changing the environment of care and 2015 tobacco ... · changing the environment of care •...
TRANSCRIPT
TOBACCO CESSATION CHANGING THE ENVIRONMENT OF CARE
and 2015 TOBACCO CESSATION UPDATE 35th Annual FSACOFP amp FOMA Family Medicine Update
July 31 2015
Dennis H Penzell DO MS FACP Certified Tobacco Treatment Specialist
Associate Professor of Medicine Department of Internal Medicine
Nova Southeastern University
CHANGING THE ENVIRONMENT OF CARE Agenda
bull Intro bull The office champion bull Assessing your office bull Patient Flow bull Barriers to implementation bull 5 As bull Teachable Moment bull How can the AHEC help you bull The office bull Pharmacology bull E Cigs
Team up to Quit Statewide Initiative
bull Statewide Effort to raise awareness of the important role health providers have in helping their patients quit their tobacco use
bull Initiative to raise awareness of the free resources available to help Floridians quit tobacco
IQuit with AHEC 1-877-848-6696
ahectobaccocom
bull Free In-person Tobacco Cessation Groups bull Receive toolsstrategies to quit and stay tobacco-
free bull Programs in English and Spanish bull Friendly respectful supportive group setting bull Free nicotine replacement therapy
FLORIDA QUIT LINE 1-877-U-CAN-NOW
bull Counseling via phone or on-line services available
bull Quitline services in English Spanish Haitian Creole
bull Translation services for all other languages
bull Free starter kit of nicotine replacement therapy
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE Agenda
bull Intro bull The office champion bull Assessing your office bull Patient Flow bull Barriers to implementation bull 5 As bull Teachable Moment bull How can the AHEC help you bull The office bull Pharmacology bull E Cigs
Team up to Quit Statewide Initiative
bull Statewide Effort to raise awareness of the important role health providers have in helping their patients quit their tobacco use
bull Initiative to raise awareness of the free resources available to help Floridians quit tobacco
IQuit with AHEC 1-877-848-6696
ahectobaccocom
bull Free In-person Tobacco Cessation Groups bull Receive toolsstrategies to quit and stay tobacco-
free bull Programs in English and Spanish bull Friendly respectful supportive group setting bull Free nicotine replacement therapy
FLORIDA QUIT LINE 1-877-U-CAN-NOW
bull Counseling via phone or on-line services available
bull Quitline services in English Spanish Haitian Creole
bull Translation services for all other languages
bull Free starter kit of nicotine replacement therapy
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Team up to Quit Statewide Initiative
bull Statewide Effort to raise awareness of the important role health providers have in helping their patients quit their tobacco use
bull Initiative to raise awareness of the free resources available to help Floridians quit tobacco
IQuit with AHEC 1-877-848-6696
ahectobaccocom
bull Free In-person Tobacco Cessation Groups bull Receive toolsstrategies to quit and stay tobacco-
free bull Programs in English and Spanish bull Friendly respectful supportive group setting bull Free nicotine replacement therapy
FLORIDA QUIT LINE 1-877-U-CAN-NOW
bull Counseling via phone or on-line services available
bull Quitline services in English Spanish Haitian Creole
bull Translation services for all other languages
bull Free starter kit of nicotine replacement therapy
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
IQuit with AHEC 1-877-848-6696
ahectobaccocom
bull Free In-person Tobacco Cessation Groups bull Receive toolsstrategies to quit and stay tobacco-
free bull Programs in English and Spanish bull Friendly respectful supportive group setting bull Free nicotine replacement therapy
FLORIDA QUIT LINE 1-877-U-CAN-NOW
bull Counseling via phone or on-line services available
bull Quitline services in English Spanish Haitian Creole
bull Translation services for all other languages
bull Free starter kit of nicotine replacement therapy
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
FLORIDA QUIT LINE 1-877-U-CAN-NOW
bull Counseling via phone or on-line services available
bull Quitline services in English Spanish Haitian Creole
bull Translation services for all other languages
bull Free starter kit of nicotine replacement therapy
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Mortality among current smokers is 2 to 3 times as high as that among persons who never smoked
bull Excess mortality is believed to be explained by 21 common diseases that have been formally established as caused by cigarette smoking
bull If smoking causes additional diseases these official estimates may significantly underestimate the number of deaths attributable to smoking
bull Smoking and Mortality mdash Beyond Established Causes Brian D Carter MPH Christian C Abnet PhD Diane Feskanich ScD Neal D Freedman PhD Patricia
Hartge ScD Cora E Lewis MD Judith K Ockene PhD Ross L Prentice PhD Frank E Speizer MD Michael J Thun MD and Eric J Jacobs PhD
bull N Engl J Med 2015 372631-640 February 12 2015
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
UNDERESTIMATING DEATHS DUE TO SMOKING
bull Overall approximately 17 of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking
bull These included associations between current smoking and deaths from renal failure
bull Intestinal ischemia
bull Hypertensive heart disease
bull Infections
bull Various respiratory diseases
bull Breast cancer
bull Prostate cancer
bull Among former smokers the relative risk for each of these outcomes declined as the number of years since quitting increased
