Emergi ging T ng Tobacco Produc ucts Luc ucinda Eng ngland nd - - PowerPoint PPT Presentation

Emergi ging T ng Tobacco Produc ucts

Luc ucinda Eng ngland nd M MD, M MSPH Office e on

• n S

mok

• king

g an and d Heal alth Centers for

• r Disease Con
• ntrol
• l an

and d Prevention

• n

Maryland S tate Council on Cancer Control Cancer Conference November 18, 2014 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the C enters for Disease C

• ntrol and P

revention

Centers for Disease Control and Prevention Office on Smoking and Health

Context: Burned Tobacco is is Still ill a P Proble lem

“ The e burden en o

• f d

dea eath an and diseas ease e from t tobac acco use e in the e United ed States es i is o

• ver

erwhel elmingly cau aused ed b by cigar aret ettes es and o d other combu busted t d toba bacco pr produ ducts; rapi pid e d elimination

• f their

ir u use will d ill dramatic ically lly reduce this is b burden.” .”

The health consequences of smoking – 50 years of progress: a report of the S urgeon General. – Atlanta, GA. : U.S . Department of Health and Human S ervices, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on S moking and Health, 2014.

Ov Overview

Who is using emerging products?

1 2 3 4

What are emerging tobacco products? What are health risks of emerging products? Which policy approaches are appropriate for emerging products?

What Are EN ENDS? Elect ectronic Cigar aret ettes es an and Vap aping D Devices es

EN ENDS

 Delivers nicotine-containing aerosol by heating a

solution (typically propylene glycol or glycerol/ glycerin nicotine, and flavoring agents, and other additives)

 Long-term health effects of inhaled propylene glycol

and glycerin are unknown

Hutzler, Paschke, Kruschinski, et al. Chemical hazards present in liquids and vapors

• f electronic cigarettes. Arch T
• xicol 2014

ENDS Aeros

• sol
• l is not
• t “Harmless

ss Water er Vapor por “

 Nicotine: 0-36 mg/ml  Flavorings/additives often not disclosed  S

• me analyses show presence of potentially allergenic

compounds such as cinnamic aldehyde (highly toxic to human embryonic stem cells)

 Overheating could lead to production of carcinogens,

such as formaldehyde, acetaldehyde, acrolein

Bhatnagar et al. E lectronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130:1418-36. Behar, Davis, Wang, et al. Identification of toxicants in cinnamon flavored electronic cigarette refill fluids. T

• xicology in vitro 2014.

Hutzler, Paschke, Kruschinski, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch T

• xicol 2014

ENDS Other P Purpo rposes

 Some E

e ENDS can an b be u e used ed t to del eliver er other er substan ances es, l like e mar arijuan ana an a and c caf affei eine

ENDS A As C s Cessa ssation Devices

Not Approved ed as as a a Ces essation Device Cen enter er f for D Drug E Eval aluation an and Res esear earch

Borderud, S . P., Li, Y., Burkhalter, J. E ., S heffer, C. E . and Ostroff, J. S . (2014), E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. doi: 10.1002/cncr.28811

 In 8 years companies have not approached FDA for approval

ENDS and C Cessa ssation

Grana, Benowitz, Glantz. E

• cigarettes: a scientific review. Circulation

2014;129:1972-86.

Cessatio ion: Rando domiz ized T d Tria rials ls

• 2 trials conducted with control arms

– Caponnetto et al., 2013 (3 e-cigarette arms)

• Participants not interested in quitting
• All arms reduced cigs/day, no difference in quits

– Bullen et al., 2013

• Participants wanted to quit
• Nicotine e-cigarette, zero nicotine e-cigarette, NR

T patch

• 6 month follow-up
• 50% reduction cigs/day (57%, 45%, 41%, p=0.08)
• Quitting 7.3%, 4.1%, 5.8% (p=0.5)

