Hi everyone my name is Dr. Jennifer Pearson
thanks for joining us.
I am new faculty at the University of Nevada,
Reno School of Community Health Sciences
I'm in the health administration and policy department
and I'm also a Nevada native I graduated
from Reno High School in 1998 left for
various levels of school and Peace Corp
and now I'm back. So I'm really happy
to be here I'm happy to be speaking
with all of you and today we're going to
talk about e-cigarettes and federal regulation.
So once we get, there we go
here's the screen. So I'm going to ask
you as I speak if you wouldn't mind
I'm going to try and leave about 10 minutes
at the end of today's talk for questions
but as I'm speaking if something comes
to you, you could just use the chat box
and then when I imagine what will happen
is a bunch of you will have questions
that will kind of all be in the same
area and we can look at those and start
to answer those
during the question and answer session.
So let's get started.
So the topics for today's talk
I'm not going to assume
that everyone here knows about the
burden of cigarette smoking and tobacco
use in the United States so I'm going to go
over that briefly I'm going to introduce
you to the Food and Drug
Administration's authority to regulate
tobacco products. I'm going to apply the
authority to specifically to
e-cigarettes and we'll get into some
some basic key cigarette research.
I should also say so my credentials
I finished a PhD in public health at Johns
Hopkins University in 2011
I am PI or principal investigator of two
studies funded by the National
Institutes of Health, National Institutes
of Drug Abuse both on e-cigarettes
I'm also an associate editor
on the recent
Surgeon General's report on
e-cigarettes among youth and young adults.
I also focus somewhat on tobacco
products that are labeled natural
organic and additive free but that won't
be the topic of today's talk.
So I really am pretty focused on e cigarette
use and have been since I'd say 2009.
So the burden of smoking.
Cigarette smoking
is the leading cause of preventable
death in the United States. It causes
480,000 deaths a year that is both
primaries of smoking and also secondhand
smoke exposure that includes also
deaths from fires deaths from
sudden infant death syndrome.
And I think sometimes a lot of us think well smoking
is solved you know because it's
certainly doing better than we ever have
in the United States. But still 480,000 nearly half a
million people each year is in my opinion
utterly unacceptable. And this is from the
most recent general surgeon
general surgeon general's report. So this was the
50th anniversary report from a few years ago
and you can see all the
cancers and chronic diseases that are
caused by smoking. The red ones are
newly associated with smoking as of 2014.
So you see it's just innumerable causes
of disease from smoking. Tobacco is also
a huge problem globally as the globe
becomes richer people move away from
from being, from causes of death
from infectious disease and we move
towards chronic disease and the estimate
is as of right now that tobacco could
kill 1.2 billion people globally by 2100.
Smoking is absolutely a public
health crisis it is overwhelmingly
caused by cigarettes and other combusted
tobacco products or other products that are burned.
It's estimated that 5.6 million of today's youth
will die prematurely from smoking. And in Washoe
County where we are at this very moment
almost 850 out of a 100,000 deaths
a year are due to smoking.
It's almost 20% of deaths among US men
and almost 16% of deaths among US women
so you know I'm sure a lot of you
are health providers and you see this
every day that smoking is truly a public health crisis.
t's also a social justice
issue so we really see that smoking is, well
tobacco marketing availability and the
lowest prices are concentrated on poor
and minority neighborhoods. You can
see here...
One moment while we turn this on.
Ok there we go
you can see here that this is the
relationship between level of education
and the prevalence of tobacco use and
you see the folks with the least
education so people who either have
no high school diploma or a GED have the
highest percentage of smoking and then
you see it decreases as your
education increases. Same thing here,
annual household income you can see that
people making the most money over
$100,000 a year 12.1% of them smoke
as opposed to people making less than 20%
of a year 32.2%. So you can see a clear gradient
relationship between smoking prevalence and income.
A lot of people say well
smoking is solved but really what's
happening is it's being concentrated in
the groups that are least able to
effectively deal with it. So like I said
earlier we see that more tobacco
retailers are near schools or low-income
areas and in other areas we see that
individuals with mental illness account
for 46% of cigarettes sold in the United States
that is a remarkable amount of consumption.
And there's actually some people think
that nicotine people are essentially
self-medicating with nicotine and that
smoking helps alleviate some of the
negative feelings both physical and
psychological associated with depression
and anxiety that's why we're seeing such
concentration of smoking in those populations.
And then we're also seeing
some significant targeting of certain
groups for example LGBTQ young adults
are nearly twice as likely to smoke
as their straight peers. And I want to just
make sure that we're all clear also that
you know a lot of lot of these
statistics are attributed to tobacco use
but according to the Surgeon General's
report from 2014 the majority of deaths
are caused by cigarettes and other
combustible tobacco products and they say
rapid elimination of their use will
dramatically reduce this burden.
So as public health professionals we are
working in a world with limited resources right
and we can't do
everything at once and so what the
surgeon general here is suggesting is
that we really need to focus on the
thing that's causing an overwhelming
amount of death and disease and that is
cigarettes and other burnt tobacco.