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
TREATING OUR PATIENTS FOR TOBACCO USE
CHANGING THE ENVIRONMENT OF CARE
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull 443000 deaths each year making it the leading preventable cause of mortality1
bull Smokers die 13 to 14 years earlier than nonsmokers bull 86 million people are living with a serious illness caused by
smoking2
bull 46 million current US smokers 70 percent say that they would like to quit3
bull Tobacco dep is a chronic disease needing multiple quit attempts4
bull 1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208
bull 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) Retrieved from httpbetobaccofreehhsgovabout-tobacco facts-figuresindexhtml
bull 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519
bull 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
The Message
Physicians have a tremendous opportunity to make a significant impact on the tobacco-use behaviors of Americans in their offices
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
System Change Definition
Specific strategies that are implemented to
support changes in health care organizations
leading to universal evidence-based
interventions with all tobacco users
The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull The US Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update calls on clinicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is
a Identified b Advised to quit c Offered evidence-based treatments
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Guideline Recommends
bull Implementing a tobacco user ID system in office
bull Providing adequate training resources and feedback to ensure that providers consistently deliver effective treatments
bull Dedicating staff to provide tobacco dependence treatment
bull Assessing the delivery of this treatment in staff performance evaluations
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Patients who have been advised to quit
smoking by the physicians have a 66
higher cessation rate
bull Former Surgeon General Regina Benjamin MD
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull There are numerous ways to develop and establish a tobacco-free culture in your medical office
bull The most important aspect is to get the entire staff and patients thinking and talking about being tobacco-free
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Examples of how to demonstrate a tobacco-free culture include
bull Make sure magazines in your exam rooms and waiting areas donrsquot have tobacco ads
bull Donrsquot allow staff to smoke on office grounds or during work hours
bull Place visual cues posters and brochures in the office
bull On a regular basis offer training (eg lectures workshops inservices) on tobacco dependence treatments
bull
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull Make one person in your practice a tobacco cessation Office Champion
bull Provides overall leadership for efforts
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE ldquoCHAMPIONrdquo
bull Charged with recommending system changes
bull Integrates tobacco cessation treatment into practicersquos daily office routine
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE Champion
bull Is passionate about helping staff patients quit
bull If possible give your Champion the time and resources to institute real change
bull Collaborative process allowing all staff and clinicians to provide input into realigning processes
bull Your practice may want to form a committee to assist the Champion in planning and implementing change and measuring success
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Evaluate your current system
1 Does your practice identify and document
tobacco users
a Whose responsibility is this
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
2 How does your practice environment currently communicate to patients the importance of quitting and your ability to assist them Tobacco-free signs at entrances Posters in waiting areas Posters in exam rooms Self-help materials in waiting areas Self-help materials in exam rooms Lapel pins Other __
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
3 How does your practice help patients quit smoking
Distribute educational materials
Refer patients to a quit lineAHEC
Refer pts to outside counseling options
Conduct tobacco cessation group visits
Counsel patients at visits
Prescribe medication at visits
Provide follow-up for pts making a quit attempt
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
4 What systems do you have in place to make sure
tobacco use is addressed at patient visits
Prompts in EHR systems
Tobacco use status as part of vital signs
Registry of patients who use tobacco
Flags or stickers on paper charts
Feedback to clinicians adherence to guidelines
Regular staff training
Other__________________________________
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
5 What are some of the challenges you face in
identifying smokerstobacco users and
helping them quit
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
6 Whose responsibility is it now to advise
patients to quit and to provide counseling
and resources
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
7 What resources are available in your
community that your patients could access
for help with their quit attempts
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Evaluate patient flow
Examine how patients flow through your office
Opportunities for exposure to tobacco cessation messages
Create a simple document that shows how patients advance through your system from the time they enter until the time they leave