Ces essation in c can ancer er patients

Bo Borderud et al, 2014 2014

• Patien

ents pres esen enting t to Mem emorial al S Sloan an Ket etter ering C Can ancer er Cen enter er 2012 2012-2013 s screen eened ed f for tobac acco use, u user ers ref efer erred ed to Tobac acco Cessation P Program (n=4504) 4504)

• Tho

hose w willing ng to enr nroll in t n treatment progr gram inc nclud uded i in s n stud udy (n=1074) 1074)

• Asse

ssesse ssed f for e-cigar aret ette u e use

• Follo

llow up at 6-12 months s for c cessa ssation st status ( s (n=414)

• Find

ndings ngs:

• 26% r

rep eported ed pas ast 30 day use o e of e e-cigar aret ettes es at b bas asel eline; e; 92% 92% o

• f e

e-cigar aret ette e user ers w wer ere e al also s smoking.

• Quar

arter erly p preval alen ence e increas eased ed f from 10.6% to 3 38.5%

Borderud S P, Li Y, Burkhalter JE , S heffer CE , Ostroff JS .E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014 S ep 22.

Ces essation in c can ancer er patients

Cont

• ntinued

 E-cigar

aret ette u e user ers :

• S

moked more cigarettes/day

• R

eported higher nicotine dependence scores

• Had more frequent and longer duration of prior quit attempts
• No difference in quitting motivation or confidence

 At f

follo llow up:

• 7-day point prevalence of smoking abstinence was no different in

e-cigarette users and non-users (44.4% vs. 43.1%).

• E
• cigarette users were less likely to have been abstinent for > 24 hrs
• After adjustment, e-cigarette users as likely to be smoking at follow

up as non-users.

Borderud S P, Li Y, Burkhalter JE , S heffer CE , Ostroff JS .E lectronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014 S ep 22.

Market eting

ENDS A Advertising ng Expend nditur ures ac across m med edia a mar arket ets

 2011:

2011: $6. $6.4 m 4 million

 2012:

2012: $18. $18.3 m 3 million

 2013:

2013: >$80 m millio illion

Cel eleb ebrity spo pokespe peopl ple Glamor

• rou
• us w

wom

• men

Hundr dreds ds o

• f flavors

Sports s and musi sic e events sp s sponso sorsh ship

Use se i in sm smoke-free ee ar areas eas

Cheape per pri price

S lide courtesy Pam Ling, UCS F

Socia ial l network rkin ing

Plac acem emen ent Next to Can andy

http://www.countertobacco.org/n ews/2014/09/12/njoy-brags-about- e-cigarette-placement-among- candy

Heal ealth Clai aims

S lide courtesy Pam Ling, UCS F

Physician an Endorsem emen ent

Wha hat tactics lead to yout uth h smoking? ng?

• Ex

Exposure to

• ads

s

• Them

emes es in a n advertising ng tha hat resona nate w with h yout uth h

• Lo

Low pric rices a and pric rice-reduc ucing ng prom

• mot
• tions
• Eas

ase e of ac acces ess to a a product

• Cand

ndy a and nd frui uit-flav avored pr produ ducts

• Heal

ealth c clai aims

• Pr

Products that ar are eas e easier er to u use se

E-cigar aret ette e ever er u use m e more t e than an d doubled ed* b bet etween een 2011 2011 and 2012 2012 among students

3. 3.3% 3% 4. 4.7% 7% 1. 1.4% 4% 6. 6.8% 8% 10. 10.0% 0% 2. 2.7% 7%

All Students High School Middle School

Y

• ut

uth h E

• cigaret

ette e E v E ver U Use, Nat ation

• nal Y

Y

• u
• uth T
• b
• bac

acco

• S

urvey, Unite ted S ta tate tes

2011 2012

1. 1.78 78 millio illion stud udent nts

>300, 300,000 000 stud udent nts

*S tatistically different (p<0.05)

Centers for Disease Control and Prevention (2013). "Notes from the Field: E lectronic Cigarette Use Among Middle and High S chool S tudents — United S tates, 2011–2012." Morbidity and Mortality Weekly R eport 62 62(35): 729-730.

