E-cigarettes: An Emerging Public Health Challenge

E-cigarettes: An Emerging Public Health Challenge


>>>GOOD AFTERNOON, AND GOOD
MORNING AND GOOD EVENING,
DEPENDING WHERE AND WHEN YOU ARE
JOIN US.
THANK YOU FOR JOINING US FOR
GRAND ROUNDS.
OUR TOPIC IS eCIGARETTES, AN
EMERGING PUBLIC HEALTH
CHALLENGE.
AN EXCITING SESSION.
LET’S GET STARTED.
FIRST, A FEW HOUSEKEEPING
ISSUES.
THERE ARE CONTINUING EDUCATION
CREDITS FOR NURSES AND OTHERS.
PLEASE CHECK OUT THE CONTINUING
EDUCATION CREDIT WEBSITE FOR
MORE INFORMATION.
YOU CAN ALSO CHECK US OUT ON OUR
WEBSITE AND ON ALL YOUR FAVORITE
SOCIAL MEDIA SITES.
WE ALSO HAVE A VIDEO SEGMENT
CALLED “BEYOND THE DATA,” WHICH
WILL BE POSTED SHORTLY AFTER THE
SESSION.
FOR TODAY’S SESSION, WE WILL BE
TAKING QUESTIONS BY E-MAIL.
THAT’S
WWW.CDC.GOV/CDCGRANDROUNDS.
WE’VE ALSO PARTNERED WITH THE
CDC PUBLIC HEALTH LIBRARY TO
FEATURE SCIENTIFIC ARTICLES
RELATED TO eCIGARETTES.
THE FULL LISTING IS AVAILABLE AT
CDC.GOV/LIBRARY/SCICLIPS.
HERE’S A PREVIEW OF OUR UPCOMING
PUBLIC HEALTH GRAND ROUNDS
SESSION.
PLEASE JOIN US LIVE OR ON THE
WEB.
I’D ALSO LIKE TO MAKE A NOTE
THAT THE NEXT SESSION, IT WILL
BE MONDAY AT 10:00.
SO THAT’S BOTH A CHANGE IN THE
DAY AND THE TIME THAT THE
SESSION WILL BE HELD.
THANK YOU.
I’D LIKE TO GIVE A SHOUT OUT TO
OUR COLLEAGUES AND FRIENDS
INCLUDING JIM BUEHLER, HEALTH
COMMISSIONER OF THE CITY OF
PHILADELPHIA.
THEY ARE HOLDING THEIR FIRST
PUBLIC HEALTH GRAND ROUNDS
TOMORROW EVENING.
WE WISH THEM WELL IN THEIR
ENDEAVOR.
IN ADDITION TO OUR OUTSTANDING
SPEAKERS, I’D ALSO LIKE TO
ACKNOWLEDGE THE IMPORTANT
CONTRIBUTIONS OF THE INDIVIDUALS
LISTED HERE, AND A SPECIAL THANK
YOU TO THE FOLKS AT THE CDC
TOBACCO LAB.
THANK YOU VERY MUCH.
AND NOW A FEW WORDS FROM CDC
DIRECTOR, DR. TOM FRIEDEN.
>>THANK YOU VERY MUCH, AND
THANK YOU VERY MUCH TO OUR
SPEAKERS FOR BEING HERE.
eCIGARETTES ARE A HOT TOPIC,
EVEN IF THEY’RE NOT COMBUSTIBLE.
AND WE HAVE TO LOOK AT
eCIGARETTES THROUGH THE LENS OF
TOBACCO AND AS A TOBACCO PROBLEM
THAT CONTINUES TO KILL CLOSE TO
HALF A MONTH AMERICANS EVERY
YEAR.
SINCE THE FIRST SURGEON
GENERAL’S REPORT ON TOBACCO IN
1964, MORE THAN 20 MILLION
AMERICANS HAVE BEEN KILLED BY
TOBACCO, AND WE STILL HAVE MORE
THAN 40 MILLION SMOKERS IN THIS
COUNTRY.
WE’VE MADE A LOT OF PROGRESS
RAISING AWARENESS OF THE HARMS
OF TOBACCO.
ONE OF THOSE WAYS THAT WE’VE
DONE THAT IS THROUGH TIPS FROM
FORMER SMOKERS’ CAMPAIGN, A
CAMPAIGN WE’VE BEEN ABLE TO RUN
FOR THE PAST THREE YEARS, AND
RIGOROUS ANALYSIS INDICATES THAT
THAT CAMPAIGN PREVENTS AT LEAST
16,000 DEATHS FOR EACH YEAR WE
RUN IT
BUT E-CIGARETTES REALLY RAISE
SOME CHALLENGES.
IF AN INDIVIDUAL WHO’S ALREADY A
SMOKER OF COMBUSTIBLE PRODUCTS
SWITCHES TO E-CIGARETTES,
THERE’S LITTLE DOUBT THAT THEIR
HEALTH WILL BE IMPROVED.
ON THE OTHER HAND, IF
ADOLESCENTS WHO WOULD NOT HAVE
BECOME SMOKERS BEGIN USING
E-CIGARETTES, THERE IS A HIGH
LIKELIHOOD THAT THEIR RISK OF
USING COMBUSTIBLE TOBACCO WILL
BE GREATER.
AND IF AN ADULT WHO TRIES TO
QUIT SMOKING USES E-CIGARETTES,
THERE IS A POSSIBILITY THAT THAT
INDIVIDUAL WILL BE MORE LIKELY
TO CONTINUE DUAL USE OR USING
BOTH COMBUSTIBLE CIGARETTES AND
E-CIGARETTES THAN QUITTING
COMPLETELY COMPARED WITH WHAT
THEY MIGHT HAVE DONE IF THEY HAD
NOT BEEN USING E-CIGARETTES.
SO WE HAVE REAL UNCERTAINTY AND
REAL RISK.
IN PUBLIC HEALTH, ONE OF OUR
MOST BASIC PRINCIPLES IS THE
PRECAUTIONARY PRINCIPLE, TO
ENSURE IN SIMPLE LANGUAGE THAT
WE’RE BETTER SAFE THAN SORRY.
IT’S IMPORTANT TO RECOGNIZE WHEN
WE THINK ABOUT E-CIGARETTES,
THESE ARE TOBACCO PRODUCTS.
THEY’RE HIGHLY ADDICTIVE, THEY
CONTAIN NICOTINE, NICOTINE IS
LIKELY TO BE HARMFUL FOR THE
DEVELOPING BRAIN.
AND CERTAINLY AN ADDICTIVE
SUBSTANCE THAT MAY RESULT IN
SOMEONE HAVING A LIFETIME OF
ADDICTION.
SO WE’RE STILL IN THE MORNING
PHASE FOR YOGI BERRA.
WE STILL QUOTE HIM AT ALL
OPPORTUNITIES.
ONE OF THOSE QUOTATIONS IS THAT
IN THEORY, THEORY AND PRACTICE
ARE THE SAME, IN PRACTICE
THEY’RE DIFFERENT.
[ LAUGHTER ]
>>WELL, IN THEORY, IF ALL
SMOKERS SWITCH TO E-CIGARETTES,
THINGS WOULD BE BETTER AND LIVES
WOULD BE SAVED.
AND THERE ARE ANECDOTES OF
PEOPLE WHO HAVE SWITCHED FROM
COMBUSTIBLES TO E-CIGARETTES.
BUT WE ALL KNOW THAT THE PLURAL
OF ANECDOTE IS NOT DATA.
IN PRACTICE, WE’VE SEEN A LOT OF
KIDS USING E-CIGARETTES
INCLUDING KIDS WHO HAVE NEVER
SMOKED COMBUSTIBLE CIGARETTES.
AND A LOT OF SMOKERS CONTINUING
TO SMOKE WHEN PERHAPS THEY WOULD
HAVE QUIT IF THEY HADN’T ALSO
BEEN USING E-CIGARETTES.
IN THEORY ALSO, WE COULD DIVORCE
THE HARM OF TOBACCO FROM THE
ADDICTIVENESS OF NICOTINE.
THIS THEORY IS AN INTERESTING
ONE, AND PERHAPS WILL BE PUT
INTO PRACTICE AT SOME POINT OR
IN SOME PLACE IN THE FUTURE.
THE IDEA WOULD BE THAT THERE
WOULD BE MANY FORMS OF NICOTINE
READILY AVAILABLE TO ADULTS, BUT
THERE WOULD BE NO ADDICTIVE
LEVELS OF NICOTINE PRESENT IN
COMBUSTIBLE TOBACCO, AT LEAST
IT’S THE THEORY.
BUT THE PRECAUTIONARY PRINCIPLE
IS KEY HERE ABOVE ALL DO NO
HARM, AND ENSURE AT A MINIMUM
THAT WE TRY TO KEEP KIDS AWAY
FROM ALL FORMS OF NICOTINE,
INCLUDING E-CIGARETTES.
WHAT WE’RE ALSO SEEING WITH
THE>>Translator: INDUSTRY I
THINK HAS RESONANCE WITH SOME
OTHER PARTS OF PUBLIC HEALTH.
WE SEE THE TOBACCO INDUSTRY
REALLY BEING RELENTLESS.
THEIR ROLE IS TO SELL PRODUCT
THAT KILLS PEOPLE, AND THEY
IDENTIFY NEW WAYS TO DO IT.
THE TOBACCO COMPANIES HAVE NOW
PURCHASED MOST OF THE
E-CIGARETTE COMPANIES TO HEDGE
THEIR BETS, AND AS YOU’LL SEE
FROM TODAY’S PRESENTATION, THE
MARKETING TOOLS BEING USED BY
E-CIGARETTES, E-CIGARETTE
COMPANIES ARE VERY SIMILAR TO
WHAT WE SAW IN TOBACCO YEARS
BEFORE.