So an aside before we move forward I just
want to make sure that we're all on the
same page with some terms that I'm going to use.
So you know we're gonna start
talking about e-cigarettes and there's a
so I was clear what kind of terms you're
supposed to use for what. So when I say smoking
I mean combusted tobacco use
like cigarette smoking, cigar smoking,
cigarillo, hookah little cigar smoking.
Burnt tobacco produces smoke however I'm not
going to use those terms when I refer to
e-cigarette use or perhaps ENDS used
people say that electronic nicotine
delivery systems might also hear ANDS used
alternative nicotine delivery systems.
People also say vaping or vape or vape pens
this is all the same thing it all means
just to consume nicotine using an e-cigarette or
whatever you want to call that thing.
These products do not produce smoke they
produce an aerosol of nicotine in like
little bitty particles and it's kind of
commonly called vapor but it's not vapor
it's not a water vapor it's technically an aerosol.
So I just want to make sure that's
clear if I say smoke or smoking I'm
referring to burnt tobacco if I say vaping
you know e-cigarette use or aerosol
I'm referring to e-cigarettes.
Okay so now we're going to move on and talk
about FDA authority to regulate tobacco
products. So this is where the magic
happens this is the FDA and it's
interesting so the FDA has lots of
different centers associated with it and
this is just these are just three kind
of the big ones that you might heard of
if you even think about the FDA ever.
The Center for Drug Evaluation and Research
this is the place where you're always
hearing about you know FDA approved this
medication well these are that's that okay.
These folks work on medical devices and then
you know if you ever hear about food recalls
for example you know salmonella outbreak
in spinach that's these folks and
there are other offices and Senators in
the FDA but this is kind of I think how most of us
think of what FDA does on a daily basis.
After 2009 we got this new center
the center for tobacco products
and I'm going to explain to you
about what they do and how they were created.
So they were created as part of
the 2009 Family Smoking Prevention and
Tobacco Control Act this is a picture of
President Obama signing that that
legislation in 2009 and what this did
was a gave FDA authority to regulate the
manufacture distribution and marketing
of tobacco products to protect public health.
And this was a new thing before
2009 in the United States no one
agency or authority regulated tobacco products.
there were some regulations
on things like cigarette pack size
you know obviously taxes we had
restrictions on age of sale but the
actual product itself was not being regulated
and part of this law
created the FDA Center for Tobacco Products or CTP
and initially the law
was limited to cigarettes, roll-your-own
tobacco and smokeless tobacco but then
FDA expanded their authority to all
tobacco products including e-cigarettes in 2016.
So FDA can do all kinds of
stuff when it concerns tobacco regulation
what they did immediately was they
banned flavored cigarettes, smokeless
and roll your own tobacco except for menthol.
So I don't know if you remember before
2009 you get pina colada
cigarettes or cherry cigarettes or
I don't know if you remember the clove cigarettes
those are no longer legal.
The idea was is that they were unusually
attractive to youth and therefore they were banned.
These authorities also require
some changes to the cigarette and smokeless
warning labels which are still somewhat in progress
it requires disclosure of ingredients in
tobacco products so before this law
there was no requirement that companies
disclose what's actually in their products,
it requires that any modified risk
claims must be supported by science
and must go through a process where FDA does
not approve but allows marketing of
modified risk claims and so part of that
upon passage of this of this law was it
bans the descriptors light, low and mild
so no longer, it's not legal anymore to
have a light cigarette it can't say light on it.
What ended up happening however
was the companies just used
colors to convey the same thing so
instead of light we now see silver
so I don't know how effective that was.
It also just generally allows for
regulation of tobacco product
characteristics and requires pre-market
certification of products meaning that
tobacco companies can no longer just put out
whatever they feel like on the market
they have to show that the product will
not significantly affect public health
essentially but it's not a huge change
from the status quo. So the Center for
Tobacco Products makes decisions about
regulation of tobacco based on what's
called a public health standard which
has three parts. So first they have to
think about the risks and benefits to
the population as a whole including both
users and non-users of tobacco products
so both smokers for example and non-smokers.
Now they has to ask
themselves whether there is an increased
or decreased likelihood but existing
users of tobacco products will stop
using such products and we want that right
that would be good for public health.
And then we have to ask ourselves
whether there is an increased or decreased
likelihood that those who do
not currently use tobacco products
most notably youth will start using tobacco products.
So those are the three things that
you have to think about whenever they have
a new tobacco product application
in front of them or whether they're
considering using some of their
authorities to perhaps do something like
ban menthol which they could do or
decrease the amount of nicotine in
cigarettes to nonzero levels being just not zero.
So we can use
the public health standard as a guide
for research we can think about, there we
go, we can think about the harm
the population harm attributed to
there we go, the population harm
attributed to tobacco use as a equation
where we have appeal so that's like
products, product characteristics
that might get someone to start using a product.