Trends s in Use se

E-cigar aret ette e ever er u use m e more t e than an d doubled ed* b bet etween een 2011 2011 and 2012 2012 among students

3. 3.3% 3% 4. 4.7% 7% 1. 1.4% 4% 6. 6.8% 8% 10. 10.0% 0% 2. 2.7% 7%

All Students High School Middle School

Y

• ut

uth h E

• cigaret

ette e E v E ver U Use, Nat ation

• nal Y

Y

• u
• uth T
• b
• bac

acco

• S

urvey, Unite ted S ta tate tes

2011 2012

1. 1.78 78 millio illion stud udent nts

>300, 300,000 000 stud udent nts

*S tatistically different (p<0.05)

Centers for Disease Control and Prevention (2013). "Notes from the Field: E lectronic Cigarette Use Among Middle and High S chool S tudents — United S tates, 2011–2012." Morbidity and Mortality Weekly R eport 62 62(35): 729-730.

Current e e-cigar aret ette e use e am among studen ents m more e than doubled between 2011 2011 and 2012 2012

1. 1.1% 1% 1. 1.5% 5% 0. 0.6% 6% 2. 2.1% 1% 2. 2.8% 8% 1. 1.1% 1%

All Students High School Middle School

Cur urrent nt E E

• Cigaret

ette e Use*, Nat ation

• nal Y

Y

• u
• uth

T

• b
• bac

acco S urvey, United d S tat ates

2011 2012

130, 130,000 000 stud udent nts

* Current use is defined as use on one or more days in the last 30 days

Centers for Disease Control and Prevention (2013). "Notes from the Field: E lectronic Cigarette Use Among Middle and High S chool S tudents — United S tates, 2011–2012." Morbidity and Mortality Weekly R eport 62 62(35): 729-730.

554,000 S tudents

E-Cigar aret ette e Ever er Use

2010 2010-2011 2011

King BA, Patel R , Nguyen KH, Dube S R . Trends in Awareness and Use of E lectronic Cigarettes Among U.S . Adults, 2010-2013. Nicotine Tob R

• es. 2014 S

ep 19.

Heal ealth Effect ects

ENDS Poten ential al for Har arm

 Direc

ect h har arm

 Expose c

e children en an and ad adoles escen ents, preg egnan ant women en, an and non- sm smokers t s to 2nd

nd ha

hand nd aeros

• sol
• l, n

nicot

• tine

 Poisoni

nings ngs among ng us users o

• r no

non-use sers s

 Uncer

ertai ain h heal ealth ef effec ects o

• f long t

ter erm e exposure

 Pulm

lmonary deliv livery o

• f propyle

lene g gly lycol, l, gly lycerin in, nic icotin ine

 Lower

er toxin burden en than an cigar aret ettes es, but n not water er v vap apor

Nic icotin ine 2014 Sur urge geon n Gene nera ral’s Re Report

1.

• 1. At hi

high e gh eno nough d ugh doses, ni nicotine ne caus uses acu cute t toxici city

2.

• 2. Nic

icotin ine ac activates es mult ltip iple le b bio iolo logic ical p l pathways thr hrough ugh whi hich h smoking i ng inc ncreases risk for d disease

3.

• 3. Nicotine e

e exposure e during fet etal al devel elopmen ent h has as las asting ad adver erse c e conseq equen ences es for brai ain devel elopmen ent

Nic icotin ine 2014 Sur urge geon n Gene nera ral’s Re Report

4.

• 4. Nicotine

e ad adver ersel ely af affec ects m mater ernal al an and fet etal al h heal ealth dur uring p ng pregna gnanc ncy, contribut uting t ng to m mul ultiple adverse

• ut

utcomes i inc nclud uding ng preterm deliv livery a and s stillb illbir irth

5.

• 5. The

he evidenc nce i is s sugge uggestive tha hat ni nicotine ne exposur ure dur uring ng ad adoles escen ence e may h have l e las asting ad adver erse e conseq equen ences es for b brai ain d devel elopmen ent

6.