THIS CREATES REAL CHALLENGES FOR
THE PUBLIC AND FOR PUBLIC HEALTH
BECAUSE WE HAVE TO KEEP PACE
WITH CHANGES IN THE TOBACCO
INDUSTRY AND ALSO HAVE TO KEEP
IN MIND THAT UNLIKE SOME OF THE
OTHER ENTITIES THAT WE BATTLE
AGAINST BE STOPPING TOBACCO
REQUIRES ALWAYS THINKING ABOUT
WHAT THE INDUSTRY IS DOING THAT
MAY UNDERMINE PUBLIC HEALTH
PROGRESS.
SO IN THAT REGARD, THANK YOU
VERY MUCH TO OUR SPEAKERS.
I’M LOOKING FORWARD TO THE
PRESENTATIONS.
[ APPLAUSE ]
>>THANK YOU.
NOW FOR OUR FIRST SPEAKER,
DR. BRIAN KING.
>>GREAT, THANK YOU, DR. THORPE,
FOR THE INTRODUCTION.
I’M VERY HAPPY TO BE HERE TODAY.
SO MY SECTION TODAY’S
CONVERSATION IS GOING TO FOCUS
ON A BACKGROUND OF CURRENT
CIGARETTES IN THE CURRENT
LANDSCAPE IN THE UNITED STATES
AS WELL AS PATTERNS OF USE AMONG
BOTH YOUTH AND YOUNG ADULT.
THEN I’LL END WITH KEY FINDINGS
BEFORE WE GO INTO SOME OF THE
OTHER COMPONENTS SUCH AS THE
HEALTH CONSEQUENCES.
SO TO START, E-CIGARETTES ARE
PART OF A BROADER CLASS OF
PRODUCTS KNOWN AS ELECTRONIC
NICOTINE DELIVERY SYSTEMS OR
“ENDS”.
WE’LL USE E-CIGARETTES AS A
UNIVERSAL TERM TO DESCRIBE THE
ENTIRE PRODUCT TYPE.
IT’S IMPORTANT TO NOTE THAT THIS
IS A RAPIDLY DIVERSIFYING
LANDSCAPE, AND THESE PRODUCTS
AND THE TERMINOLOGY USED TO
DESCRIBE THEM CONTINUES TO
CHANGE ON A NEARLY A DAILY
BASIS.
THERE’S DIFFERENT TERMINOLOGY
USED BY THE MANUFACTURERS,
RETAILERS, AS WELL AS THE
INDIVIDUAL USERS OF THESE
PRODUCTS.
IT’S ALSO IMPORTANT TO NOTE THAT
THESE PRODUCTS ARE MANUFACTURED
BY DIFFERENT ENTITIES, INCLUDING
THE TRADITIONAL TOBACCO
INDUSTRY, AS WELL AS THOSE FROM
THE SMALLER PRIVATE SECTOR, AND
THERE’S STILL A VARIETY —
THEY’RE SOLD BY A VARIETY OF
VENUE INCLUDING CONVENIENCE
STORES, BAKE SHOPS, AND THE
INTERNET.
AT LAST COUNT, THERE’S CURRENTLY
450 DIFFERENT BRANDS, BUT I CAN
TELL YOU THAT CONTINUES TO
CHANGE DAILY.
NOW THERE ARE CURRENTLY THREE
MAJOR TYPES OF E-CIGARETTES.
THIS IS THE CIGALIKES.
THESE ARE PRE-FILLED, AND THE
USER DISCARDS THE ENTIRE DEVICE
AFTER THE LIQUID HAS BEEN
DEPLETED.
THE MIDDLE SIZE ARE TYPICALLY
RECHARGEABLE AND CAN BE REFILLED
USING CARTRIDGES WITH A
PREFERRED FLAVORING OR NICOTINE
CONCENTRATION OF CHOICE.
AND ON THE FAR LEFT WE HAVE THE
MODIFIED E-CIGARETTES WHICH ARE
FREQUENTLY REFERRED TO BY USERS
AS MODS AND ARE CUSTOMIZABLE BY
THE USER.
THEY CAN FILL THE DEVICE WITH
THEIR LIQUID OF CHOICE
CONTAINING VARYING LEVELS OF
FLAVORS AS WELL AS NICOTINE
CONCENTRATION.
SO IRRESPECTIVE OF THE TYPE OF
E-CIGARETTE, THE BASIC ANATOMY
IS — BASIC ANATOMY IS SIMILAR.
THAT’S WHAT’S PRESENTED HERE.
THEY SHARE COMPONENTS INCLUDING
A BATTERY THAT SERVES AS A POWER
SOURCE, THEY ARE ELECTRONIC.
AN AT MISER TO HEAT THE SOLUTION
AND A CARTRIDGE TO HOLD THE
SOLUTION.
THAT CREATES AN AEROSOL THAT THE
USER INHALES.
NOW BEFORE WE GET INTO THE
PATTERNS OF USE, IT’S IMPORTANT
TO DISCUSS E-CIGARETTES IN THE
CONTEXT OF TOBACCO PREVENTION
AND CONTROL OVER THE PAST 50
YEARS.
AND SO PRIOR TO THE FIRST
SURGEON GENERAL’S REPORT,
TOBACCO USE ROSE DRAMATICALLY.
BUT AFTER 1964 AND THE FIRST
SURGEON GENERAL’S REPORT WE
IMPLEMENTED INTERVENTION.
THAT INCLUDED THE DOCTOR THAT
LIMITED ADVERTISING FOR TV AND
RADIO.
AFTER THAT, TOBACCO USE BEGAN TO
DECLINE.
AND THIS WAS FOLLOWED IN 1998 BY
THE MASTER SETTLEMENT AGREEMENT
WHICH FURTHER RESTRICTED THE
SALE AND MARKETING OF TOBACCO
PRODUCTS TO THE POPULATION
LEVEL.
HOWEVER, THIS WASN’T WITHOUT THE
CONTRIBUTION OF OTHER PROVEN
EVIDENCE-BASED INTERVENTIONS
THAT WE KNOW WORK TO EFFECTIVELY
REDUCE TOBACCO USE AT THE
POPULATION LEVEL.
THOSE INCLUDE OUR TRIED AND TRUE
INTERVENTIONS INCLUDING
INCREASING THE PRICE OF TOBACCO,
IMPLEMENTING COMPREHENSIVE
SMOKE-FREE LAW, HARDHITTING MASS
MEDIA CAMPAIGNS, PROVEN ACCESS
TO STATION RESOURCE ALONGSIDE
SUSTAINED AND FULLY FUNDED
COMPREHENSIVE TOBACCO-CONTROL
PROGRAMS AT THE STATE AND LOCAL
LEVEL.
AND AN ADDITIONAL COMPONENT IS
CRITICAL TO THE DISCOURSE IS
REGULATION.
THESE PROVEN INTERVENTION THAT’S
I’VE DISCUSSED SHOULD BE DONE IN
COORDINATION WITH EFFECTIVE
REGULATION.
NOW IN THE U.S. IN 2009, THE
U.S. FOOD AND DRUG
ADMINISTRATION WAS GRANTED THE
AUTHORITY IT REGULATE THE
MANUFACTURING, MARKETING, AND
SALE OF TOBACCO PRODUCTS.
NOW THE DEFINITION OF A TOBACCO
PRODUCT IS ANY PRODUCT THAT’S
MADE OR DERIVED FROM TOBACCO
THAT IS INTENDED FOR HUMAN
CONSUMPTION.
NOW GIVEN THAT THE NICOTINE IN
E-CIGARETTES IS TYPICALLY
DERIVED FROM TOBACCO, THE FDA
HAS PROPOSED TO REGULATE
E-CIGARETTES CONTAINING TOBACCO
— CONTAINING NICOTINE AS
TOBACCO PRODUCTS.
THAT OCCURRED IN APRIL OF 2014.
THE RULE IS NOT YET FINALIZED SO
E-CIGARETTES ARE CURRENTLY
UNREGULATED AT THE FEDERAL LEVEL
IN THE UNITED STATES.
BEFORE THE PATTERNS OF USE, I
WANT TO MENTION THAT THE PUBLIC
HEALTH FRAMEWORK IN THE JUNCTURE
OF THE REPORT OF THE HEALTH
CONSEQUENCE OF TOBACCO WHICH WAS
RELEASED 2014, AND IN
PARTICULAR THAT REPORT NOTED
THAT SHIFTS IN THE PATTERNS OF
TOBACCO USE THAT WE’RE SEEING
OVER TIME INCLUDING THE MARKED
INCREASE IN E-CIGARETTES COULD
HAVE NEGATIVE AND POSITIVE
INDIVIDUAL AND POPULATION HEALTH
IMPACTS.
BUT THE REPORT ALSO IMPORTANTLY
NOTED THAT THE BURDEN OF DISEASE
FROM TOBACCO USE IN THE U.S. IS
OVERWHELMINGLY CAUSED BY
CIGARETTES AND OTHER COMBUSTIBLE
TOBACCO PRODUCTS.
THUS, ANY OF THIS NEGATIVE OR
POTENTIAL POSITIVE IMPACT OF THE
E-CIGARETTES SHOULD BE
CONSIDERED IN THE CONTEXT OF HOW
THESE PRODUCTS MAY IMPACT
COMBUSTIBLE TOBACCO USE
INCLUDING CIGARETTES.
LET’S LOOK AT ESTIMATES AMONG
THE U.S. POPULATION.
WE’LL START WITH ADULTS.