Abuse liability are are the
characteristics of the product that
makes someone want to continue using
despite negative consequences so that's
like its ability to look to deliver
nicotine for example. And its toxicity so
you know we can have a product
that has high abuse liability
so it delivers nicotine really well
but it's not particularly toxic and
that might have a different population harm
but a product that is both very
addictive or has a very high abuse
liability and it's also very toxic and I
should say as an aside nicotine is not
particularly harmful on its own so you
can think about nicotine replacement
therapy right the patch the gum you can
actually buy these things over the counter
right there's there's no
restrictions on this. That's because the
nicotine is not the thing that causes
the disease now there might be a little bit
of cardiovascular effects it's the
delivery system so it's the burning
tobacco leaf that is the huge problem here.
So we think about e-cigarettes
this is a very interesting and complex
public health problem because and we'll
get into this e-cigarettes are not just
one thing so they have different levels
of appeal and different abilities to
induce dependence and they have
different levels of abuse liability they
also have somewhat different levels of
toxicity, we'll get into that more also.
So when someone asks you are
e-cigarettes all bad or are they all good
they are neither you say no,
or you say yes because it's not a simple answer
and we're going to talk about that.
So my question and the question of folks
in tobacco science is how do we keep people
in these nice green circles? So think of
the population, population can be in any
one of these circles right and they've
got little arrows you know go over here
and start smoking then can go over here and
start using e-cigs or they can stay in
their, intheir little green
circle and obviously want everyone
to stay here right we want them to be non-users.
But if they manage to find their way
down to the cigarette use category.
One of my questions for my research in my
work is how do we move them either to the
less harmful nicotine products which
I'll show you why I think that they're
less harmful or you know preferably how
do we move them into former use
this this is number two if I have mine
this is number one this is what we want
definitely want everyone to hang out up
there and non-current use if they're
going to move either here or here then
we want them to end up down here. But if
they are unable or unwilling to get into
the former use category then it is better
for them to be here and to be here or here
okay so from a public health standpoint
you know I would love everyone to
end up in former use or to
stay in current use but we have a very
diverse population of people with
different things going on in their lives
and different abilities at different
points of their lives and so we need to
acknowledge that and I think a lot of
you as as probably as providers
probably have experienced that
yourselves right you are with someone
you're inviting them to quit smoking and
they're saying you know it's just not for me right no.
So let's, we're gonna skip over this
So now I'm going to talk about FDA
regulation and apply it to e-cigarettes.
So a little bit of in the weeds
history here. So in 2009
FDA denied import of e-cigarettes from
Smoking Everywhere and NJOY these are
two e-cigarette companies and what they
said was you cannot import these because
they are an unapproved drug device
combination intended to help treat
withdrawal symptoms, nicotine addiction
and if you want to import these you have
to go through the Drug Evaluation side
of FDA and you have to essentially be
treated like nicotine patches or chantix.
And these companies of course are like
no no no we don't want to do that
we just want to import
our stuff and sell our stuff and make our money.
So they took FDA to court and
the court ended up decided in favor of
the e-cigarette companies essentially
they said just because something has
nicotine doesn't mean it's supposed to
be used for cessation. However that was
funny because a lot of people use them
for a cessation anyway so it's kind of
funny this is so this is how e-cigarettes
became regulated as tobacco products
even though as you can see there's no
tobacco leaf in them sometimes the
nicotine is derived from tobacco but you
know if for me ideally I would like to
see some sort of modified regulation
where they are treated more like a drug
or device than a tobacco product so that
we can really start working on treating
these things as people are using them
which is predominantly as cessation devices but
you know we are
in this situation so we're going to
go with it so like I mentioned
earlier e-cigarettes are not a
single product class so when someone
says doing e-cigarettes help people quit
smoking you say yes or no because the
answer is it depends. So we have a few
different kinds we have this first
generation which are called
cigalikes by us researchers and that's
because they look like cigarettes and
they have these little bitty, little
bitty batteries let me go back. So like
on cigalike this is the battery
and this is where the fluid the
nicotine containing fluid and these
little batteries don't do a great job
aerosolizing nicotine and therefore the
nicotine doesn't get all that deep into
the lungs and therefore it can get
absorbed to the bloodstream and thus
smokers do not find it particularly
reinforcing it doesn't do a good job
alleviating withdrawal and craving
symptoms and people who try these often
abandon them and say this is not going to help me.
Second generation these look more like
markers like big
Sharpie markers and they often are what
we call an open system so you can see
here this part right here is the tank
and you can unscrew that and put in
whatever kind of nicotine fluid you like
there's a wick in there and there's
a coil that heats up there's a wicked and a
coil that heats up in here to but you can
actually see it here and these things
tend to be a little better at delivering
nicotine and therefore tend to be
a little better at helping people quit smoking.
These products are also
products that people can use to vape cannabis.
So we need to remember that
it's not really these so much though you
can buy some some pre-made cannabis
products that do look like this but it's
mostly these products that people
use to vape cannabis.