• 6. The

e eviden ence i e is i inad adeq equate e to i infer er t the p e pres esen ence o e or ab absen ence e of a a cau ausal al r rel elationship b bet etween een e exposure e to n

• nicot
• tine and r

risk for

• r can

ancer er.

Numbe ber of c cal alls to poison cen enter ers for c cigar aret ette e or e-cigar aret ette e e exposures es, by m month — United ed S States es, Sep eptem ember er 2 2010–February 2014 2014

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm

ENDS A Aeros

• sol
• l Seco

cond Han and Exposu sure

 Use

se o

• f e-cigar

aret ettes es i in t the h e home e or c car ar c could expose se chi hildren/ n/no nons nsmokers to nic icotin ine, as w well ll as t to propylen ene e glycol an and/or glycer erin, an and other er toxican ants, through inhal aled ed aer aerosolized ed v vap apor an and surfac ace e de depo posits.

• S

tudies of third hand tobacco smoke found that smoke components, including nicotine, are deposited and reemitted from indoor surfaces over time, and can result in substantial nicotine exposure levels.

• Nicotine from e-cigarettes also deposits on indoor surfaces,

creating a reservoir of nicotine that could be ingested, absorbed transdermally, or inhaled by children.

S inger BC, Hodgson AT , Nazaroff WW (2003) Gas-phase organics in environmental tobacco smoke: 2. E xposure-relevant emission factors and indirect exposures from habitual smoking. Atmos E nviron 2003:37:5551–5561. Goniewicz ML, Lee L. E lectronic cigarettes are a source of thirdhand exposure to nicotine. Nicotine T

• b R

es e-published August 30, 2014.

ENDS A Aeros

• sol
• l Secon
• nd Hand E

Expos

• sure

Montse Ballbè, Jose M. Martínez-S ánchez, Xisca S ureda, Marcela Fu, R aúl Pérez-Ortuño, José A. Pascual, E steve S altó, E steve Fernández, Cigarettes vs. e-cigarettes: Passive exposure at home measured by means of airborne marker and biomarkers, E nvironmental R esearch, Volume 135, November 2014, Pages 76-80.

Poten ential al Har armful Inter eract action with h Cigar aret ettes es

 Glam

amorize e an and r ren enormal alize e tobac acco use

 Lead

ead to regul gular us use o

• f ni

nicotine ne a and nd/or us use o

• f

ciga garettes in y n yout uth o h or adul ult non

• n-sm

smokers

 Delay

ay qui uitting ng and nd/or dimini nish h the he cha hanc nces a smoker r will q ill quit it by le leadin ing t to lon

• ng-ter

erm dual al use se

 Discoura

urage ge smoke kers from us using ng proven n qui uit met ethods

 Increas

ease e form rmer s r smoker rel elap apse

ENDS P Potentia ial l for r Benef efit

Onl nly und under two c circumst stances: s:

 Are c

e complet etel ely s substituted ed for al all combusted ed t tobac acco produc ucts in e n establishe hed adul ult s smokers w who ho woul uld

• ther

erwise c e continue e sm smoking

 Assis

ist in in r rapid id t transit itio ion t to a s socie iety w wit ith lit little le or no us use o

• f b

bur urne ned produc ucts

Dual U Use

 Most

st e e-cigar aret ette u e user ers ar are c e curren ent or f former er s smoker ers

 Smokers o

• ften b

n begi gin n us using e ng e-cigar aret ettes es to c cut b bac ack or qui uit s smoking ng and nd b become dua ual us users

 Cutting b

bac ack o

• n t

trad aditional al cigar aret ettes es does es not red educe e ris isk of a all ll-cau ause m e mortal ality

 Cutting b

bac ack o

• n t

trad aditional al cigar aret ettes es does es not red educe e risk sk o

• f CVD in a l

a linear ear f fas ashion

U.S . Department of Health and Human S

• ervices. The Health Consequences of S

moking: 50 Years of Progress. A R eport of the S urgeon

• General. Atlanta, Georgia. . U.S

. Department of Health and Human S ervices , Centers for Disease Control and Prevention. Office on S moking and Health 2014. U.S . Department of Health and Human S

• ervices. How Tobacco S

moke Causes Disease: The Biology and behavioral Basis for S moking Attributable Disease. A R eport of the S urgeon General. Atlanta Georgia. U.S . Department of Health and Human S ervices , Centers for Disease Control and Prevention. Office on S moking and Health 2010. Bjartveit and Tverday. Health Consequences of smoking 1-4 cigarettes per day. Tobacco Control 2005.