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Think about these questions relative to tobacco cessation as you document your current patient flow 1 Where do patients go when they enter the office 2 What do they see and do before theyrsquore called back
for their visit 3 Who do patients see before meeting the physician 4 What questions are asked when vital signs are
measured 5 What information is exchanged with patients before
the patient-clinician encounter
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
6 How do clinicians support tobacco cessation during the encounter
7 How is tobacco cessation counseling andor other treatment documented
8 What reminder systems and prompts are in place to alert clinicians of opportunities to discuss tobacco cessation
9 What path do patients take as they exit the office Do they make any stops to speak with staff
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Pt Checks In
Billing and Scheduling
In waiting Room
Vitals
Meets Clinician
Patient Leaves
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
bull New patient visits
bull Annual physicals
bull Well-child visits (discuss smoking in the home and car)
bull Womenrsquos wellness exams bull Problem-oriented office visits for the many diseases caused or affected by
tobacco use andor exposure to secondhand smoke (upper respiratory conditions diabetes hypertension asthma etc)
bull Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE Some key ldquoteachable momentrdquo opportunities include
A recent health scare
Build ldquoteachable momentrdquo reminders into flow sheets and EHR templates for annual exams and tobacco-affected conditions
A major component to any conversation is assessing patientsrsquo attitudes toward and readiness to change
Teachable moments actively engage patients in conversations to a Build a dialogue b A desire for behavior change and eliminate resistance to change c Help patients set goals that are specific measurable attainable realistic and time-referenced (SMART) dImprove continuity
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Stages of change
Adapted from Knight 1997
Precontemplation
Contemplation
Preparation
Action
Maintenance Termination Relapse
Donrsquot want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Referrals
Providing systematic support and follow-up to patients motivated to quit can be a challenge to implementing a systematic approach to helping tobacco users quit
Find out what type of referral resources are available in your community
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Make referrals Use the fax referral form
Why make referrals to an AHEC
bull Form provides opportunity to engage tobacco using patients
bull Discussion and signature promote commitment from patients
bull Involve family members that are present for ongoing support
bull Trained Tobacco Specialist calls patients to determine readiness for change and most appropriate quitting approach
bull AHEC Tobacco Cessation Curriculums are evidence-based
bull Post class follow-up is provided at regular intervals
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Follow-up
bull After a quit date or started medication monitor progress
bull Plan to follow up with patients on their quit date a week later and about a month later
bull E mail visits phone visits etc
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull Try to avoid thinking of patients who relapse as noncompliant non adherent
bull Itrsquos a chronic disease
bull When counseling pt who has relapsed begin by normalizing and focusing on the positive
bull He or she has learned something new about the process of changing behavior
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
bull Acknowledge the difficulty of the behavior change and provide encouragement
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Standardize your office system
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
EMR
bull Identify smoking status
bull Prompts reminding doc to encourage quitting
bull Advise about smoke-free environments
bull Connect patientsfamilies cessation resources
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Tobacco-use registries
bull Registry list of patients who use tobacco
bull Keep track of which patients need services
bull Creates opportunity to capture and organize
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Make assignmentsteam approach
bull As you begin the process of change bring together your health care team led by your Office Champion to discuss how best to adapt tobacco cessation activities into your practice setting The team must
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Roles of multidisciplinary team members Physicians
bull Deliver strong personalized individualized advice to quit smokingusing tobacco
bull Assess readiness to quit
bull Deliver brief interventions to smokers ready to quit
bull Review medication options and prescribe cessation meds or advise the use of NRT
bull Refer patients to other team members for supplemental counseling
bull Perform follow-up counseling
bull Keep current on research
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
Nurses ARNPs PAs andor health educators
bull Assess smoking status readiness to quit
bull Provide counseling with a focus on
avoid triggers
cope with cravings
getting social support
bull Perform follow-up counseling bull Support previous education about use of meds
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CHANGING THE ENVIRONMENT OF CARE
ReceptionistsMedical assistants