We also now have what
we're calling the third-generation
sometimes they're called personal
vaporizers or mods and these are
products that are pretty sophisticated
you can change the wattage you can
change the resistance on the coils so you
can change how hot they get, you can
change how much visible aerosol people
produce, you some of them have like puff
cameras on them some of them can link
with via Bluetooth to your phone I mean
there's they're pretty sophisticated and
they can get pretty big too. This down
here is actually a e-hookah that you
know you can see these little this like
right here this is like a mouthpiece
this would be a mouthpiece and then we have
what I'm calling fourth generation
though I don't even know if this
necessarily even belongs in an
e-cigarette category and a lot of you are
probably becoming aware of a product
called JUUL it's very small it looks
like a thumb drive or a pen drive
whatever you want to call it and it has
little cartridges, it's not an
open system at the closed system
and it uses nicotine salts these other
products use nicotine in a propylene
glycol and vegetable glycerin solution
but the JUUL uses nicotine salts and it is
either the second or first most popular
e-cigarette on the market right now
it went from nothing to quite a lot of
market share in about a year. I'm very
interested to see what happens with this
product because it delivers nicotine
very well so smokers who are unable or
unwilling to quit find this stuff very
reinforcing very satisfying
unfortunately if you have a product that is
satisfying to adults then they're also a
product that is satisfying kids and that is a
problem especially since these things
are small they are easily concealed
so as you can see different populations
will have different public health effects
right so something that might be
good for one population can be bad for
another population and that's why I say
this is a very complex issue there's no
one-size-fits-all answer to how we
should deal with these products.
Okay
so e-cigarettes I'm just I'm going to
make a case here that you should think
of e-cigarettes as being much less
harmful than cigarettes. So first of all
cigarettes have 69 known human carcinogens
four thousand chemicals you're inhaling
tar you're inhaling carbon monoxide
I can't think of a single consumer product
that is worse for you than cigarettes okay
they blow everything else out of
the water they are terrible.
So it is
somewhat a low bar or a high bar it's
easy it's easy to have a consumer
product that is less harmful than
cigarettes right. However e-cigarettes
depending on the type of e-cigarette are
much less to significantly much less harmful.
So these products have
most of them nicotine not all of them
have nicotine they're propylene glycol and
vegetable glycerin which are humectants
they do have toxic constituents such as
tobacco-specific nitrosamines and heavy
metals but at much lower levels
somewhere between 9 and 450 times
lower than tobacco smoke. We also know
that some flavors are cytotoxic meaning
that if you have cells in a petri dish
and then you've bathed the cells in nicotine
fluid with different flavors that
it will kill the cells. So like cinnamon
for example in cytotoxic flavors that
have kind of a buttery flavor can be
cytotoxic so we want to use regulation
to remove those from products because
that's simply unacceptable we don't
that's like that's low-hanging fruit
we can get rid of that. So here's just one
example of a study that was comparing
biomarker levels so these are all some
these are all some well-known
biomarkers of harm from smoking from
tobacco use and you can see they're
comparing smokers to former smokers
and then within smokers and former smokers
they have those groups divided into two groups.
So here we see dual cigarette
and nicotine replacement therapy users
such as patches, gum, inhaler, etc., and then
here you see dual cigarette e-cigarette users
and you can see just looking across
the two groups you can see
there's really not much of a difference between
their biomarkers of harm in some
cases they're a little higher
bu there's statistically significantly
similar to each other I think in every case.
So if you continue to smoke using
e-cigarettes or NRT will not improve
your biomarkers of harm. But if you just
look at former smokers there's a
different a different story here so yeah
thank you
So looking at just NRT only users so
once again those are people who are
using patches or gum so there are former
smokers who are still using some form of nicotine
replacement therapy and we're
comparing them the people who are only
using e-cigarettes. You see across all
these different categories of biomarkers of
harm you see similar or even lower
biomarkers of harm for the e-cigarette
users compared to the NRT users
and remember NRT is FDA approved smoking
cessation available over-the-counter
anyone can go in and buy it. So this to
me is a good indication that at least on the
short term e-cigarettes are
about as harmful as NRT may you know
we really need the long-term cohort
data so we need to follow people for 30,
40, 50 years to really know that for certain
but given the data that we have this is
not the only study out there are lots
of other studies that show the same thing
given the data that we have our
best guess as of right now is that
e-cigarettes are in general as a class
less harmful definitely than cigarettes
and might be comparable to NRT.
So they also deliver nicotine a little bit more
differently than cigarettes so this is
from a recent study and this down the
side here this is nicotine plasma levels
and then right here this is time so what
they did is say had people come into the lab
and use an e-cigarette in a
controlled manner and then took blood
from them at five minutes and at twenty
minutes and at 35 minutes and so what
you see here this green this is a
cigarettes you can see like five minutes
after you start smoking a cigarette your
nicotine levels in your blood go way up
right that's why people find cigarettes
so reinforcing and so hard to quit
because you get a rush in nicotine
immediately you know the thing that we
say in tobacco control right is that you
feel the hit within seven seconds of your first inhalation.
With e-cigarettes they're a little bit
different so you see this red line
it does eventually achieve plasma levels
nicotine plasma levels
of a cigarette but it takes 35 minutes
and this is for a new generation device
or you know a second generation device
those ones that look like markers
Is this just for one hit of...
No no they are they are doing a
controlled bout so they're taking
I think this is from I think its 10 puffs.