Reduc ucing ng smoking ng witho hout ut qui uitting ng

U.S . Department of Health and Human Services. How T

• bacco S

moke Causes Disease: The Biology and behavioral Basis for S moking Attributable Disease. A R eport of the S urgeon General. Atlanta Georgia. U.S . Department of Health and Human Services , Centers for Disease Control and Prevention. Office on S moking and Health 2010.

Provide ider r knowle ledg dge and b d belie liefs

 Stat

atewide sam ample e of p physician ans an and NPs p providing c car are e to

• chi

hildren 1 n 11-17 17 years of a age in MN, 2013 2013

• Self-reported knowledge about e-cigarettes
• 18%

“nothing at all”

• 65%

“a little”

• Very or somewhat uncomfortable talking to patients: 53%

 Nationa

nal sur urvey o

• f o
• bstetricians

ns/gy gyne necologi gists 2012

• 14% e- cigarettes have no adverse effects during pregnancy
• 2/3 wanted to know more about the potential health effects of

noncombustible tobacco products;

• Only 5% believed themselves to be fully informed

Pepper, McR ee, and Gilkey. Health providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. Journal of Adolescent Health 2014. E ngland LJ, Anderson BL, Tong VT, et al. S creening practices and attitudes of obstetricians-gynecologists toward new and emerging tobacco products. Am J Obstet Gynecol. 2014 May 29

Provide ider r knowle ledg dge and b d belie liefs

 Ran

andom sam ample e of NC p physician ans s surveyed ed i in 2 2013

• 48% reported that patients sometimes or frequently

ask about e-cigarettes

• 67% indicated that e-cigarettes are a helpful smoking

cessation aid

• 35% recommend e-cigarettes to their patients
• 13% believed that e-cigarettes are approved by the

FDA for smoking cessation

Pepper, McR ee, and Gilkey. Health providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. Journal of Adolescent Health 2014.

What d do existing recommendations s say?

US P Preventive S e Services es Tas ask F Force

http://www.uspreventiveservicestaskforce.org/Page/Name/topics-in-progress

North A Amer erican an Quit itlin line Consortium

T

• bacco dependence treatment professionals, including quitlines, are struggling

with how to address e-cigarette use in the context of cessation. In the absence of established best practices, quitlines are creating treatment protocols for counseling and medications delivery. In the fall 2014, NAQC will publish an evidence synthesis on the topic to address these important questions.

http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/Issue_Papers/MedicationsUpdateIssuePa perr.pdf

Other er R Recommen endations

• Amer

erican an H Hear eart Association

• For
• rum of
• f I

Int nternation

• nal Res

espiratory S Societ eties es (FIRS RS)

• American L

n Lung ung Association

• CDC (Div

ivis isio ion o

• f R

Reproductiv ive Healt lth)

• Interna

nationa nal A Association n for t the he Stud udy of L Lung ung Can ancer er

Regula latio ion

State e act action o

• n E

ENDS

 No sa

sales s to m minors s (34 st states) s)

 No use

e wher ere e smoking i is not al allowed ed (3 s states es)

 Addit

itio ional l promis isin ing s strategie ies may in inclu lude r retaile iler lic licensin ing, m marketin ing r restric ictio ions, taxatio ion

 CDC will s

ill soon track ENDS le legis isla latio ion on http ttp://w //www.cdc.gov/t /tobacco/s /state_system/

States es an and C Communities es Rationa nale for prohi hibiting ng ENDS us use in n al all plac aces es whe here s smoking ng is is not allo llowed