bull Distribute health questionnaire and smoking-cessation
screening tools
bull Self-help materials are in waiting areas and exam rooms
bull Schedule follow-up appts for smoking cessation visits
bull Make follow-up calls to patients
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
PHARMACOLOGY
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
PHARMACOLOGY
bull Gum Chew and park One or two an hour
bull Lozenge Donrsquot bite lozenge let it dissolve
bull Patch Can use with gum or lozenge
bull Inhaler Can mix with patch
bull Bupropion Can use with patch and Varenicline
bull Varenicline May smoke for first week
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
DOUBLE NICOTINE THERAPY
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
ELECTRONIC CIGS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes DESIGN
BATTERY
lsquoVAPORIZINGrsquo UNIT
Where heating occurs
CARTRIDGE Contains the liquid
nicotine solution
3 COMPONENTS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components
bull A cartridge that resembles a cigarette filter
bull Atomizing devicersquo or lsquoheating elementrsquo which lsquoaerosolizes the flavor solutionrsquo and turns the liquid solution into the inhaled substance
bull Battery activates the heating element
bull Commonly contain nicotine do not actually contain tobacco
bull Although some classes of e-cigarettes are marketed as nicotine-free products even ldquonicotine-free e-cigarettesrdquo actually do contain at least trace amounts of nicotine
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic Cigarettes
bull Aerosol generated from an e-cig is commonly but inaccurately referred to as lsquovaporrsquo
bull Vapor gaseous state of a substance
bull An aerosol is a suspension of fine particles of liquid solid or both in a gas
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic Cigarettes
bull Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols
bull The e-cig aerosol simulates cigarette smoke
bull Following a puff the aerosol is delivered into the userrsquos mouth and lungs by inhalation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic Cigarettes
bull Aerosol is exhaled into the environment
bull Generate different physical and chemical characteristics during operation
bull Hoffman AC Evans SE Abuse potential of non-nicotine tobacco smoke components acetaldehyde
bull nornicotine cotinine and anabasine Nicotine Tob Res 201215622ndash32 [
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic Nicotine Delivery Systems (ENDS)
bull Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid)
bull Varying volumes of solution in the product
bull Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin])
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Electronic Nicotine Delivery Systems (ENDS)
bull Wide range of additives and flavors and battery voltage
bull Quality control is variable Design flaws lack of adequate labeling
bull Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol
bull Levels of nicotine and other chemicals delivered to users generated by the exhaled aerosol
bull Trtchounian A Talbot P Electronic nicotine delivery systems is there a need for regulation Tob Control 20112047ndash52
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Vaping in Public Places
bull Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
When heated and vaporized propylene glycol
can form propylene oxide an International
Agency for Research on Cancer class 2B carcinogen
bull Laino T Tuma C Moor P Martin E Stolz S Curioni A Mechanisms of propylene glycol and
triacetin pyrolysis J Phys Chem A 20121164602ndash4609
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes Prompting Kids to Smoke
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
National Youth Tobacco Survey of
Middle School and High School Students
2011 2012 2013
bull Dr Rebecca E Bunnell Office on Smoking and Health National Center
for Chronic Disease Prevention and Health Promotion Centers for Disease
Control and Prevention
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-cigarette use was associated with increased intentions to smoke cigarettes
bull 2011-2013 the number of never-smoking youth who used e-cigarettes increased three-fold from 79000 to over 263000
bull Intention to smoke conventional cigarettes was 439 among ever e-cigarette users and 215 among never users
bull Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users
(Adjusted Odds Ratio 170 95 Confidence Interval 124-232)
bull Nicotine Tob Res (2014)First published online August 20 2014 Rebecca E BUNNELL ScD MEd
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
bull Adolescents and teenagers who have never smoked cigarettes are giving electronic cigarettes (e-cigs) a try
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes as a Cessation Aid
Evidence evaluating efficacy of products as a cessation aid is sparse
bull Confined to 2 randomized controlled trials
bull 1 large cross-sectional study
bull Anecdotal reports
bull Internet-based surveys
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
JOURNAL OF CIRCULATION BENOWITZ
Circulation 20141291972-1986
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
A large cross-sectional study 2014
bull Smokers who wanted to quit without professional help were significantly more likely to report abstinence using e-cigarettes than with traditional cessation aids or going ldquocold turkeyrdquo
bull Brown J Beard E Kotz D Michie S West R Real-world effectiveness of e-cigarettes when used to aid smoking cessation a cross-
sectional population study Addiction May 20 2014
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Human Health Effects