But don't quote me on that so they reach
levels of comparable to cigarette
smokers but it takes takes a longer time.
So this is one of the reasons why
addiction scientists hypothesize that
e-cigarettes are not as addictive as
cigarettes because you're not getting
that drug hit all at once as quickly
the quickness of drug
delivery is one of the things that
predicts how addictive a drug will be.
How quickly you feel the subjective
effects of the drug and then you see
the little cigalike the little
devices that look like cigarettes they
never get to the point of a cigarette
and they just kind of, they're not doing
so great. So you can see how maybe a
cigarette smoker who is trying to
quit might not find these little
cigalike, e-cigarettes particularly useful.
So who is using e-cigarettes this is
from CDC so this is from I believe
yeah 2014 data so this is 2014.
So in 2014, 12.6%
of adults had ever tried an e-cigarette
and then of that 12.6%
the majority 55.4% are recent former
smokers maybe they quit in the past year.
Second most 47.6% of current smokers
8.9% are long-term former smokers
and 3.2% are
never cigarette smokers and then if we
look at who is currently using e-cigarettes
meaning any use in the past
30 days we see 3.7%
of US adults in 2014
were past 30 day users of that 22% of
that 3.7% were recent former smokers,
15.9% for current cigarette smokers, 2.3%
were a long-term former and
0.4% were never smokers. So what does
this suggest to me? This suggests that
there is an association between being a
former smoker a recent former smoker and
e-cigarette use current and ever.
I cannot tell the directionality of this
association because this is
cross-sectional data so I can't tell if
quitting smoking came first and then
they started using e-cigarettes or if
they started using e-cigarettes and then
they quit smoking. But I do think that
this is interesting and
suggestive of a relationship.
We also have a recent study from some people at
UC San Diego they did some really
interesting work with some population
level data and I have their conclusions
drawn out here. So let's first look at
the figure this is figure from the
current population surveys using supplements.
So this is the quit attempt rate
and then the annual cessation rate.
So obviously higher quit
attempt rate will lead to annual
a higher annual cessation rate right
because you have to try to quit before
you quit at least directly.
So you see it's pretty flat
from a one to three to six to
twenty ten and e-cigarettes were rare
really in 2009, 2010, 2011, they really
started taking off between I say 2011
and 2014 so you see there's a little bump
here in quit attempts and there's
also a little bump in cessation and then
when they looked at just the 2014 data
and they stratified by whether or not
someone had used e-cigarettes in the
past 12 months they see a big difference
both in quit attempts and
in actual cessation. And once again we can't
say for certain that's because they were
using an e-cigarette but this is again
suggestive that e-cigarettes and
cessation and quit attempts are
associated in the population so this is
among adult smokers.
But what about the
kids right. So we hear so much about kids
using e-cigarettes and it makes a lot of the news.
So the main concerns about
e-cigarette use in youth the first one is
that e-cigarette use is harm enhancing
for youth and really for all
non-tobacco users that is absolutely true
they while they're not as harmful
as cigarettes they are harmful
they're not harmless they're not just water
vapor. So if you you know consider they're
harm reducing for adult smokers who are
unable or unwilling to quit if they
switch completely right partial switching
is not going to do it they have to switch completely.
But they're harm
enhancing for people who are not using anything.
There's also some concern that
nicotine might be a problem for the
adolescent brain it might prime them
to be more responsive to other
substances of abuse in the future.
It's kind of up for debate about that but you
know it's best just precautionary
principle let's just let's just go ahead
and say best guess just avoid it.
The other concern is that e-cigarette use
as a gateway to more harmful forms of
tobacco use namely cigarette smoking.
This is a very difficult question to
answer with observational research
you are not going to do a randomized
controlled trial where you get a bunch of
kids and like randomize half of them to
e-cigarette use and half of them to none-cigarette use
and then see what happens right.
so that's not going to happen
the data is absolutely
all over the map on this. An occlusion
conclusions depend on the definitions of
exposure in the outcome so it depends on
how you define e-cigarette use,
depends on how you define cigarette use,
and so what I think is most useful right
now is we don't really need
to think to ask to know if
e-cigarettes are a gateway to anything.
Who cares?
For me we should think of e-cigarettes
perhaps as a marker of future risk behavior
right. So if you're
a clinician and you find out one of
your patients as a kid and he's using e-cigs
you might want to be like okay what else
is this kid getting in to, right?
Because what we're seeing is that it's
well my hypothesis I guess is
that it is like the lowest consequence
harm risk behavior that kids have found
right now it's really easy to sneak.
You don't smell like anything so my theory
is they're playing with some risk behaviors.
And so if you find this out
you kind of know this kid might be
pointing the direction that you don't
want that kid to go in right.
And so as I said who cares if it's a gateway or
not I mean let us scientists try to figure it out,
but for application
purposes kids should not be using
e-cigarettes it doesn't matter if it's a
gateway right
just boom that's all you need to know.
So just also kind of orient you to the
population level data
this is trends in past 30 day use
which is all often considered current
use for kids for cigarettes and
e-cigarettes among high school students
and I updated it with 2016 data.
