© U N I V E R S I T Y O F U T A H H E A L T H

TOBACCO & VAPING

KYLE MOORE, DO

BEHAVIORAL HEALTH ECHO

NOVEMBER 7, 2019

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

What you need to understand about trends and treatment

Kyle V. Moore D.O.

TOBACCO AND VAPING

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Identify different nicotine delivery systems and their unique characteristics

Review harmful effects of tobacco and nicotine

Understand general trends in smoking and vaping

Review the FDA approved medications for smoking cessation

Introduce electronic nicotine delivery systems and their components

Discuss electronic nicotine delivery systems as smoking cessation and future implications

OBJECTIVE AND GOALS

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

NICOTINE VERSUS TOBACCO

Nicotine

Tobacco Alkaloid produced from nightshade family

of plants (it’s an insecticide)

Psychostimulant and mood modulator, and it is HIGHLY addictive

Pharmacokinetic

rapid brain delivery

persist 6-8 hours

metabolized in liver, lung, and brain (primarily to cotinine)

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

-Cultivation dates back to 1400 BC

-Many ways to consume

-Introduced around the world in

1600s, major driver for New World

economy

-WWI, cigarettes included in rations

-US General Surgeon Report of 1964

-Changes in policy

TOBACCO HISTORY

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Photo by David

Gallie from Pexels

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Cancer related illness

Mouth

Larynx

Esophagus

Lung

Stomach

Pancreas

Kidney

Bladder

Uterine

Cervix

Leukemia

Non-cancer health effects

Skin wrinkling, cataracts, age-related macular degeneration, erectile dysfunction, lower estrogen, earlier menopause, yellowing skin, drug-drug interactions

Cost* (individually and for society)

Social Stigma

Second-hand smoke (asthma in children)

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Men more likely to smoke than women

Non-Hispanic American Indians/Alaska have highest prevalence

Non-Hispanic Asians have lowest prevalence

Lower education>>>>higher education

Lower income>>>>>higher income

LBGTQ>>>>>heterosexual/straight

Geography

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

The majority of smoker want to quit

Around 70%

Usually MANY, MANY attempts before long-term abstinence

Numbers for “average” quit attempts range from 6-40

Many of damaging effects are reversible

Erectile dysfunction After 10-15 yrs, all cause mortality returns to “baseline”

Weight gain

6-10 pounds in first year

Motivations

Listen

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Nicotine Replacement Therapy (NRT)

5 FDA approved, NRT medications

Nicotine Gum

Nicotine Lozenge

Nicotine Nasal Spray*

Nicotine Inhaler*

Nicotine Patch

*indicate Rx required

Bupropion (Wellbutrin, Zyban)

Varenicline (Chantix)

Nonnicotine Medications

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Gum

Available in 2 and 4 mg doses

Not to “chew” like traditional gum (cheek it)

Lozenge 2 and 4 mg doses

Inhaler

Requires Rx

Effective but only with extensive use (>6 cartridges daily)

Nasal Spray

Also requires Rx Reduces

Manages withdrawal symptoms quickly

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Nicotine Patches

7, 14, and 21 mg doses

Dose based on # of cigarettes daily (can use for dip)

High-dose nicotine patch therapy is safe and often needed

Side Effects

skin irritation, vivid dreams, insomnia

Can take off patch at night if needed

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Medication Information Dosing

Start 1 week before quit date

Initial dose of 150 mg daily x 3 days, with increase to bid thereafter

Usual length of treatment 6-12 weeks

No need to taper when discontinuing

Monocyclic antidepressant

inhibits reuptake of norepinephrine and dopamine

influences dopamine in mesolimbic system and nucleus accumbens

antagonistic effect on nAChR

SR was FDA approved

Side Effects

Insomnia and dry mouth

Contraindications

Hx of seizures, head trauma (LOC, skull fracture), eating disorders

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Medication Information Dosing

Start 1-5 weeks before quit date

0.5 mg qd x 3 days, followed by 0.5 mg bid x 4 days, followed by 1 mg bid for duration of therapy thereafter

12-24 weeks for typical treatment*

No need for taper

Binds and blocks α4β2 nicotinic acetylcholine receptors (where nicotine binds)

Has an agonist effect at receptor with release of dopamine

Side Effects

Nausea in 30%

Vivid dreams

Black Box Warning

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

ENDs

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Battery-powered

heat a liquid solution to generate an aerosol (vapor).

First introduced in US in 2006

Mods versus Pods

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Contents glycerin, propylene glycol, nicotine, and flavorings

Variety

Hundreds of brands and thousands of flavors of “e-juice”

Nicotine free e-liquid?