bull The data on health effects studied primarily in healthy people with short-term exposure reveal little or no evidence of severe adverse events
bull Respiratory irritation and the bronchial constriction from a propylene glycol aerosol raise concerns about harm to people with asthma and COPD
bull There are no reports of e-cigarette safety in patients with known cardiovascular disease
bull Circulation 2014
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes
A study 75 of healthy smokersrsquo pulmonary function after acute ad lib puffing of an e-cigarette (Nobacco medium 11 mg) for 5 minutes (after refraining from smoking tobacco
cigarettes for 4 hours) found no effect on spirometry but did find significantly increased dynamic airway resistance (18) and decreased expired nitric oxide (16) Sham e-cigarette use had no significant effects
Vardavas CI Anagnostopoulos N Kougias M Evangelopoulou V Connolly GN Behrakis PK Short-term pulmonary effects of using an electronic cigarette impact on respiratory flow resistance impedance and exhaled nitric oxide Chest 20121411400ndash1406
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Secondhand E-Cigarette Aerosol Exposure
bull SHS exposure to e-cig aerosol exposes a
nonsmoker to nicotine particulates and several potentially toxic organic chemicals
bull Lower level than from conventional cig smoke bull The biological effects are expected to be much
less than that of secondhand smoke bull Nonsmokers are exposed to some nicotine and
the regular use of e-cigs has the potential to contaminate the environment with nicotine
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Society for Research on Nicotine and Tobacco Studies provide new evidence on lsquothirdhandrsquo exposure to nicotine
accuracy of product labels
FRIDAY FEBRUARY 7 2014
bull Analyzed three brands of e-cigs filled with varying nicotine concentrations
bull The e-cigarettes were smoked or ldquovapedrdquo with a syringe in an exposure chamber
bull Nicotine levels on five surfaces of the smoking chamber were measured The glass floors walls windows wood and metal
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Nicotine levels on surfaces
bull Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces
bull The floor and glass windows had the greatest increases in nicotine residue
bull Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Carbonyl Compounds in Electronic Cigarette Vapors Effects of Nicotine Solvent and Battery Output Voltage
bull Vegetable Glycerin (VG) and propylene glycol (PG) are the most
common nicotine solvents used in e-cigarettes (ECs)
bull At high temperatures both VG and PG undergo decomposition to low molecular carbonyl compounds including the carcinogens formaldehyde and acetaldehyde
bull The aim of this study was to evaluate how various product characteristics including nicotine solvent and battery output voltage affect the levels of carbonyls in EC vapor
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CONCLUSION
bull Vapors from EC contain toxic and carcinogenic carbonyl compounds
bull Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors
bull High-voltage EC may expose users to high levels of carbonyl compounds
bull The levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke
Kosmider Leon Pharm D Nicotine amp Tobacco Research Volume 16 Issue 10 2014 pp 1319-1326
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
bull Dow Chemical Company states that
ldquoinhalation exposure to [propylene
glycol] mists should be avoidedrdquo
bull Dow Chemical Co Product Safety Assessment (PSA) propylene glycol
bull 2013 httpwwwdowcomproductsafetyfinderproghtmHealthInfo
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Physicochemical Studies Needed
bull Need a better understanding of the types of e-cigarettes currently in use and the ingredients they contain
bull To understand e-cigarette exposure it is important to determine how heating time and duration of puffing alter exposure composition and characteristics of the vapor
bull How each of these factors is affected by the design features of different devices
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Physicochemical Studies
bull Evaluate how smoking e-cigs deposit nicotine and other chemicals in the environment and how these emissions and depositions affect SHS and third hand exposures
bull Research is needed to evaluate the efficacy of vaping devices in delivering chemicals drugs and pharmaceuticals other than nicotine (Marijuana)
bull Document manufacturing practices and quality control issues so that the listed ingredients correspond to the actual composition of the device
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Use Patterns
bull What is optimal dose for cessation by
product type
bull Dose and use patterns needed to
-sustain nicotine addiction
-or satisfy nicotine craving over time
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Psychological Effects
bull Whether e-cig use facilitates abstinence from smoking conventional cigarettes
bull Does it result in complete independence from nicotine addiction
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
SO WHAT DO WE DO
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Summary of Current Recommendations for Clinical Guidance
bull E-cigarette use should be included in our tobacco screening questions
bull Docs need education about e-cigarettes
bull We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Summary of Current Recommendations for Clinical Guidance
bull Patients should be separated into 3 treatment