So you see in 2011 cigarette smoking was
way up at almost 16%
e-cigarette use was down at 1.5%
and then as e-cigarettes became more
prevalent in the adult population we saw
kids using them more too. I mean where do
they get them from? They get some from adults.
Also online
so this change right here
this is some inside baseball news for
you all. This change is probably not real
the National Youth tobacco survey changed
the way it asked about e-cigarettes
between 2013 and 2014
and 2013 they said hey tell us all
what other tobacco products you use
and they had a list
it was just check all that apply. And in
2014 they asked hey have you used
e-cigarettes Yes/No
they also made that change for hookah
and if you if I put hookah on this you'd see
the same thing this huge increase in
prevalence of hookah use and it's this is a
well-known survey design thing when
you ask when you ask these questions
differently you get different prevalences
so I think this number is
correct I don't think this change is
correct it was probably more like this right.
So we were probably underestimating
use in 2011 and 2012 and 2013 and now
we're more at the right prevalence estimate.
So could you erase my scribbles (laughing)
Okay
Thank you so um
so what you're seeing is yeah e-cigarette use
took off in 2015 it outperformed
cigarettes what we're seeing is also
really good news for public health
because the thing that is causing the most harm
is continuing to decrease and
if e-cigarettes were a gateway
to cigarette smoking I would expect
you know here it takes off I would expect
this.. whoops I did not mean to do that
sorry
I would expect, oh my, anyway I would
expect an increase. Now it could be
that this line should be more like that
though probably not that dramatic. So it
could be that these things are a gateway
and this decrease would have been more
dramatic without e-cigarettes on the market
we can't know for certain but
certainly what we need to be doing is
keeping an eye on this, keep an eye on
prevalence of cigarette use and
e-cigarette use and we need to make sure
that this doesn't start to tick up
at minimum.
Okay and then also I just want
to make a quick point here you can look
at this, this is the source publication
for my colleagues and I
I just want to make the point that when you see
distribution so this is the frequency of
use in past 30 day cigarette use and
e-cigarette use when you see it
bimodal distribution like this where
there's a lot of use in one to two days
the past 30 days and there's a lot of
use in the past 30 days and then there's
kind of a lot of incidental use right there
that suggests that you know these
folks are experimenting,
these folks are addicted right.
What you're not seeing for e-cigarette use is
that you're seeing a lot of
experimentation and you're not seeing a
lot of past 30 days use. And among the
past 30 day users the you know 90% of
the past 30 day users are also using
other tobacco products so there's very
little past 30 day e-cigarette exclusive use.
So if you also see a kid if you're a
provider you see a kid is using
e-cigarettes that kids probably using
other tobacco products, almost certainly.
So yes in summary it's complicated right
e-cigarettes are complicated.
Really for me the question is how do we
use policy and product regulation to
amplify any positive effects and
eliminate any negative effects
of e-cigarettes on public health.
And yeah it's hard it's complicated and we could
ask similar questions about other
consumer products right. So we could ask
those questions about alcohol the
majority people can use alcohol without
a problem but for a subset of people
alcohol causes major problems, so how do we
regulate a product that has different
effects on different populations?
Marijuana gosh we'll see we'll let you
know in a few years how that goes.
Prescription opioids we're well aware
that there is a huge problem with opioid
abuse in our country right but also
these are products that are extremely
useful to people who have chronic pain.
And even think about automobiles we need
these things to get around and live our
lives but when used improperly they can
harm or kill us right. So we need to
figure out how to use policy, law and
product regulation to make all of these
consumer products as
good for us as they can be and to
minimize negative consequences of their use.
And here's something interesting so
FDA recently announced a couple months
ago that they want to reduce the amount
of nicotine in cigarettes to a point
where they think there's some sort of
sweet spot where nicotine will be or
sorry cigarettes will be
not particularly addicting for people who
are starting and so it'll be easier to quit.
But you notice that this picture
here this is not of a cigarette this is
of an e-cigarette because at the same
time that they said that they wanted to
decrease nicotine in cigarettes they
also said they want to for people who
are having a hard time quitting they
want to make lower harm products
containing nicotine more available. So
that's very interesting to me what
they're saying is we want to stop using
policy on the thing that causes the
overwhelming amount of death and disease
in our country a cigarette, the burnt tobacco.
When we want to see if we can
move millions of people from the high
harm product to either no smoking
ideally or if they can't do that
instead of them going to a black market we'd
like to see them use a low harm product
that's still has nicotine in it.
And I think that's a very very interesting
idea it'll probably take years to
implement because companies will sue
like crazy and what you actually saw is
this is Altria's stock price and this is
British American Tobacco stock price
Altria aka Philip Morris they changed their name
a few years ago because they thought you know
people don't like Philip Morris and they're right
and what you saw is after
FDA made their announcement their stock
price plummeted same thing in British
American Tobacco and to me when you see
that it's usually good news for Public Health.