Lethality of drinking/exposure

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Origins

Two Stanford students, smokers

Higher nicotine, lower vapor

Nicotine benzoate (more nicotine delivery without nausa)

Changes in company over time

Altria purchase

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Patrick, ME et al: ”Trends in

Adolescent Vaping 2017-

2019. N Engl J Med 2019

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

A recent meta-analysis indicated that in teens and young adults who have never smoked, the odds of smoking initiation are three to six times greater in those who have ever used e-cigarettes than in those who have never used e-cigarettes.(11)

One study also showed links between e-cigarette use and subsequent marijuana use in teens. (12)

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Smoking “traditional” cigarettes is associated with preterm birth, fetal growth restriction, low birth weight, sudden infant death (SIDS), and more

Nicotine is a teratogen!

ACOG Committee Opinion-2013

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Well….. It’s complicated

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Conclusion 17-3. There is insufficient evidence from randomized controlled trials about the effectiveness of e-cigarettes as cessation aids compared with no treatment or to Food and Drug Administration–approved smoking cessation treatments.

Conclusion 18-1. There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Conclusion 4-1. There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated.

Conclusion 5-3. There is substantial evidence that except for nicotine, under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes.

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Hajek et al. New England Journal January 2019

The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group

Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]).

Varenicline monotherapy approaches 40% 1-year abstinence rates

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

A 26-year-old G2P0010 presents to your office with her partner for her first visit. She is nervous as her first pregnancy ended in SAB.

She has been a light smoker since age 19. Currently smoking 0.5 pack per day, but often less during the work week.

She tried quitting smoking during her last pregnancy with gum but wasn’t able to completely stop. After the miscarriage, she resumed smoking higher volume.

”I’m thinking of trying to switch to vaping. What do you think?”

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Precautionary Principle

Avoid e-cigarettes because the long-term effects are unknown.

Compared with traditional, combustible cigarettes, e-cigarettes are safer and should be encouraged if nicotine is used at all.

Harm Reduction

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

There are various routes of delivery for nicotine.

Tobacco remains one of the greatest contributors to morbidity and mortality worldwide.

Understand the correct use/dose of smoking cessation medications and why combinations are best

Traditional smoking is at record low, while ”vaping” is increasing substantially especially among youth

Many known and unknown risks with vaping

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

1) Raymond, BH et al: The Nicotine Content of a Sample of E-cigarette Liquid Manufactured in the United States. J Addict Med. 2018 Mar/Apr;12(2):127-131. doi: 10.1097/ADM.0000000000000376

2) Klein MD, Soko NA et al. “Electronic Cigarettes: Common Questions and Answers. Am Fam Physician. 2019 Aug 15;100(4):227-235.

3) Hajek et al. “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy”. New England Journal of Medicine January 2019

4) Stratton, K. ”Pubic Health Consequences of e-cigarettes: consensus report” 2018 pp.xxiv + 750

5) Patrick, ME et al: Trends in Adolescnet Vaping 2017-2019. N Engl J Med 2019; 381:1490-1491; DOI: 10.1056/NEJMc1910739;

6) https://stocksnap.io/photo/265ZLMJF5D

7) https://freerangestock.com/photos/24323/no-smoking-beyond-this-point.-.html

8) Who.int

9) https://truthinitiative.org/press/press-release/first-its-kind-free-e-cigarette-quit-program-now-available-young-vapers-looking

10)Ebbert, Jon: “E-cigarette Mods & Pods”. 26th Annual Nicotine Dependence Conference-Tobacco and Nicotine: A Continuum of Risk. May 19-20 2019, Rochester, MN.

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

11) Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults. JAMA Pediatr. 2017;171(8):788-797 (31)

12) Dai H, Catley D, Richter KP, et al. Electronic cigarettes and future marijuana use. Pediatrics. 2018;141(5):e20173787. (32)

13) Herron, AJ; Brennan, TK. “The ASAM Essentials of Addiction Medicine-Third Edition”.

14) https://www.lung.org/our-initiatives/research/monitoring-trends-in-lung-disease/tobacco-trend-brief/overall-tobacco-trends.html

15) https://unsplash.com/s/photos/e-cigarette

16) https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes

17)Sam Wong (Nov 10, 2018). "How worrying is it that more and more teens are using e-cigarettes?". New Scientist.

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Kyle Moore, D.O.

Addiction Medicine Fellow

University of Utah

Kyle.Moore@hsc.utah.edu

© U N I V E R S I T Y O F U T A H H E A L T Hh t t p s : / / p h y s i c i a n s . u t a h . e d u / e c h o / c l i n i c a l - s u p p o r t - a r e a s / b e h a v i o r a l - h e a l t h . p h p

Thank you!

Join our next session on November 14th

on

Stimulant Use Disorder

with

Dr. Rachel Caspar