THIS SLIDE PRESENTS ESTIMATES OF
EVERY USE OF E-CIGARETTES.
THAT’S EVEN JUST ONE TIME USE
AMONG U.S. ADULTS DURING THE
PERIOD 2010 TO 2013.
AS YOU SEE, MARKED INCREASES
OCCURRED PRIMARILY AMONG CURRENT
AND FORMER CIGARETTE SMOKERS.
IN 2013, OVER 1/3 OF CURRENT
CIGARETTE SMOKERS EVER USED AN
E-CIGARETTE, WHILE ONE IN TEN
FORMER SMOKERS USED THE
PRODUCTS.
IN CONTRAST, RATES OF
E-CIGARETTES HAVE REMAINED
RELATIVELY STABLE AMONG NEVER
CIGARETTE SMOKERS OVER TIME.
THIS REPRESENTS THE PAST 30 DAY
OR WHAT WE CALL CURRENT USE OF
E-CIGARETTES.
THIS IS AMONG ADULTS.
DURING THE PERIOD 2012 TO 2013,
9.4% OF CONVENTIONAL CIGARETTE
SMOKER ALSO CURRENTLY USED
E-CIGARETTES.
HOWEVER, IT ALSO IMPORTANT TO
LOOK AT THE CONVERSE HERE.
AMONG CURRENT USERS, THREE
QUARTERS ARE CURRENT SMOKERS IN
2012 TO 2013.
THIS IS A PHENOMENON WE CALL A
DUAL USE, WHICH WE’RE GOING TO
HEAR MORE ABOUT LATER TODAY FROM
SOME OF OUR OTHER PRESENTERS.
SO NOW LET’S LOOK AT DATA AMONG
YOUTHS.
THESE DATA FROM THE NATIONAL
YOUTH TOBACCO SURVEY DEMONSTRATE
THAT EVERY USE AMONG U.S. MIDDLE
AND MICHELLE STUDENTS HAS
INCREASED CONSIDERABLY SINCE
2011.
IN 2014, OVER ONE QUARTER OF
U.S. HIGH SCHOOL STUDENTS AND
ONE IN TEN MIDDLE SCHOOL
STUDENTS HAD EVER USED AN
E-CIGARETTE AT LEAST ONCE IN
THEIR LIFETIME.
THIS IS OF CONCERN BECAUSE MOST
OF THESE PRODUCTS CONTAIN
NICOTINE WHICH WE’VE ALREADY
DISCUSSED, WHICH ASIDE FROM
BEING HIGHLY ADDICTIVE CAN BE
POTENTIALLY HARMFUL TO THE
DEVELOPING ADOLESCENT BRAIN.
WE’LL MORE BEFORE THAT LATER
FROM OUR SUBSEQUENT SPEAKERS.
THIS SLIDE IS THE PATTERNS OF
CURRENT USE.
AGAIN, PAST 30-DAY USE AMONG
YOUTH.
YOU SEE THAT IN 2014, A 13.4% OF
U.S. HIGH SCHOOL STUDENTS HAD
USED AN E-CIGARETTE IN THE PAST
30 DAYS, AND ABOUT 3.9% OF
MIDDLE SCHOOL STUDENTS HAD USED
THESE PRODUCTS IN THE PAST 30
DAYS.
AND WE’RE ALSO SEEING ALARMINGLY
HIGH PREVALENCE OF E-CIGARETTES
AMONG YOUTH WHO HAVE NEVER USED
CONVENTIONAL CIGARETTES.
IN WHICH HAS INCREASED NEARLY
THREEFOLD SINCE 2011.
AND 2013, IT WAS 263 OHIO IS
U.S. MIDDLE AND HIGH SCHOOL
STUDENTS WHO HAD NEVER USED A
CONVENTIONAL CIGARETTE HAD USED
AN E-CIGARETTE.
MOREOVER, A RECENT CDC STUDY
THAT WAS PUBLISHED FOUND THAT
AMONG THESE NONSMOKING YOUTH,
THE INTENTION TO SMOKE
CONVENTIONAL CIGARETTE IS HIGHER
AMONG THOSE WHO ACTUALLY USED
E-CIGARETTES.
ONE LIMITATION OF THESE
ADDITIVES IS A CROSS SECTION.
THAT MEANS YOU COLLECT THE DATA
AT ONE POINT IN TIME.
SO THERE’S AN EMERGING BODY OF
RESEARCH THAT HAS FOLLOWED THE
SAME YOUTH OVER TIME TO BETTER
UNDERSTAND WHAT THE RELATIONSHIP
IS BETWEEN E-CIGARETTES AND
CIGARETTE USE.
AND THIS SLIDE PRESENTS TWO OF
THOSE STUDIES THAT HAVE BEEN
PUBLISHED TO DATE IN THE PEER
REVIEW LITERATURE.
THE FIRST EXAMPLE IS A STUDY
PUBLISHED IN THE “JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION”
THAT FOUND AMONG HIGH SCHOOL
STUDENTS IN LOS ANGELES, THOSE
WHO HAD EVER USED E-CIGARETTES
AT BASELINE WERE 2.7 TIMES MORE
LIKELY TO REPORT INITIATION OF
COMBUSTIBLE TOBACCO USE OVER THE
NEXT YEAR COMPARED TO NONUSERS.
AND THERE WERE SIMILAR FINDINGS
IN A STANLEY CUP SUBSEQUENT
STUDY OF — IN A SUBSEQUENT
STUDY OF JAMA THAT FIND A
GREATER ODDS OF PROGRESSING TO
CIGARETTE SMOKING.
A CAVEAT, THESE ARE A SMALL
SAMPLE SIZE AND GENERALIZED
ABILITY TO BROADER POPULATIONS
IS LIMITED.
WE NEED FURTHER LONGITUDINAL
RESEARCH.
BUT THE INITIAL FINDINGS ARE
STILL QUITE CONCERNING AND
SUGGEST THAT THERE’S A POTENTIAL
PATH FOR E-CIGARETTE USE TO LEAD
TO CONVENTIONAL TOBACCO USE IN
THE FUTURE AMONG YOUTH.
SO ONE OF THE FACTORS THAT’S
IMPORTANT TO NOTE HERE IN TERMS
OF THE ESCALATING USE OF
E-CIGARETTES AMONG YOUTH IS THE
AVAILABILITY OF FLAVOR.
AND THE CDC RECENTLY RELEASED AN
MMWR IN THE PAST MONTH THAT
FOUND THAT IN 2014 AMONG MIDDLE
AND HIGH SCHOOL STUDENTS WHO
USED AN E-CIGARETTE IN THE PAST
63 DAYS, 62.3% OR 1.58 MILLION
STUDENTS NATIONWIDE HAD USED A
FLAVORED E-CIGARETTE.
WE KNOW FROM THE EXISTING
LETTERS FOR CONVENTIONAL
PRODUCTS THAT FLAVORS CAN MAKE
THESE PRODUCTS PARTICULARLY
APPEALING TO YOUTH.
SO IN CONCLUSION, E-CIGARETTES
ARE CURRENTLY UNREGULATED IN THE
UNITED STATES.
THE PRODUCT LANDSCAPE IS RAPIDLY
GROWING AND DIVERSIFYING AS WE
SPEAK.
E-CIGARETTE USE HAS INCREASED
STEADILY AMONG U.S. ADULTS IN
RECENT YEARS.
THAT’S PRIMARILY BEEN DRIVEN BY
CURRENT AND FORMER CIGARETTE
SMOKERS.
MOREOVER, WE’RE SEEING
ALARMINGLY SHARP INCREASES IN
YOUTH E-CIGARETTE USE WHICH HAVE
OCCURRED SINCE 2011 AND EMERGING
LONGITUDINAL DATA SUGGESTS THAT
E-CIGARETTE USE MIGHT LEAD TO
SUBSEQUENT COMBUSTIBLE TOBACCO
USE AMONG YOUTH IN THE FUTURE.
ONE OF THE FACTORS THAT MAY BE
CONTRIBUTING TO THIS YOUTH USE
OF E-CIGARETTES IS FLAVORS.
IN 2014, WE HAD NEARLY 1.6
MILLION CURRENT USE E-CIGARETTE
USERS WHO HAD USED A FLAVORED
E-CIGARETTE.
SO THAT CONCLUDES MY PORTN OF
THE TALK ON PATTERNS OF USE
AMONG YOUTH AND ADULTS.
NOW I’M GOING TO TURN IT OVER TO
MY COLLEAGUE, DR. JONATHAN
SALMON, TO DISCUSS THE HEALTH
CONSEQUENCES OF E-CIGARETTES.
[ APPLAUSE ]
>>MY CHARGE IS TO DISCUSS WHAT
WE MIGHT SURRISE IS OF THE
HEALTH CONSEQUENCES OF
ELECTRONIC
ELECTRONIC E-CIGARETTES BASED ON
THE COMPONENTS AND INITIAL
STUDIES OF HEALTH CONSEQUENCES.
THE AEROSOL CONTAINSPROPLEAN
GLYCOL AND SOME CONVENTION AS A
VEHICLE.
IT MAY CONTAIN NICOTINE AND DOES
IN THE PREDOMINANCE OF USE, AND
THE DOSAGE CAN VARY DEPENDING ON
THE CONCENTRATION IN THE LIQUID
AS WELL AS THE OPERATION.
FLAVORINGS WHICH ARE A POTENTIAL
CONCERN, AND THEN A VARIETY OF
CONTAMINANTS HAVE BEEN
IDENTIFIED WITHIN THE AEROSOL,
SOME LISTED HERE.
TOBACCO SPECIFICALLY, METALS,
FORMALDEHYDE, AND ACROLEIN.