So in summary the e-cigarettes ultimate
effect on public health is complex and
evolving as I think I've
hopefully made the point. We can use policy
and regulation to force companies priorities
to align with ours and public health as
much as possible. And the challenge
the public health challenge is how do we
allow smokers to pursue quitting in
whatever way gets them there I do not
care how you quit if you need to stand
on your head for 20 minutes a day and do
the Macarena and that gets you to quit fine
if you need to put on a patch and use an
e-cigarette and use verticin and
go to Fiji I quit that is the number one
thing I do not care how you get there
because the thing is is that when adults
quit fewer kids quit, fewer kids start smoking
essentially it changes norms
it changes supply of the product in the
population. So we need to support adults
to quit and how way they want to get there
while simultaneously avoiding
attracting youth to e-cigarettes and I put
this circular firing squad because if
any of you are in tobacco control you
might know that we've had a lot of
debate about e-cigarettes and their
role in tobacco control and public
health and I think we're doing ourselves
and smokers and non-smokers a disservice
when we waste all of our time debating
things like gateways when in fact all we
need to say is kids shouldn't use
e-cigarettes and adults should quit.
So let's get this number down to zero, how about it?
And I thank you for your attention
please do email me if you'd like
to talk some more.
Thanks
Do we have any questions?
I've seen the chat going on
we did see it a question earlier. So
if someone uses an e-cig with little or
no nicotine just to control the need for
something in their hand is it less
dangerous than smoking tobacco product?
Yes it is.
Do we have any other questions please feel free to
unmute yourself with the icon in the lower left
corner of your zoom screen or send them in
via the chat.
A lot of questions
and feel free to challenge me if you
I have a feeling that for some of you this
might be new and surprising that you
to hear someone a tobacco researcher
say e-cigarettes aren't terribly bad
for you and smokers who are unable or
unwilling to quit should switch.
So please do challenge me I love challenges
Um what about the difference in milligrams in e-cigs?
Right, right, right,
so you're asking about nicotine
concentration. So the question is what about
differences in milligrams? So I'm
going to interpret that to mean you're
asking about different nicotine concentrations.
So different products have higher or lower nicotine
concentrations remember that nicotine is
not the thing that's particularly harmful.
So um nicotine's in a patch
you can buy it over the counter right.
So different products have different
nicotine concentrations the smaller
products the smaller batteries have
higher nicotine concentrations because
they don't do as good a job at
delivering nicotine so they need to have more
nicotine in it to get it into you.
People who have those really big devices that
you know look like pieces of electronics
those can have much lower concentrations
of nicotine because they do a better job
delivering it to the lungs. So you know
a higher nicotine concentration is not inherently
more or less harmful you know it is an
indication someone who was like a
heavier smoker might want a higher
nicotine concentration than a lighter
smoker nicotine itself is adversive
so if you get a lot of it you feel queasy
your heart rate starts to starts to
pound I don't know if anyone saw
it came out years ago and
one of the jokes in it was they were trying
to kill a guy by covering him in nicotine patches
that's theoretically possible in fact
there have been some poisonings from nicotine
fluid that didn't have child safe caps on it
and that's a big problem clearly
something that could be addressed by regulation.
So yeah I hope I answered your question.
Another question does vaping or e-cigarettes
cause popcorn lungs?
Ah good question
so yeah this is a big thing that came out in the
in the news I'm aware of one case
of popcorn lung from vaping and that
is from that that flavoring that gives
like a buttery flavor.
So this is another
obvious opportunity for regulation that
flavoring that has caused popcorn
lung and I don't know what his exposure
was like but I imagine it was pretty heavy
should absolutely not be in that
product right, that that should be
you should use regulations to
remove that. That is once again like I
said low hanging fruit. But when you
think about
yes um you know there was
one guy that was maybe there might be
more people, I am aware of one case
one case study. That one person that is
unacceptable but at the same time when
you can compare it to the 490,000 people
from tobacco you know
it's dwarfed.
I think my point is e-cigarettes
are not harmless they're
harmful and you know you've seen on the
news the batteries exploding and um yeah
these things happen.
But they happen the negative effects
happen in a much lower rate
than cigarette smoking which
happens every day, every hour every second.
Yes
So there's another one,
do you think it's possible to sway adults without
swaying kids this seems a bit difficult
to do without perpetuating the image of smoking
with kids see smoking they think it's cool.
Yeah so good question.
So in the UK they have taken a very
different approach to e-cigarettes so
they have an explicit harm-reduction
slant to their National Health Service
which I guess makes sense they have a
National Health Service right so they're
trying to decrease costs.
They have this thing called the
Nudge Commission which is
trying to kind of slowly affect people's
behavior without them realizing and what
they have been doing is actually
actively promoting you e-cigarettes to
people who call the National quit line
and they have seen significant drops in
cigarette smoking without increases in
youths smoking and the way that they've
done that is they have seriously
controlled access to these products so
they have strong age controls I would
love to see tobacco 21 laws in every
state in the country right now there's
only a few states that do that and I
would like to see those apply to
e-cigarettes as well.
And I think that we
can frame these devices as crutches
to help you stop smoking right.
And I think
I can't speak for kids I don't know what
they think is cool or uncool but I think
if we're able to speak honestly about
these products as a thing that people
who are smoking can use to quit.
and not as a cool fun thing you use at parties.