 Compar

are t e to c clean ean ai air, not cigar aret ette e smoke

 Ther

ere e ar are e no m man anufac acturing s stan andar ards

 Pot

• tent

ntial to e

• expos
• se you
• uth, pregnant

nt w wom

• men, a

and n non

• n-

smoker ers t to aer aerosolized ed nicotine e an and o

• ther

er toxins

 No e

eviden ence p e public u use i e is n nec eces essar ary for s smoker ers t to “s “switc tch” – could en enab able d e dual al u use

Smokeless T ss Tobacco

Smokel eles ess T Tobac acco

 Types

s of sm smokeless ss tobacco:

• Chewing tobacco (loose leaf, plug, or twist and may come in

flavors)

• S

nuff (moist, dry, or in packets [U.S . snus])

• Dissolvables (lozenges, sticks, strips, orbs)

Snus nus

 A t

type o

• f moist

st sn snuff

 Pac

ackag aged ed in r read eady-to to-use e pouches es t that r res esem emble e smal all tea b ea bag ags

 Pouch is plac

aced ed b bet etween een c cheek eek or t teet eeth an and gum gums, does s no not r requi uire spitting ng

 Mar

arket et s shar are e data a unavaila ilable le

Dis issolv lvable les

Fo Form Descrip iptio ion Mar arket et S Shar are ( e (in 2011) Lozen enges es Orbs Res esem emble p e pel ellet ets

• r tab

ablet ets Res esem emble s e smal all mints s Data u a unavai ailab able Data u a unavai ailab able Stic icks ks Toot

• othpick-lik

like ap appear earan ance Data u a unavai ailab able St Strips Thi hin n sh sheets s lik like breat ath o

• r

medic icatio ion st strips Data u a unavai ailab able e

Heal ealth Effect ects (Smokel eles ess)

 Nic

icotin ine a addic ictio ion

 Can

ancer er of the he mout uth, h, e esopha hagus gus an and pan ancreas eas

 Leu

eukoplak akia, a, g gum diseas ease

 Increas

eased ed r risk f for p pret eter erm b birth an and stillb illbir irth w when us used d dur uring ng pregna gnanc ncy ( (Swedish h snus nus)

 Nic

icotin ine poisoni ning i ng in n child ildren

 May increas

ease t e the e risk of dea eath f from hear eart d diseas ease e an and st stroke

U.S . Department of Health and Human Services. The Health Consequences of S moking: 50 Y ears of Progress. A R eport of the S urgeon General. Atlanta, Georgia. . U.S . Department of Health and Human Services , Centers for Disease Control and Prevention. Office on S moking and Health 2014. Piano MR , Benowitz NL, FitzGerald GA, et al. Impact of smokeless tobacco products on cardiovascular disease: Implications for Policy, Prevention, and Treatement. A policy statement from the American Heart Association. Circulation 2010;122:1520-44.

US S Snus nus

Lawler, S tanfill, Zhang, Ashley, Watson. Chemical characterization of domestic oral products: T

• tal nicotine, pH,

unprotonated nicotine, and tobacco-specific N-nitrosamines. Food and Chemical T

• xicity 2013 57:380-6.

US S Snus nus

Lawler, S tanfill, Zhang, Ashley, Watson. Chemical characterization of domestic oral products: T

• tal nicotine, pH,

unprotonated nicotine, and tobacco-specific N-nitrosamines. Food and Chemical T

• xicity 2013 57:380-6.

US S Snus nus

 Cam

amel el an and M Mar arlboro Snus nus ar are t e top-selling b ng brand nds

 2006

2006-201 2010, 0, 147 147 samples

 Compared w

with 2006 2006

• Pouch size increased in both brands
• Camel snus pouches were higher in total, unprotonated nicotine

and NNN /NNK by 1.9, 2.4, 3.3- fold respectively.

• Marlboro snus pouches were higher in total, unprotonated

nicotine by 2.1, 1.9, fold, respectively but 1.5-fold lower in NNN /NNK.

.