categories based on their tobaccoe-cigarette use status
bull 1 Tobacco product users who are willing to quit should receive intervention to help them quit
bull 2 Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit (5As 2As+R Meds)
bull 3 Those who recently quit using tobacco products should be provided relapse prevention treatment
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Summary of Current Recommendations for Clinical Guidance
bull If a patient has failed initial tx has been intolerant to or refuses to use conventional smoking cessation medication and wishes to use e-cigs to aid quitting it is reasonable to support the attempt
bull Benowitz Circulation 2014
bull Palozzolo Frontiers in Public Health 112013
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
CAVEAT
Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date
bull BENOWITZ ET ALCirculation 20141291972-1986
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Summary of Current Recommendations for Clinical
Guidance
bull It is important to stress that patients should quit
smoking cigarettes entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tob health risks
bull For patients with existing CVD or stroke or at risk of a
CVD event intensive cessation counseling and pharmacotherapy should be offered as soon as possible
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
SAFETY
bull Scientific evidence regarding human health effects of e-cigs is limited
bull While e-cigarette aerosol may contain fewer toxicants than
cigarette smoke studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive
bull Products are unregulated
bull Some evidence suggests that e-cigarette use may facilitate smoking cessation but definitive data are lacking
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
SAFETY
bull No e-cig has been approved by FDA as a cessation aid
bull Environmental issues and non-user exposure concerns
bull The health impact of e-cigarettes for users and the public cannot be determined with currently available data
bull Exposure to kids
bull Long Term
bull Tob Control 2014 May23 Suppl 2ii36-40 doi 101136tobaccocontrol-2013-051470
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
SAFETY
bull There are as yet no long-term safety studies
of e-cigarette use it may be appropriate to
advise the patient to consider setting a quit
date for their e-cigarette use and not plan to
use it indefinitely (unless needed to prevent
relapse to cigarettes)
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
SAFETY
bull The efficacy of e-cigarettes as a primary smoking cessation aid has not been established as being better than other cessation modalities
bull At best a modest effect on cessation likely equal to or slightly better than that of nicotine patches without behavioral support
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes What to tell them
Although some cite a desire to quit smoking by using the e-cigarette other common reasons for using the products
-Circumvent smoke-free laws
-Cut down on conventional cigarettes
May reinforce dual use patterns and delay or deter quitting
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes What to tell them
bull Pts should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking the products are
a unregulated b contain toxic chemicals c have not been proven as cessation devices
bull The pt should also be advised not to use the product
indoors or around children because studies show that bystanders may be exposed to nicotine and other toxins (at levels much lower than cigarettes) through passive exposure to the e-cigarette aerosol
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
E-Cigarettes What to tell them
bull There are no long-term safety studies of e-cigarette use so patients should be urged to set a quit date for their e-cigarette use and not plan to use it indefinitely
bull Stress that patients should quit smoking cigs entirely as soon as possible
bull Continued cigarette smoking even at reduced levels continues to impose tobacco-induced health risks (particularly for cardiovascular disease)
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Chuck Bell Programs Director of Consumers Union
Publisher of Consumer Reports
ldquoWe are deeply concerned about the growing number of calls to poison control centers across the country about liquid nicotine exposures mdash including more than 1600 last year involving children under 5rdquo said ldquoWe commend Attorney General Eric Schniederman and his staff for aggressively enforcing New Yorkrsquos law mandating child-resistant packaging Long island Exchange-62315
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in Rat Model
Alzoubi KH1 Khabour OF Alharahshah EA Alhashimi FH Shihadeh A Eissenberg T
bull Investigated whether waterpipe smoking impairs learning and memory in the hippocampus special concern due to the particular popularity of waterpipe use
among youth
bull Tobacco smoking is a global health hazard that kills about 5 million people annually bull Waterpipe smoking is among the most popular methods of tobacco consumption worldwide bull Additionally possible molecular targets for expected learning and memory impairment were
determined bull In this study rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h times
5 daysweek for 1 month and outcomes were compared to a control group exposed only to fresh air
bull Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase glutathione peroxidase (GPx) superoxide dismutase (SOD) glutathione (GSH) oxidized glutathione (GSSG) GSHGSSG ratio)