I think we can do it UK is doing it
you know and then,
and here I'm going to be super controversial.
How many kids are we willing
to allow to start using e-cigarettes,
in exchange for adults quitting?
I don't know. But the
reality is that in the public health
on a public health level we're not going
to have a situation were absolutely zero
kids are going to use e-cigarettes right
it's just it's not the reality of public health.
So my feeling right now is
that we use all the stuff that we
know works in tobacco control, we
continued attacks, we continue to regulate,
we use warnings they use media campaigns
we get tabacoc 21 and every state, we make
chantix or varenicline over the counter
which is something that I'm working on
which is the best treatment for smoking
and let me know you know we make NRT
more accessible, we do all of these things
but perhaps we also say and hey
if you can't quit any other way
use e-cigarettes and then once we get to the
point where smoking is a very low
prevalent situation then we focus on
e-cigarettes then we say okay let's
get rid of these things too because
they're not harmless and now they're
causing a problem. But we have
limited resources in public health and I
really feel strongly that we need to
focus on the thing that causes almost
half a million deaths every year.
So a doctor asked
if a patient comes in says they smoke a
pack a day how many milligrams
is the equivalent for an e-cig?
That is hard to say because it depends on the device.
So definitely that person
shouldn't be using the little devices
the little cigarette looking devices,
but that person could use the
second-generation device with a
milligram with a nicotine concentration
of like 18, 1.8 milligrams per
milliliter or they could use one of those
big devices where it's like 6.
So it really depends on the device
what I recommend
and this is gonna sound crazy once again
for a public health person is that people
smokers who want to quit go talk to
smokers who have quit using e-cigarettes
and see what their advice is see what
their process has been. And a lot of
those people are utter evangelists about
e-cigarettes they're saying you know
this thing saved my life and they are
happy to talk about it. So that's my advice.
Kelli Goatly-Seals from the state
said that there was a recent study by QRI
talking about the aldehydes in e-cigs from the
flavoring, are there any other harm
markers that you didn't discuss today?
Yea so there's a few things. So there's
well known formaldehyde study there's
they do they produce particulate matter
PM 2.5 which you definitely don't want
to be inhaling
once again not harmless right
there is absolutely harm associated with
these things. So let's see, acrolein,
choline, formaldehyde yeah I mean
some of them have TNAs in them
but once again in almost every case
there are much lower levels than cigarettes.
The famous formaldehydes study that
came out from some people, I believe at
UC San Diego that or maybe San Diego State,
they essentially what they did
is they really kind of like burned an
e-cigarette they cranked it up to
like its highest ability to produce heat
and then had little to no liquid in it and
then were able to produce a lot of
formaldehyde off that product and kind
of the metaphor that I use is like
imagine you put a piece of toast in the
toaster and crank it up to its
highest setting then you put down and
then when it wants to come up you're like
put it down again and then when it want to come
put it down again and then you go
here is your piece of toast and like
no one we're actually going to eat that
piece of toast right it's burnt
it tastes bad
and that's the same thing. So that
product people are probably not using
inhaling that amount of formaldehyde
because it's averse it tastes terrible
but it's not acceptable that that
product can produce that amount of formaldehyde
it's not okay. We can use regulation to
put guardrails on these products and
make sure that they're not able to produce
toxic levels of anything.
It's the beauty of regulation.
And then same question from a couple people
second hand.
Ah second hand so yeah that's a big thing
depending on the setting of the e-cigs
sometimes it's super visible right if
this we get huge clouds of aerosol.
I am not aware of any studies...
Whoa there's some
crazy stuff going on next door
Oh okay alright sorry
so I'm not aware of any studies
that have shown negative
exposures from secondhand vapor.
So the last study I remember looking at they
essentially put a person in like a
column like a glass column pumped full of
aerosol and they were able to detect, so
nicotine in that person's blood but they
weren't able to detect any other
biomarkers of harm and that's probably
because if you think about a cigarette and
there's always sidestream smoke right because
it's burning, it's always burning. With an e-cig
that doesn't happen it only
produces aerosol when you take a drag
off of it and exhale.
And it also it's an aerosol so
it dissipates pretty quickly it kind of
falls to the ground. So I am not I guess
what I'm saying is the data is not
supportive that secondhand aerosol is
particularly harmful. The best advice
though is that certainly pregnant women
and kids especially infants and people
with respiratory disease should not be
exposed to this because there might be
some harms that we just haven't gotten to yet.
And I think best-case scenario is
that it should not be allowed indoors
just in general.
I am more ambivalent about multi-unit housing
I'm very supportive of smoking bans and
multi-unit housing I'm not convinced
that e-cigarette aerosol can travel far
enough for it to affect neighbors
in multi-unit housing. So, but I'm open to
science that would suggest otherwise
that's just my best guess right now.
All of this is my best guess by the way.
As things come out you make, you change your
ideas right and that's like what
happens when you're a scientist.
Okay so I
think we're over time.
So are we done?
Good yeah
Okay
Thank you so much everyone for
joining us today.
Bye! Thank you, email me!
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