THESE ARE COMPOUNDS FOR WHICH WE
HAVE SOME INFORMATION.
OF COURSE, WE HAVE A GREAT DEAL
ABOUT NICOTINE.
AND I’LL BE ADDRESSING THAT.
THE ELECTRONIC CIGARETTES
DELIVER AN AEROSOL THAT IS
COMPOSED OF THE DROPLETS
GENERATED BY THE DEVICE.
THESE ARE PARTICULATE IN NATURE
AND OF THE RIGHT SIZE TO REACH
THE AIR– SIZE TO REACH THE AIRWAYS AND ALVEOLI, AIR SACS,
WITHIN THE LUNG.
THE DROPLETS ARE DEPOSITED
WITHIN THE LUNG.
THEY MAY ACT THERE.
THEN, OF COURSE, SOME MOVE
ACROSS THE MEMBRANE, THE LINING
OF THE LUNG, INTO THE
CIRCULATION.
FOR EXAMPLE, NICOTINE.
IN THINKING ABOUT THE POTENTIAL
HEALTH RISKS, LET’S START WITH
NICOTINE.
THIS TOPIC WAS REVIEWED IN DEPTH
IN THE 2014 REPORT OF THE
SURGEON GENERAL.
I’M GOING TO QUICKLY RUN THROUGH
CONCLUSIONS FOUND THERE.
OF COURSE, AT HIGH ENOUGH DOSES,
NICOTINE HAS ACUTE TOXICITY,
RAISING CONCERN FOR THE
POTENTIAL OF POISONING,
PARTICULARLY FOR INFANTS, AND
CHILDREN.
NICOTINE IS A PHARMACOLOGICALLY
ACTIVE MOLECULE THAT ACTIVATES
MULTI BIOLOGICAL PATHWAYS.
WE’RE PARTICULARLY CONCERNED
ABOUT NICOTINE EXPOSURE DURING
FETAL DEVELOPMENT.
THIS IS A CRITICAL WINDOW FOR
BRAIN DEVELOPMENT, AND WE HAVE
DATA FROM BOTH HUMAN AND ANIMAL
MODELS, IF THERE ARE LASTING
ADVERSE CONSEQUENCES OF NICOTINE
EXPOSURE DURING PREGNANCY.
THERE ARE OTHER EFFECTS ON FETAL
HEALTH AND ADVERSE BIRTH
OUTCOMES ARE A CONSEQUENCE.
CONTINUING THE SUGGESTIVE
EVIDENCE THAT NICOTINE EXPOSURE
DURING ADOLESCENTS, WHEN THE
BRAIN IS STILL DEVELOPING, MAY
HAVE LASTING ADVERSE
CONSEQUENCES.
AND IN SUMMARY, NICOTINE
BEGINNING WITH GESTATION AND
MOVING THROUGH ADULTHOOD OF
COURSE HAS ADVERSE EFFECTS,
AMONG WHICH IS ADDICTION.
THE 1988 SURGEON GENERAL’S
REPORT WAS THE FIRST TO OFFER
CONCLUSIONS THAT, IN FACT,
NICOTINE IS THE DRUG IN TOBACCO
THAT CAUSES ADDICTION.
WE HAVE EVIDENCE FROM POISON
CENTERS ABOUT THE CONCERN OF
ACUTE TOXICITY FROM POISONING.
THIS IS COUNTS OF CALLS OF
POISON CENTERS ACROSS A
FOUR-YEAR SPAN.
YOU SEE THE RISING NUMBER OF
REPORTS RELATED TO E-CIGARETTES.
ONE PARTICULAR CONCERN IS
FLAVORINGS.
THE PREVALENCE OF FLAVORINGS IN
ELECTRONIC CIGARETTES HAS
ALREADY BEEN HIGHLIGHTED.
MANY OF THESE FLAVOR ARE
USED IN FOODS WHERE THEY ARE
GENERALLY RECOGNIZED AS SAFE.
THEY ARE GENERALLY RECOGNIZED AS
SAFE FOR INGESTION BUT NOT
INHALATION.
AN ENTIRELY DIFFERENT ROUTE OF
DELIVERY, OF COURSE, FROM EATING
FOODS WITH FLAVORING.
ONE FLAVORING HAS ALREADY BEEN
LINKED TO A SERIOUS LUNG
DISEASE.
THAT IS FLAVORING USED TO GIVE A
BUTTER-LIKE FLAVOR IN WORKERS
MAKING MICROWAVE POPCORN WITH
BUTTER FLAVORING.
A SERIOUS OBSTRUCTIVE LUNG
DISEASE THAT CAN BE FATAL.
BRONCHIOLITIS WAS IDENTIFIED
MORE THAN A DECADE AGO.
WE KNOW SOME OF THE FLAVORINGS
IN USE IN E-CIGARETTES HAVE A
STRUCTURE SIMILAR
THIS WAS AN AREA OF CONCERN.
WE HAVE DATA ON RESPIRATORY
SYMPTOMS IN CHILDREN WHO ARE
USING ELECTRONIC CIGARETTES.
THESE ARE DATA FROM THE SOUTHERN
CALIFORNIA STUDIES, CHILDREN’S
HEALTH STUDY, LOOKING AT THE
PREVALENCE OF BRONCHITIC
SYMPTOMS IN USERS OF ELECTRONIC
CIGARETTES.
THESE ARE 11th AND 12th GRADERS.
EVERY USER HAVING A TWO-FOLD
INCREASE RISK OF CHRONIC COUGH,
AND EVEN AMONG THOSE WHO ARE NOT
CIGARETTE SMOKERS, THERE WAS AN
INCREASED RISK OF ABOUT 60%.
WITH REGARD TO SMOKING
CESSATION, IT’S ALREADY
MENTIONED, THERE ARE MANY
ANECDOTES AND TESTIMONIALS AS TO
THE POTENTIAL EFFECTIVENESS OF
ELECTRONIC CIGARETTES FOR
SMOKING CESSATION.
HOWEVER, HARD EVIDENCE IS
LIMITED.
THERE’S BEEN A RECENT REVIEW,
SYSTEMATIC REVIEW WITH FINDING
OF ONLY A FEW TRIALS THAT
ACTUALLY MET METHODOLOGICAL
CRITERIA.
THESE STUDIES POINTED TO THE TWO
CONCLUSIONS HIGHLIGHTED AT THE
BOTTOM.
ELECTRONIC CIGARETTES MAY HELP
TO REDUCE THE NUMBER WHO
CIGARETTE SMOKE.
AND THERE’S LITTLE EVIDENCE ON
EFFICACY FOR CESSATION COMPARED
WITH PROVEN CESSATION THERAPIES
FOR WHICH THERE’S THE
SUBSTANTIAL BODY OF CLINICAL
TRIAL EVIDENCE.
WHEN WE TAKE A LOOK AT THE
ENTIRE PICTURE AND LOOK AT
POTENTIAL HARM AND THE POTENTIAL
BENEFITS OF HAVING ELECTRONIC
CIGARETTES AVAILABLE, WE SEE
THAT THERE ARE A SUBSTANTIAL
NUMBER OF POTENTIAL HARMS AS
WELL AS SOME POTENTIAL BENEFITS.
SO TO HIGHLIGHT THOSE, AND GOING
BACK IN PART TO DR. FRIEDEN’S
OPENING REMARKS, WE HAVE CONCERN
ABOUT USE, THE INCREASED
EXPOSURE TO NICOTINE.
THE RISK FOR INITIATION OF
CONVENTIONAL CIGARETTES, THE
LONG-TERM CONSEQUENCES FOR BRAIN
DEVELOPMENT.
AND OF COURSE, TODAY’S
ADOLESCENTS ARE TOMORROW’S
MIDDLE-AGED AND OLDER ADULTS WHO
WILL BECOME AT RISK FOR THE
NONCOMMUNICABLE DISEASES CAUSED
BY CIGARETTE SMOKING WHICH IS
BECOME SMOKERS.
FOR CURRENT SMOKERS CONCERNED
ABOUT LESS CESSATION AND, OF
COURSE, PERHAPS INCREASED
DISEASE RISK COMPARED TO WHAT
THEY WOULD HAVE SHOULD THEY
COMPLETELY STOP SMOKING.
FOR FORMER SMOKERS, THE
POSSIBILITY OF RETURNING TO
BEING NICOTINE ADDICTED AND
GENERALLY FOR SOCIETY,
RENORMALIZATION OF NICOTINE AND
SMOKING AS A POTENTIAL FOR
SECONDHAND AEROSOL EXPOSURE.
ON THE BENEFIT SIDE, THE
POTENTIAL FOR DISEASE RISK FOR
THOSE WHO SWITCH COMPLETELY FROM
COMBUSTIBLE CIGARETTES TO
ELECTRONIC CIGARETTES.
OR THE POSSIBILITY THAT THOSE
SMOKERS WILL REDUCE OR QUIT
CIGARETTES.
AND PERHAPS REDUCE THE DISEASE
MORBIDITY.
WE ARE, OF COURSE, AT A POINT
WHERE WE HAVE INCOMPLETE
EVIDENCE.
THE RISE OF ELECTRONIC
CIGARETTES IS RECENT, AND THE
HEALTH STUDIES ARE ONLY
BEGINNING.
HERE ARE SOME OF THE CRITICAL
NEEDS — SURVEILLANCE FOR
EMERGENCE OF PATTERNS FOR
E-CIGARETTES THAT IS UNDERWAY IN
MANY DIFFERENT SURVEYS AND
STUDIES, CAREFULLY TRACKING
NICOTINE ADDICTION.
THERE ARE SENTINEL EVENTS OF
CONCERN.