bull We found that WTS exposure led to impaired short- and long-term memoryIn conclusion there is reason for concern that WTS exposure may impair cognitive ability
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Parental receptivity to child biomarker testing for
tobacco smoke exposure A qualitative study Patient Educ Couns 2015 Jun 9
Rosen LJ1 Tillinger E2 Guttman N3 Rosenblat S4 Zucker DM5 Stillman F6 Myers V7
bull Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their childrens exposure Biomarkers demonstrate exposure and may motivate behavior change but their acceptability is not well understood
METHODS bull Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel Data were analyzed using thematic
analysis RESULTS bull Consent to testing was associated with desire for information for reassurance or to motivate change and with concerns for long-term health taking
responsibility for ones child and trust in research Opposition to testing was associated with preference to avoid knowledge reluctance to cause short-term discomfort perceived powerlessness and mistrust of research Most parents expressed willingness to allow measurement by urine (83) hair (88) or saliva (93) but not blood samples (43) and believed that test results could motivate behavior change
CONCLUSIONS bull Parents were receptive to non-invasive child biomarker testing Biomarker information could help persuade parents who smoke that their children
need protection
PRACTICE IMPLICATIONS bull Biomarker testing of children in smoking families is an acceptable and promising tool for
education counseling and motivation of parents to protect their children from TSE Additionally biomarker testing allows objective assessment of population-level child TSE
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Cigarette smoking is associated with a reduction in the
risk of incident gout results from the Framingham Heart Study original cohort
Wang W1 Krishnan E2
Rheumatology (Oxford) 2015 Jan54(1)91-5
OBJECTIVE
bull Cigarette smoking is correlated with other risk factors for gout such as adiposity and alcohol intake The goal of this study was to study the direction and magnitude of association between cigarette smoking and risk for gout
CONCLUSION bull Cigarette smoking is associated with lower incidence of gout and this is
not explained by differences in the prevalence of risk factors The mechanistic underpinnings of this epidemiological finding merits further study
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Lung-Cancer Screening with Low-Dose Computed Tomography Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
KEY CLINICAL POINTS
bull The National Lung Screening Trial (NLST) showed that screening with low-dose CT reduced the risk of death from lung cancer by 20 among persons 55 to 74 years of age who had a smoking history of at least 30 pack-years and were current smokers or were former smokers who had quit within the previous 15 years
bull Risks of screening include frequent false positive findings that often require CT surveillance and less commonly lead to invasive biopsy or surgery that reveals benign findings
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Lung-Cancer Screening with Low-Dose Computed Tomography
Michael K Gould MD
N Engl J Med 2014 3711813-1820 November 6 2014
bull Most guidelines recommend that high-risk smokers and former smokers be offered screening with low-dose CT and engaged in a process of shared informed decision making to weigh the pros and cons and make an individualized choice
bull There is concern that the favorable balance between the benefits and harms of screening observed in the idealized conditions of the NLST may be difficult to replicate when lung-cancer screening is introduced in diverse clinical practice settings
bull Current smokers should be advised that screening is not a substitute for smoking cessation Patients with positive screening-test results are more likely than those with negative results to quit smoking but the effect of participating in a screening program on the rate of smoking cessation is uncertain
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
THANK YOU
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
Bibliography
1 Centers for Disease Control and Prevention Current Cigarette Smoking Among Adults Aged ge 18 Years ndash United States 2005-2010 Morbidity and Mortality Weekly Report 2011 60 (35) 1207-1208 2 US Department of Health amp Human Services Be Tobacco Freegov Tobacco Facts and Figures (November 30 2013) 3 Centers for Disease Control and Prevention Quitting Smoking Among Adults ndash United States 2001-2010 Morbidity and Mortality Weekly Report 2011 60 (44) 1513-1519 4 Fiore MC Jaen CR Baker TB et al Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline Rockville MD US Department of Health and Human Services Public Health Service May 2008 5 United States Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics National Hospital Ambulatory Medical Care Survey 2009 6 American Academy of Family Physicians Family Medicine Office Champions Tobacco Cessation Final Report (to Pfizer) July 2011 7 AAFP Health of the Public Survey 2011 8 National Commission on Prevention Priorities Preventive Care A National Profile on Use Disparities and Health Benefits Partnership for Prevention August 2007 9 Prochaska JO Norcross JC Stages of change Psychotherapy 2001 38(4) 443-448 10 Motivational Interviewing Mid-Atlantic Addiction Technology Transfer Center 11Grana Benowitz Glantz Circulation 20141291972-1986 12Treating Tobacco Dependence Practice Manual Through a Systems-Change Approach American Academy of Family Physicians 2013
QUESTIONS
QUESTIONS