S tepanov I, Jensen J, Biener L, Bliss R L, Hecht S S , Hatsukami DK. Increased pouch sizes and resulting changes in the amounts of nicotine and tobacco-specific N-nitrosamines in single pouches of Camel S nus and Marlboro S

• nus. Nicotine T
• b R
• es. 2012 Oct;14(10):1241-5.

US S Snus nus

 2011,

2011, 216 s 216 samples gathered from 6 U 6 US regions, compar ared ed w with sam amples es collec ected ed i in 2010

• TS

NA levels increased in Marlboro and Camel snus, and in some Camel dissolvables

• Unprotonated nicotine levels did not change compared with 2010,

but varied by region, as much as 3.2-fold

S tepanov I, Biener L, Y ershova K, Nyman AL, Bliss R , Parascandola M, Hatsukami DK. Monitoring tobacco-specific N-nitrosamines and nicotine in novel smokeless tobacco products: findings from round II of the new product

• watch. Nicotine T
• b R
• es. 2014 Aug;16(8):1070-8.

US S Snus nus

. http://www.tobaccotoday.info/2014/06/14/swedish-match-submits-100000-page-modified-risk- tobacco-product-mrtp-application-to-fda-to-truthfully-market-general-snus-to-smokers-as-less- hazardous-alternative-to-cigarettes/

Dis issolv lvable les

. http://www.journalnow.com/business/business_news/local/article_9d001b58-f9f2-11e2-8fad- 0019bb30f31a.html

Hookah

 Wat

ater pipes es that ar are u e used ed t to smoke e spec ecial ally m mad ade t e tobac acco that comes es i in d differ eren ent f flavors, such a as apple, , mint, c , cherry, , choco colate, co coco conut, l lico corice ce, ca cappucci ccino

 Als

lso c calle lled nar argh ghile, , argileh eh, s , shisha, , hubbl bble-bub bubbl ble, a , and goza za

 Often s

n smoked i in gr n group ups, mout uth h piec ece s e shar ared ed.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/

Ho Hookah ah

 Man

any use sers t s think i it is l s less ss harmful, ho hookah h smoking ha ng has many o

• f the

he sam ame e heal ealth risk sks s as as c cigar aret ette e smoking ( ng (canc ncer, car ardiovas ascular ar d diseas ease) e)

 Hookahs

hs produc uce hi high gh levels o

• f

carcino noge gens ns a and nd carbon m n mono noxide

 An

n ho hour ur-long ho ng hookah s h session c n can n involve 200 200 puffs, a and 90, 90,000 m 000 ml of smoke i inhaled, compared with 2 h 20 p puf uffs from s smoking a ng a singl ngle ciga garette, or 5 500 ml ml s smo moke

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/

Ho Hookah ah

 High s

gh scho hool seni niors

• 1 of 5 boys, 1 of 6 girls used hookah in the last year

 Colleg

ege s e studen ents

• 22-40% used in last year

 Ad

Adults

• 18.2% of 18-24 year olds use

everyday, some days, or rarely

• 1. Prevalence and Correlates of S

moking and Cessation-R elated Behavior among S urvivors of Ten Cancers: Findings from a Nation- Wide S urvey Nine Years after Diagnosis, Cancer E pidemiol Biomarkers Prev, Published online Aug 6, 2014 doi: 10.1158/1055- 9965.E PI-14-0046

Colleg ege e Studen ents

Ber erg, S Strat atton, S Schau auer er et et al

• al. P

Per ercei eived ed Har arm, A Addictiven enes ess, an and Social al A Accep eptab ability of Tob

• bacco P
• Prod
• duc

ucts an and Mar arijuan ana a Among

• ng Young A
• ung Adul

ults: Marijua uana na, H Hook

• okah,

h, and nd Electroni

• nic Cigar

aret ettes es Win.