NICOTINE POISONING, RESPIRATORY
COMPLICATION THAT’S MIGHT POINT,
FOR EXAMPLE, TO ADVERSE EFFECTS
OF FLAVORING.
TOXICOLOGICAL SCREENING, AND THE
ROLE OF FLAVORINGS, AND FINALLY,
STUDIES EFFECT IN KEY POSSIBLY
SUSCEPTIBLE GROUPS AS I HAVE
LISTED HERE.
AND I’M SURE THERE ARE OTHER
ADDITIONS THAT WOULD BE MADE.
SO OUR EVIDENCE IS STILL
INCOMPLETE ON HEALTH EFFECTS,
BUT WE KNOW THAT WE NEED TO
GATHER MORE.
SO WITH THAT, LET ME CONCLUDE
AND PASS THE BATTON TO
DR. JOHN WIESMAN, SECRETARY OF HEALTH IN WASHINGTON STATE.
>>GREAT.
THANK YOU.
IT’S A PLEASURE TO TALK TO YOU
ABOUT WORKING ON THE FRONT LINES
AT THE STATE AND LOCAL LEVELS IN
TERMS OF THE E-CIGARETTE ARENA.
SO E-CIGARETTES POSE A
SIGNIFICANT CHALLENGE FOR US IN
PUBLIC HEALTH PRACTICE AS WE
ATTEMPT TO ADDRESS YOUTH ACCESS
AND PREVENT YOUTH FROM
INITIATING SMOKING AND VAPING
BECAUSE WE HAVE TWO GOALS THAT
MAY BE AT SOMEWHAT ODDS WITH
EACH OTHER.
AS DR. FRIEDEN SAID EARLIER, ON
THE ONE HAND, FOR ADULTS WHO
SMOKE AND ARE ADDICTED TO
NICOTINE AND HAVE NOT YET QUIT,
ENCOURAGING THEM TO TOTALLY
SWITCH TO E-CIGARETTES IS
PROBABLY LESS HARMFUL THAN
SMOKING.
YET, ON THE OTHER HAND, FOR
YOUTH, TAKING UP E-CIGARETTE USE
IS HARMFUL TO THEIR HEALTH AND
SHOULD NOT BE DONE AT ALL.
SO IMPLEMENTING PUBLIC POLICY
THAT WILL CAN ACCOMMODATE BOTH
OF THESE GOALS CAN BE TRICKY.
THIS IS PART OF TODAY’S
PRESENTATION, OUTLINES THE
CHALLENGES WE FACE IN PUBLIC
HEALTH PRACTICE WITH THIS
DILEMMA.
IN WASHINGTON STATE, OUR MOST
RECENT YOUTH DATA SHOW
E-CIGARETTE USE IN THE CHART IN
THE YELLOW ON THE BOTTOM, AND
THOSE USING ONLY COMBUSTIBLE
CIGARETTES IN THE BLUE ON THE
TOP, AND THOSE USING BOTH
E-CIGARETTES AND COMBUSTIBLE
CIGARETTES OR DUAL USE, IS IN
GREEN IN THE MIDDLE.
FOR 10TH GRADERS IN WASHINGTON,
17.9% ARE USING E-CIGARETTES.
AND SIMILARLY, 7.5% ARE USING
COMBUSTIBLE CIGARETTES.
WHETHER OR NOT E-CIGARETTES ARE
A GATEWAY TO FUTURE TOBACCO USE,
I THINK WE CAN ALL AGREE WE
WOULD LIKE TO SEE THESE NUMBERS
BE ZERO ACROSS THE BOARD FOR OUR
YOUTH.
WHEN IT COMES TO PUBLIC HEALTH
PRACTICE AND OUR GOAL TO PROTECT
YOUTH FROM USING E-CIGARETTES
AND TOBACCO, OUR STRATEGIES RELY
ON EITHER REDUCING DEMAND OR
REDUCING SUPPLY AS TO
E-CIGARETTE ACCESS.
IN ORDER FOR THIS TO BE
SUCCESSFUL, WE NEED TO HAVE
ADEQUATE FUNDING TO IMPLEMENT
THESE STRATEGIES.
AND AS YOU’RE GOING TO SEE IN
THE NEXT SLIDE, THAT IS
CURRENTLY CHALLENGING FOR MANY
OF US.
SO THE TACTICS THAT WE USE TO
IMPLEMENT THESE TWO STRATEGIES
INCLUDE PUBLIC EDUCATION AND
HEALTH PROMOTION MESSAGES AND
CAMPAIGNS AND CHANGING POLICIES,
SYSTEMS, AND ENVIRONMENTS
THROUGH COMMUNITY COALITIONS,
ORGANIZATIONAL POLICIES, AND
PUBLIC POLICY EFFORTS WHICH
OFTEN REQUIRE LEGISLATION AND
REGULATION.
AS WE LOOK AT THE ABILITY TO
REDUCE DEMAND, ONE APPROACH IT
TO EDUCATE OUR YOUTH AND THEIR
PARENTS ON E-CIGARETTE HARM IN
AN EFFORT TO PREVENT YOUTH
SEEKING TO PURCHASE AND USE
CIGARETTE PRODUCTS.
HOWEVER, FOR MANY OF US WHO HAVE
STATE INVESTMENTS IN TOBACCO
PREVENTION AND CONTROL, THE
RECESSION TOOK A HUGE TOLL ON
OUR TOBACCO FUNDING.
THAT IS THE CASE FOR WASHINGTON.
WASHINGTON’S RESOURCES FOR
TOBACCO PREVENTION AND CONTROL
FOR YOUTH RANKED 45th IN 2014
FOR THE PERCENT OF
CDC-RECOMMENDED FUNDING FOR
THESE PROGRAMS.
WE’RE NOT ALONE.
WASHINGTON JOINS 23 STATES AND
THE DISTRICT OF COLUMBIA IN
SPENDING LESS THAN 10% OF THE
CDC RECOMMENDATIONS ON TOBACCO
PREVENTION PROGRAMS.
THERE ARE SIX STATES THAT
ACTUALLY SPEND 50% OR MORE OF
THOSE RECOMMENDED AMOUNTS, AND
THOSE ARE ALASKA, NORTH DAKOTA,
DELAWARE, WYOMING, HAWAII, AND
OKLAHOMA.
THE STATE OF WASHINGTON HAS NOT
HAD ANY SIGNIFICANT RESOURCES TO
IMPLEMENT THE STATEWIDE PUBLIC
EDUCATION AND HEALTH PROMOTION
CAMPAIGN AROUND E-CIGARETTES.
WITH EXTREMELY LIMITED
RESOURCES, CURRENT EFFORTS FOCUS
ON EDUCATING PARENTS AND ADULTS
TO WHAT E-CIGARETTES ARE,
COUNTERACTING THE MISBELIEF THAT
THEY’RE HARMLESS, AND
ENCOURAGING PARENTS TO TALK WITH
THEIR CHILDREN ABOUT
E-CIGARETTES.
WE’VE DESIGNED A WEB PAGE TO
HELP PROVIDE THIS ACCURATE
INFORMATION ON E-CIGARETTES AND
VAPING.
LIMITED STATE FUNDING HAS BEEN
PROVIDED TO LOCAL HEALTH
DEPARTMENTS, COMMUNITY-BASED AND
TRIBAL HEALTH AGENCIES TO
PROVIDE EDUCATION TO THEIR
RESPECTIVE COMMUNITIES, AND
ADDRESS COMMUNITIES EXPERIENCING
DISPARITIES.
AT THE LOCAL LEVEL, SPECIFIC
EDUCATIONAL PROGRAM EFFORTS
INCLUDE A COMMUNITY-DRIVEN
COALITION IN KING COUNTY CALLED
206 RISING, WITH THE MESSAGE
THAT MOST YOUTH RISE ABOVE THE
INFLUENCE.
206 RISING FOCUSES ON REDUCING
AND PREVENTING YOUTH SUBSTANCE
ABUSE INCLUDING E-CIGARETTES.
IN ADDITION, DON’T BE FOOLED
MESSAGING ON E-CIGARETTES WILL
APPEAR SOON ON BILLBOARDS AND
LIGHT RAILS IN SELECTED AREAS OF
THE CITY.
TACOMA PIERCE COUNTY HEALTH
DEPARTMENT LAUNCHED ITS THINK
AGAIN PIERCE COUNTY EDUCATIONAL
CAMPAIGN IN JULY OF 2015 WHICH
INCLUDES A WEBSITE, BILLBOARDS
ON CAB TV, BUSES, AND SHELTERS
AND A FACEBOOK PAGE.
A SECOND APPROACH TO REDUCING
DEMAND IS TO INCREASE THE COS
OF PRODUCTS, THEREBY
DISCOURAGING THEIR USE.
THIS HAS BEEN AN EFFECTIVE
STRATEGY THAT’S ALREADY BEEN
MENTIONED FOR REDUCING TOBACCO
DEMAND FOR BOTH ADULTS BUT
ESPECIALLY FOR YOUTH.
IT REMAINS TO BE SEEN IF THIS
STRATEGY WILL BE EFFECTIVE FOR
E-CIGARETTES, ESPECIALLY SINCE
THESE TEND TO BE SEEN AS
ELECTRONIC DEVICES COMPLETE WITH
USB CHARGING PORTS, AND FOR THIS
GENERATION THAT PAYS LARGE SUMS
FOR ELECTRONICS, THERE IS A
QUESTION OF HOW PRICE SENSITIVE
THEY MAY BE.
FURTHERMORE, WHILE THE INITIAL
COST FOR THE STARTER KIT CAN BE
LARGE, THE ONGOING COSTS ARE
RELATIVELY SMALL.
