidney damage
Reduced blood flow to heart
Tachycardia
Heart attack
Sudden cardiac arrest
Stroke
Delirium
Electronic Nicotine Delivery Device
& Other Drugs
• New legal synthetic drug trend among young
adults- a synthetic cigarette liquid known as "Blue
Blossoms."
• Blue Blossoms fragrance is even labeled, "Not for
human consumption" and "Product is not for sale
to minors.”
• The effects of Blue Blossoms include, but are not
limited to: distorted sense of time, bursts of
euphoria, lowered awareness, and elevated heart
rate.
% of stores that sell e-cigarettes in the
Central Valley (HSHC 2013)
Mariposa
28.6%
Merced
40.0%
Madera
Kings
32.1%
21.5%
Tulare
43.6%
Kern
Fresno
California
42.0%
28.8%
45.7%
European Union E-Cigarettes
Regulation
•
•
•
•
•
•
Starting in 2016
Advertising Banned
Graphic Health Warning Labels
Child-Proof
Nicotine Limited to 20mgs
Outlawing Menthol Cigarettes (4-year delay)
Indoor and Outdoor use NOT Regulated
FDA Regulation (or lack thereof)
• No FDA Regulation
– Blocked imports in 2008
– Launch toxicological studies 2009
– Seized NJOY shipments 2009
– NJOY sued the FDA, claiming the e-cigarettes
should be regulated like cigarettes, not a medicine
– 2010, both the lower and applet court agreed
with NJOY
– 2013, FDA “poised” to announce regulations in
October
Regulation (or lack thereof)
• No FDA Regulation
– No Product Standards
– No Minimal or maximum of nicotine or other
chemical constituents
– No Indoor Air Regulations
– No Minor Restrictions
– No Advertising Restrictions
– The Wild, Wild , West
Only California State Wide Law
• As of 2011, CA law makes it unlawful for a
person to sell or otherwise furnish an
electronic cigarette to persons less than 18
years of age.
– CAL. HEALTH AND SAFETY CODE § 119405 (West
2013). E-Cigs Code
Corbett 648 (Died a Horrible Death)
• Summary: Would extend the restrictions and
prohibitions against the smoking of tobacco
products to include electronic cigarettes.
– 04/17/2013 Senate Health (Y:6 N:2 A:1)
– 04/30/2013 Senate Judiciary (Y:4 N:2 A:1)
– 05/24/2013 Senate Floor (Y:21 N:10 A:8)
– 06/25/2014 Assembly Governmental Organization
Committee
– 08/06/2014 Assembly Appropriations-Failed, but
17 voted Y and 0 N for reconsideration
Thank You Bee Sacramento
California Democrats accepting more campaign
cash from tobacco industry
By Laurel Rosenhall [email protected]
Read more here: http://www.sacbee.com/2014/08/02/6601133/california-democrats-accepting.html?sp=/99/749/#storylink=cpy
Editorial: Democrats choose tobacco money
over public health By the Editorial Board
Read more here: http://www.sacbee.com/2014/08/05/6605012/editorial-democrats-choose-tobacco.html
Cities Move to Regulate E-Cigarettes
in California
Richmond
Long Beach
Los Angeles
San Francisco
Contra Costa County
Arcata
Beverly Hills
Campbell
Carlsbad
Fremont
Mill Valley
Mountain View
Petaluma
Santa Clara County
Seal Beach
Solana Beach
Tiburon
Walnut Creek
Eureka
Marin County
Morgan Hill
Oroville
San Bernardino
Santa Maria
Sebastopol
Temecula
Union City
Del Mar
Fairfax
Arvin
Kern County Board of SupervisorsAddressing Illegal sales of ENDDs
6/24/2014- BOS amended Chapter 8.60.010 of the
Kern County Ordinance code relating to Tobacco
Retailer Permits to include electronic smoking
devices and paraphernalia in the definitions.
The amended ordinance would require retailers
selling electronic smoking devices and
paraphernalia to obtain an Environmental Health
Permit. These retailers would also be included in
the Division’s compliance check process to ensure
children are not sold tobacco products & ENDDs.
Definitions???
Definitions are the keys to making changes in the existing laws:
Chapter 8.60.010
Section D: "Tobacco product" means any product that contains tobacco, is derived from tobacco, or
contains synthetically produced nicotine and is intended for human consumption. "Tobacco product"
includes electronic smoking devices(s) and electronic smoking device paraphernalia, but does not
include any product specifically approved by the United States Food and Drug Administration for use
in treating nicotine or tobacco dependence.
Section I: "Smoking paraphernalia" means tobacco paraphernalia, electronic smoking devices, and
electronic smoking device paraphernalia.
Section J: "Electronic smoking device" means an electronic and/or battery-operated device, the use of
which may resemble smoking, which can be used to deliver an inhaled does of nicotine or other
substance. "Electronic smoking devices" include any such electronic smoking device, whether
manufactured, distributed, marketed, or sold as an electronic cigarette, an electronic cigar, an
electronic cigarillo, an electronic pipe, an electronic hookah, or any other product name or descriptor.
"Electronic smoking device" does not include any product specifically approved by the United States
Food and Drug Administration for use in the mitigation, treatment, or prevention of disease.
Section K: "Electronic smoking device paraphernalia" means cartridges, cartomizers, e-liquid, smoke
juice, tips, atomizers, electronic smoking device batteries, electronic smoking device chargers, and any
other item specifically designed for the preparation, charging, or use of electronic smoking devices.
Thank You!
Nsele M Nsuangani, MPH
Health Educator-Project Director
Tobacco Education Program
Environmental Health Division
Kern County Public Health Services Department
Phone: (661) 862-8751
Email: [email protected]