• n. Sub

ubstanc nce us use a and nd misus use 2014

 Stud

udy o

• f 2

2 uni universities in t n the he Sout uthe heast, 2 2000 stu tudents ts

 Mar

arijuan ana a (19.2%) an and h hookah ah ( (16.4%) w wer ere e the e most com

• mmon
• nly u

used prod

• ducts in t

the l e las ast mont

• nth

 E-cigar

aret ettes es wer ere l e lower er (4 (4.5 .5%)

 The

here were hi high r gh rates of c conc ncur urrent us use, e

• esp. i

in n e- cigar aret ette e use sers

 Mar

arijuan ana a was as t the m e most p positivel ely per ercei eived ed p product followed ed by h hookah ah an and e-cigar aret ettes es

Hook

• okah

Ber erg, S Strat atton, S Schau auer er et et al

• al. P

Per ercei eived ed Har arm, A Addictiven enes ess, an and Social al A Accep eptab ability of Tob

• bacco P
• Prod
• duc

ucts an and Mar arijuan ana a Among

• ng Young A
• ung Adul

ults: Marijua uana na, H Hook

• okah,

h, and nd Electroni

• nic Cigar

aret ettes es Win.

• n. Sub

ubstanc nce us use a and nd misus use 2014

FDA C Cen enter er for Tobacco P Products

http://www.fda.gov/TobaccoProducts/Labeling/ucm388395.htm

Proposed newly “deemed” products would include electronic cigarettes, cigars, pipe tobacco, certain dissolvables that are not “smokeless tobacco,” gels, and waterpipe tobacco. Once the proposed rule becomes final, FDA can use regulatory tools, such as age restrictions and requiring scientific review of new tobacco products and claims to reduce tobacco- related disease and death

S u S ummary

 ENDS ar

are e not “ “saf afe”

 Unr

nregul gulated s sale and nd d distribut ution d n driving d ng demand nd

 Ces

essation c clai aims ar are e unproven en

 Poten

ential al f for h har arm an and ben enef efit d dep epen ends on the e cont

• ntext of
• f c

com

• mbusted tob
• bacco
• prod
• ducts

 Dual

al u use/ e/del elayed ed quitting i is a m a maj ajor c concer ern

Key Tak ake e Away Points

 Emergi

ging ng smokeless produc ucts are no not witho hout ut r risk a and nd t the heir us use c can n resul ult i in e n exposur ure to hi high gh levels of ni nicotine ne a and nd carcino noge gens ns

 Some

e compan anies es m might be e ab able e to mak ake r e red educed ed h har arm c clai aims if ap applications ar are ac e accep epted ed b by the e FDA.

 Hook

• okah is used

ed l les ess freq equen ently t than an cigar aret ettes es, b but a a single e ho hookah s h session n can n resul ult in n hi high gh levels of e exposur ure to carcino noge gens ns a and nd carbon m n mono noxide

 Many y

young ung adul ults who ho us use ho hookah h us use o

• the

her t tobacco prod

• ducts c

con

• ncurrent

ntly

Key Tak ake e Away Points

Lucinda E ngland, MD, MS PH LBE9(@ cdc.gov

CDC Office on Smoking and Health

National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health

Contact act

www.cdc.gov/tobacco

Res esources es

US PHS TF

• http://www.uspreventiveservicestaskforce.org/
• http://www.fda.gov/T
• baccoProducts/default.htm
• http://www.tobaccofreekids.org/tobacco_unfiltered/tag/e-

cigarettes CDC

• http://www.cdc.gov/tobacco/campaign/tips/
• http://www.cdc.gov/reproductivehealth/T
• baccoUsePregnancy/Pr
• viders.html

Online training

• http://iml.dartmouth.edu/education/dsr/
• https://www.smokingcessationandpregnancy.org/

Res esources es

E lectronic cigarettes

• http://www.fda.gov/T
• baccoProducts/default.htm
• http://www.tobaccofreekids.org/tobacco_unfiltered/tag/e-

cigarettes

• http://www.cdc.gov/reproductivehealth/T
• baccoUsePregnancy/Pr
• viders.html
• http://publichealthlawcenter.org/programs/tobacco-control-legal-

consortium

Other er s statem emen ents/rec ecommen endations