THIS MAP SHOWS THE FIVE STATES
AND DISTRICT OF COLUMBIA THAT
TAX E-CIGARETTES.
WHILE 123 STATES PROPOSED TAXING
E-CIGARETTES IN 2014, NONE OF
THOSE PIECES OF LEGISLATION
PASSED.
THERE ARE A NUMBER OF DIFFERENT
POTENTIAL APPROACHES TO TAXING
THE ELECTRONIC NICOTINE
DISPENSERS, INCLUDING BY THE
MILLILITERS OF LIQUID, BY THE
MILLIGRAMS OF NICOTINE, OR AS A
PERCENTAGE OF SALES OR THE
WHOLESALE PRICE AKIN TO WHAT
SOME OF OUR STATES CALL OTHER
TOBACCO PRODUCT TAXATION.
STRATEGIES FOR REDUCING THE
SUPPLY OR ACCESS OF ELECTRONIC
CIGARETTE EQUIPMENT AND LIQUID
FOR USE GENERALLY REQUIRE
LEGISLATION AND REGULATION.
IN ORDER TO ENFORCE LAWS THAT
RESTRICT ACCESS, THE LICENSING
OF THOSE BUSINESSES THAT SELL
THESE PRODUCTS IS ESSENTIAL.
WE NEED TO KNOW WHO IS SELLING
PRODUCTS AND WHERE THEY ARE
SELLING THE PRODUCTS TO
IMPLEMENTS AN EFFECTIVE
OVERSIGHT SYSTEM.
KANSAS IS CURRENTLY THE ONLY
STATE THAT LICENSES ITS
E-CIGARETTE RETAILERS, ALTHOUGH
MASSACHUSETTS MAY SOON FOLLOW.
ANOTHER STRATEGY TO REDUCE
SUPPLY IS TO RAISE THE AGE
FOR LEGAL PURCHASE OF ELECTRIC DEVICES AND SUPPLIES.
MOST STATES LIMIT SALES TO 18
AND OVER, FOUR, ALABAMA, ALASKA,
NEW JERSEY, AND UTAH LIMIT SALES
TO 19 AND OVER.
EARLIER THIS YEAR, HAWAII IS
LEADING THE NATION, HAVING
RAISED THE AGE OF LEGAL PURCHASE
TO 21 AND OVER.
OTHER REGULATORY ACTIONS THAT
CAN BE TAKEN INCLUDE REQUIRING
CHILD-RESISTANT CONTAINERS TO
COMBAT THE INCREASE IN NICOTINE
OVERDOSES, ESPECIALLY IN OUR
YOUNGEST CHILDREN.
RETAILERS COULD ALSO BE REQUIRED
TO PLACE WARNINGS ON THE LABELS
OR AT POINTS OF SALE.
ANOTHER POLICY STEP WOULD BE TO
PROHIBIT SPECIFIC FLAVORS AS WAS
DONE WITH COMBUSTIBLE
CIGARETTES.
AND ADDITIONAL REGULATORY ACTION
WOULD BE TO PROHIBIT PUBLIC USE.
CURRENTLY IN WASHINGTON STATE,
FOUR COUNTIES AND A CITY IN
ANOTHER COUNTY PROHIBIT PUBLIC
USE OF E-CIGARETTES.
ADDITIONAL COUNTIES ARE
CONSIDERING LOCAL RESTRICTIONS
ON THE USE AND SALE.
AS YOU CAN SEE FROM THIS MAP,
THE STATES IN ORANGE PROHIBIT
THE USE OF BOTH E-CIGARETTES AND
COMBUSTIBLE CIGARETTES IN PUBLIC
INDOOR SPACES.
AN EMERGING CHALLENGE OF GREAT
CONCERN IS THE NEW INTERSECT
WITH E-CIGARETTES AND MARIJUANA
OR THC.
WASHINGTON STATE ALONG WITH
THREE OTHER STATES, ALASKA,
OREGON, AND COLORADO, AND THE,
DID HAVE LEGALIZED THE USE OF
RECREATIONAL MARIJUANA.
23 STATES HAVE LEGALIZED THE USE
OF MARIJUANA FOR MEDICAL
PURPOSES.
THESE STATES ARE NOW SEEING A
PROLIFERATION OF E-CIGARETTES
PRELOADED WITH THC, AND THE SALE
OF E-JUICE WITH THC.
THIS IS EXTREMELY CONCERNING IN
PART BECAUSE THE USE OF THC IN
THIS DELIVERY MODE DOES NOT
PRODUCE THE USUAL SMELL OF
MARIJUANA.
THIS MAKES IT IMPOSSIBLE TO
DISTINGUISH WHAT IS BEING
CONSUMED IN AN E-CIGARETTE —
NICOTINE, THC, OR BOTH.
WE NO HAVE A SITUATION IN WHICH
WE CAN’T TELL WHAT SUBSTANCES
OUR YOUTH ARE CONSUMING IN
E-CIGARETTES.
THESE PRODUCTS ADD ANOTHER
PUBLIC HEALTH CHALLENGE FOR US.
THIS LAST LEGISLATIVE SESSION IN
WASHINGTON, WE ATTEMPTED TO PASS
A COMPREHENSIVE LAW ADDRESSING
THE MANY ASPECTS OF CIGARETTES
AS IT RELATES TO YOUTH ACCESS IN
YOUTH.
WHILE MOST LEGISLATORS ARE ALARM
TED RAPID UPTAKE OF E-CIGARETTE
USE IN OUR YOUTH, WE FOUND IT A
CHALLENGE TO GET MAJORITY
APPROVAL FOR A COMPREHENSIVE
LEGISLATION BECAUSE TOO MANY
LEGISLATORS OBJECTED TO
DIFFERENT ASPECTS OF THE BILL.
THE RESULT WAS THAT WE COULD NOT
OBTAIN MAJORITY SUPPORT FOR THE
ENTIRE BILL.
THUS, WE WILL MOVE TO A MORE
LIMITED APPROACH THIS NEXT
SESSION.
WE ALSO FOUND IT A CHALLENGE TO
OBTAIN ENOUGH SUPPORT WITH THE
DILEMMA I OPENED MY TALK WITH —
THAT FOR ADULTS WHO SMOKE AND
HAVE BEEN UNABLE TO QUIT,
TOTALLY SWITCHING TO E-CIGARETTE
USE IS A REASONABLE PUBLIC
HEALTH HARM REDUCTION STRATEGY.
THAT HAS MADE IT DIFFICULT TO
PASS REGULATIONS AND
RESTRICTIONS THAT MAKE TOTAL
SENSE FOR PREVENTING YOUTH
ACCESS BECAUSE IT MAY
SIMULTANEOUSLY MAKE IT MORE
DIFFICULT FOR ADULT HARM
REDUCTION.
THUS, THE PUBLIC HEALTH DILEMMA
AND PRACTICE.
TO HELP WITH THIS, WE MUST
CONTINUE OUR PUBLIC HEALTH
RESEARCH.
WE MUST UNDERSTAND HOW MUCH OF A
GATEWAY E-CIGARETTES ARE TO
COMBUSTIBLE TOBACCO USE.
WE MUST UNDERSTAND ADULT USE OF
E-CIGARETTES TO SEE WHETHER
ADULTS ARE USING E-CIGARETTES TO
SUPPLEMENT THEIR COMBUSTIBLE
TOBACCO USE IN TIMES AND PLACES
WHERE THEY CAN’T USE
COMBUSTIBLE TOBACCO RATHER THAN
REDUCING THEIR RISK BY TOTALLY
REPLACING THEIR COMBUSTIBLE
TOBACCO USE.
WE MUST BETTER UNDERSTAND ALL OF
THE HEALTH RISKS WITH
E-CIGARETTE USE WHICH IS VERY
CHALLENGING IN THE INDUSTRY HERE
THAT IS UNRELATED AND RAPIDLY
CHANGING.
SO WITH ALL OF THAT SAID, AS
PUBLIC HEALTH PROFESSIONALS, WE
CAN’T WAIT FOR ALL THE DATA WE
OR OUR POLICYMAKERS MIGHT LIKE
TO HAVE.
WE HAVE TO ACT WITH THE
INFORMATION WE HAVE AND THE
THREAT WE UNDERSTAND.
FOR THESE REASONS, WE IN
WASHINGTON STATE WILL CONTINUE
TO WORK TOWARD IMPLEMENTING
SENSIBLE PUBLIC POLICY AIMED AT
PROTECTING OUR YOUTH.
WITH THAT, I’LL TURN IT OVER TO
MATT MYERS FOR OUR LAST
PRESENTATION.
[ APPLAUSE ]
>>THANKS, JOHN.
I WANT TO TALK ABOUT THE IMPACT
OF THE EMERGENCE OF E-CIGARETTES
ON THE GOAL OF OBTAINING A
TOBACCO-FREE GENERATION.
MY FOCUS IS ON THE IMPACT OF THE
EMERGENCE OF E-CIGARETTES ON OUR
NATION’S YOUTH.
OVER THE LAST 15 YEARS, THERE
HAS BEEN SUBSTANTIAL PROGRESS
BOTH IN REDUCING THE PERCENTAGE
OF YOUTH WHO START SMOKING AND
THE AMOUNT THEY SMOKE.
THE REDUCTION IN CIGARETTE USE
IS HAS ALSO BEEN ACCOMPANIED BY
A DRAMATIC CHANGE IN ATTITUDES
AMONG YOUTH.
SMOKING IS NO LONGER COOL, CHIC,
OR SEXY.
IN ADDITION, PROGRESS AND PLACES
THAT HAVE ADOPTED BEST PRACTICES
FURTHER DEMONSTRATE THAT
AVAILABLE TOOLS CAN DRIVE DOWN
YOUTH TOBACCO USE EVEN LOWER
THAN IT IS TODAY.
INDEED, MUCH LOWER.
THE LESSON IS KNOW HOW TO
DRAMATICALLY REDUCE YOUTH
TOBACCO USE.
THIS MEANS THAT E-CIGARETTES ARE
NOT NEEDED TO ACHIEVE A
TOBACCO-FREE GENERATION.
THE ISSUE IS ARE THEY A THREAT
TO THAT GOAL.
SINCE 1997, CURRENT CIGARETTE
SMOKING AMONG YOUTH HAS FALLEN
FROM 36.4% TO 15.7%.
FREQUENT CIGARETTE USE HAS
FALLEN EVEN FURTHER, FROM 16.7%
TO 5.6%.
TODAY YOUTH WHO DO SMOKE SMOKE
FEWER CIGARETTES.
THE CHANGE IS DRAMATIC.
THE DECLINE IN TOBACCO USE ALSO
CUTS ACROSS RACIAL AND ETHNIC
LINES.
ALTHOUGH WE HAVE NOT MADE THE
SAME PROGRESS AMONG THOSE IN THE
LOW SOCIO-ECONOMIC CLASS, AND
AMONG CERTAIN VULNERABLE
POPULATIONS SUCH AS NATIVE
AMERICANS, THE LGBT COMMUNITY,
AND THOSE WITH SYMPTOMS OF
MENTAL ILLNESS.
NATIONAL FIGURES ALSO DON’T TELL
THE ENTIRE STORY.
SIX STATES HAVE ALREADY REDUCED
YOUTH TOBACCO USE TO BELOW 10%.
THREE ARE AT OR BELOW 7.5%,
DEMONSTRATING THAT HIGHER TAXES,
TOUGHER LAWS, HARD-HITTING MASS
MEDIA, AND TOBACCO-CONTROL
PROGRAMS AS RECOMMENDED BY THE
CDC WORK.
FOR DECADES, THE TOBACCO
INDUSTRY SUCCESSFULLY PORTRAYED
CIGARETTE SMOKING AS COOL, SEXY,
AND A SIGN OF RUGGED MASCULINITY
AND INDEPENDENCE EXEMPLIFIED BY
THE MARLBORO MAN AND VIRGINIA
SLIMS WOMAN.
THE SLIDE IS AT THE HEART OF THE
PROGRESS THAT HAS BEEN MADE.
TODAY’S TEEN HAS NEVER SEEN A TV
AD FOR CIGARETTES.
AND SINCE 1998, 17 YEARS AGO,
MANY FORMS OF THE MOST EGREGIOUS
CIGARETTE ADVERTISING HAVE BEEN
BANNED.
THE QUESTION IS DO E-CIGARETTES
THREATEN THE PROGRESS THAT’S
BEEN MADE.
THE E-CIGARETTE INDUSTRY SADLY
IS USING THE SAME MARKETING
TACTICS, THE SAME THEMES, AND
THE SAME IMAGES AND MESSAGES
THAT THE TOBACCO INDUSTRY USED.
INDEED, TODAY, THE MAJOR
CIGARETTE COMPANIES ALSO MAKE
E-CIGARETTES.
THE THREAT IS WILL THIS ALTER
DECADES OF WORK THAT HAS CHANGED
YOUTH PERCEPTION AND YOUTH
BEHAVIOR.
LET ME SHOW YOU WHAT TEENS ARE
SEEING TODAY.
CIGARETTE ADS WERE BANNED ON TV
IN 1969, PRECISELY BECAUSE OF
THEIR POWERFUL EFFECT ON YOUTH.
FOR MANY, THE E-CIGARETTE ADS
NOW ON TV IS THE FIRST TIME THEY
HAVE EVER SEEN TOBACCO ADS ON
TV.
THE ADS GLAMORIZE THE USE OF
E-CIGARETTES IN A WAY NOT SEEN
FOR CIGARETTES IN YEARS.
THEY PLAY OFF THE MOST
SUCCESSFUL IMAGES USED BY THE
CIGARETTE INDUSTRY INCLUDING THE
RUGGED, MASCULINE, REBELLIOUS,
AND FIERCELY INDEPENDENT IMAGE
THAT MADE MARLBORO THE CIGARETTE
OF CHOICE FOR MILLIONS OF
ADOLESCENT, BOTH BOYS AND GIRLS.
AS ALSO FEATURED, TODAY’S
EQUIVALENT OF THE VIRGINIA SLIMS
WOMAN, DEPICTING E-CIGARETTE USE
AS SEXY AND REBELLIOUS.
E-CIGARETTE ADS AS APPEARED IN
MAGAZINES THAT REACHED MILLIONS
OF TEENS INCLUDING “ROLLING
STONE” AND “”SPORTS ILLUSTRATED”
WEEKLY.
THE INDUSTRY NOTES THAT SEX
SELLS.
LIKE CIGARETTE MAKERS HAVE LONG
DONE, E-CIGARETTE MAKERS PORTRAY
THE USE OF THEIR
PRODUCTS AS SEXUALLY ATTRACTIVE.
THEY USE THINGS SUCH AS THE ”
“SPORTS — THE “SPORTS
ILLUSTRATED” SWIMSUIT ISSUE.
THIS IS 2014, THIS IS 2015.
THEY DRESS MAN IN SCANTILY CLAD
OUTFITS TO PARADE AROUND NEW
YORK GIVING FREE SAMPLES DURING
FASHION WEEK.
ANYBODY WHO THINKS THIS IS ABOUT
HARM REDUCTION NEEDS TO REDEFINE
HARM REDUCTION.
SPONSORSHIP OF SPORT, ESPECIALLY
SPORTS THAT GLAMORIZE RISK
TAKING WAS LONG A KEY PART OF
THE CIGARETTE INDUSTRY’S
ARSENAL.
BUT THIS TACTIC HAS BEEN BANNED
FOR ALMOST TWO DECADES.
E-CIGARETTES HAVE BROUGHT IT
BACK.
INCLUDING NEW SPORTS THAT APPEAL
PARTICULARLY TO MODERN
RISK-TAKING YOUTH.
FOR DECADES, THE TOBACCO
COMPANIES ALSO USED SPONSORSHIP
AT MUSIC EVENTS TO PROMOTE
CIGARETTES TO HUGE AUDIENCES
INCLUDING KIDS.
CIGARETTE SPONSORSHIPS ARE NOW
BANNED.
BUT E-CIGARETTE BRANDS HAVE
BROUGHT THIS TACTIC BACK.
A 2009 FEDERAL LAW BANNED FRUIT
AND CANDY-FLAVORED CIGARETTES,
BUT MANY E-CIGARETTE COMPANIES
NOW PITCH SIMILAR FLAVORS.
PINA COLADA CIGARETTES HAVE NOW
BEEN REPLACED BY PINA COLADA
E-CIGARETTES.
THE VARIETY IS INFINITE.
THEY ALSO USE CARTOONS.
THE WEBSITE FOR BLUE
E-CIGARETTES FEATURED A CARTOON
PITCHMAN NAMED MR. COOL,
REMINISCENT OF THE JOE CAMEL
CARTOON CHARACTER THAT SO
EFFECTIVELY MARKETED CIGARETTES
TO KIDS IN THE 1990s AND WAS
BANNED BY THE 1998 MASTER
SETTLEMENT AGREEMENT WITH THE
STATES PRECISELY BECAUSE OF ITS
IMPACT ON OUR NATION’S YOUNG
PEOPLE.
NOW THE CONCERN ABOUT THE IMPACT
OF E-CIGARETTE MARKETING AS
CURRENTLY DONE IS NOT
INCONSISTENT WITH SUPPORT FOR
AGGRESSIVE MARKETING OF
FDA-APPROVED SMOKING CESSATION
PRODUCTS TO SMOKERS.
A COMPARISON OF MARKETING FOR
NICOTINE REPLACEMENT THERAPY
WITH MARKETING FOR E-CIGARETTES
DEMONSTRATES THAT IT IS POSSIBLE
TO TARGET SMOKERS WITHOUT A
MAJOR IMPACT ON YOUTH USING
IMAGES THAT APPEAL TO ADULT
SMOKERS FOR THE PURPOSE OF
ENCOURAGING THEM TO QUIT WITHOUT
APPEALING TO YOUTH.
THESE ADS CLEARLY TARGET ADULT
SMOKERS WITH A MESSAGE ABOUT THE
BENEFIT OF QUITTING SMOKING.
NOTE, NONE OF THE THEMES THAT
YOU SAW IN E-CIGARETTE ADS
APPEARED HERE.
RISK TAKING IS REPLACED WITH
THEMES ABOUT CARING ABOUT YOUR
HEALTH AND YOUR FAMILY.
NOW THE QUESTION COMES, WHAT CAN
THE FEDERAL GOVERNMENT DO?
THE FEDERAL GOVERNMENT HAS THE
LEGAL AUTHORITY TO TAKE STEPS TO
MINIMIZE THE THREATS POSED BY
E-CIGARETTE MARKETING THAT THE
PROGRESS THAT HAS BEEN MADE TO
YOUTH.
WHILE I WILL TODAY FOCUS ON THE
FOOD AND DRUG ADMINISTRATION,
IT’S IMPORTANT TO RECOGNIZE THAT
BOTH THE CDC.
AND AS YOU HEARD EARLIER,
FEDERAL GOVERNMENT IS A VITAL
ROLE TO PLAY IN IMPLEMENTING A
COMPREHENSIVE APPROACH.
THE 2009 FAMILY SMOKING
PREVENTION AND TOBACCO CONTROL
ACT AUTHORIZES FDA TO ASSERT
JURISDICTION OVER ALL OTHER
TOBACCO PRODUCTS INCLUDING
E-CIGARETTES AND INCLUDING ITS
MANUFACTURING, MARKETING, AND
SALES.
FDA ANNOUNCED ITS INTENTION TO
DO SO IN 2010 BUT DIDN’T ISSUE A
PROPOSED RULE UNTIL APRIL OF
2014.
YESTERDAY, THE PROPOSED FINAL
RULE WAS TRANSMITTED IT THE
WHITE HOUSE WHERE IT IS NOW
UNDERGOING REVIEW.
IF ADOPTED, THE PROPOSED RULE
WILL FOR THE FIRST TIME PUT IN
PLACE A NATIONWIDE MINIMUM AGE
OF SALE.
REQUIRES AGE VERIFICATION,
PROHIBITS VENDING MACHINE SALES
AND FREE SAMPLES, AND PROVIDES
THE STATES WITH THE RESOURCES TO
EFFECTIVELY ENFORCE THESE LAWS.
WHILE FDA HAS AUTHORITY OVER THE
TYPE OF MARKETING THE
E-CIGARETTE HAS EMPLOYED, FDA’S
PROPOSED RULES DID NOT INCLUDE
ANY RESTRICTIONS ON E-CIGARETTE
MARKETING.
HOW QUICKLY AND HOW EFFECTIVELY
IT DOES SO WILL HAVE A DIRECT
IMPACT ON YOUTH ATTITUDES AND
YOUTH USE ON THESE PRODUCTS.
WHILE THE PROPOSED RULE ALSO DID
NOT ADDRESS THE ISSUE OF
FLAVORED E-CIGARETTES, IT’S
POSSIBLE, INDEED HOPEFUL THAT
THE FINAL RULE WILL DO SO OR, AT
THE VERY LEAST, INDICATE HOW FDA
PLANS TO ADDRESS THIS ISSUE IN
THE FUTURE.
AND IT’S USEFUL TO RECOGNIZE
THAT WITH THE PASSAGE OF 2009
ACT AND ASSERTION, THE FDA HAS
AUTHORITY OVER ALL NICK-TEEN
CONTAINING PRODUCTS.
WHILE I HAVE FOCUSED ON HOW FDA
CAN USE ITS AUTHORITY NARROWLY
TO REIN IN THE E-CIGARETTE
INDUSTRY’S BEHAVIOR THAT
THREATENS THE PROGRESS THAT’S
BEEN MADE, THE FDA HAS THE
ABILITY TO THINK MORE BROADLY,
INDEED MORE BOLDLY, HOW TO
DEVELOP A COMPREHENSIVE SET OF
RULES DESIGNED TO SUPPORT
ONGOING EFFORTS TO REDUCE
TOBACCO USE AMONG ALL KINDS OF
YOUTH, AND AT THE SAME TIME, AS
JOHN SAID, HOW TO MOVE AS MANY
PEOPLE AS POSSIBLE WHO ARE
CURRENTLY SMOKERS AWAY FROM
PRODUCTS THAT CAUSE HARM TO
PRODUCTS THAT POSE A MINIMUM
RISK AT MOST.
IN CONCLUSION, IT IS STILL
DIFFICULT TO KNOW THE IMPACT OF
CURRENT USE OF E-CIGARETTES
AMONG YOUTH, OR ON THE EVENTUAL
USE OF CIGARETTES.
HOWEVER, IT’S NOT TOO EARLY TO
BE CONCERNED.
THE CURRENT E-CIGARETTE
MARKETING PRACTICES AND USE OF
FLAVORINGS THAT MAKE THESE
FLAVORINGS SO APPEALING TO
YOUTH POSE A THREAT TO THE
PROGRESS THAT HAS BEEN MADE.
DESPITE THE FOCUS AND INTENSE
FOCUS ON E-CIGARETTES, IT IS
VITALLY IMPORTANT THAT WE
CONTINUE TO RECOGNIZE AND
CONTINUE TO FOCUS ON THE FACT
THAT GEOGRAPHIC PLACES THAT HAVE
ADOPTED BEST PRACTICES OF
TOBACCO CONTROL HAVE SHOWN THAT
IN THE ABSENCE OF THE
E-CIGARETTES, WE HAVE THE
ABILITY TO CREATE A TOBACCO-FREE
GENERATION.
THE CRITICAL QUESTION FOR ALL OF
US IN ACHIEVING THAT GOAL IS DO
WE HAVE THE POLITICAL WILL TO
ACHIEVE IT.
THANK YOU.
[APPLAUSE]
>>THAT BRINGS US TO THE NEXT
COMPONENT OF TODAY.
THE QUESTION-AND-ANSWER SESSION.
I ENCOURAGE YOU IF YOU’RE IN THE
ROOM TO STEP TO THE MICROPHONE
ON EITHER SIDE.
AND THOSE ON LINE CAN ALSO
SUBMIT A QUESTION.
WE HAVE ABOUT TEN MINUTES.
WE’LL START WITH THE ONLINE
QUESTIONS FIRST.
>>CAN YOU ELABORATE A LITTLE
BIT ON THE RESEARCH THAT HAS
BEEN DONE ON THE LONG-TERM
EFFECTS OF THE SYRUP THAT IS PUT
IN E-CIGS?
WHAT HARMFUL SIDE EFFECTS WILL
THIS POSE IN THE FUTURE?
WHEN INHALED, WHAT DOES IT DO TO
THE LUNGS?
IS IT JUST AS HARMFUL AS THE TAR
PRODUCED WHEN CIGARETTES ARE
BURNED?
>>SO, THIS IS ONE OF THE ISSUES
I SPOKE TO.
CONCERN ABOUT THE FLAVORING.
THERE WE HAVE CONCERNS FROM THE
EXPERIENCE, THE CHEMICAL
PRODUCED BY WORKERS AND CITED IN
THE LABORATORY, AS WELL.
WE DON’T HAVE THE LONG-TERM
EVIDENCE THAT THE QUESTIONER
ASKS FOR.
I THINK THAT’S WHY IN
HIGHLIGHTING RESEARCH, I POINT
TO THE NEED FOR WATCHING FOR ANY
CASES OF ACUTE LUNG DISEASE JUST
LIKE THAT EXPERIENCED BY THE
WORKERS.
WE NOW HAVE THE POSSIBILITY THAT
CHILDREN WILL BEGIN TO INHALE
THESE FLAVORS, AEROSOLS INTO THE
LUNGS AT A YOUNG AGE WHILE THE
LUNGS ARE STILL INCOMPLETE IN
GROWTH.
AND PERHAPS HAVE LASTING
EFFECTS.
I THINK THE QUESTION POINTS TO
THE IMPORTANT ISSUE FOR CAREFUL
MONITORING.
>>WE HAVE A QUESTION IN THE
ROOM.
YES?
>>THANK YOU SO MUCH TO ALL FOUR
SPEAKERS FOR A GREAT
PRESENTATION.
I WAS WONDERING IF ANY OF YOU
MIGHT BE ABLE TO COMMENT ON THE
INTERNATIONAL LANDSCAPE ON
E-CIGARETTES’ REGULATION OR
SURVEILLANCE OF — MAYBE
PARTICULARLY TOUCH ON PUBLIC
HEALTH ENGLAND PHYSICIAN ON THIS
AND HOW IT AFFECTS OUR NATION’S
EFFORTS.
>>I CAN TRY.
THE INTERNATIONAL LANDSCAPE IS
REALLY DRAMATICALLY VARIED.
THERE ARE A NUMBER OF NATIONS
THAT ARE TREATING E-CIGARETTES
AS DRUGS BECAUSE OF THE CONTENT
OF NICOTINE AND, THEREFORE, ARE
REQUIRING THEM TO GO THROUGH THE
DRUG APPROVAL PROCESS.
THERE’S SEVERAL NATIONS THAT
HAVE BANNED THE SALE OF
E-CIGARETTES FROM THE VERY GET GO WITH REGARD TO THIS.
A NUMBER OF NATIONS ARE TREATING
THEM AS CONSUMER PRODUCTS.
THE EUROPEAN UNION’S TOBACCO
PRODUCT DIRECTIVE HAS DEVELOPED
A TWO-PHASE APPROACH TO THEM
THAT WILL GO INTO EFFECT NEXT
YEAR, IN PART REQUIRING
TREATMENT OF E-CIGARETTES WITH
LEVELS OF NICOTINE BELOW 20
MILLIGRAMS PER — AS CONSUMER
PRODUCTS, ANYTHING OVER AS A
MEDICINE.
THE U.K. HAS TAKEN A DIFFERENT
APPROACH FROM THE VERY
BEGINNING.
IT HAS A LONGER HISTORY OF
REGULATING PRODUCTS TO TRY TO
REDUCE THE HARM OF CIGARETTES
UNDER ITS MEDICINE SYSTEMS AND
HAS A SEPARATE AND INDEPENDENT
SET OF RULES AND REGULATIONS TO
REGULATE THEIR SALE AND
MARKETING.
DIFFERENT THAN THE TYPE OF
MARKETING THAT WE HAVE SEEN IN
THE UNITED STATES.
AND THE YOUTH DATA THAT THEY
HAVE SEEN IN THE U.K. VARIES
SOMEWHAT FROM THE UNITED STATES
WHICH IS PARTLY AN IMPORTANT
LESSON FOR ALL OF US WHICH IS
HOW DIFFERENT COMMUNITIES WILL
RESPOND TO THIS WILL, IN FACT,
DEPEND.
A NUMBER OF VARIABLES
INDEPENDENT OF THE PRODUCT
ITSELF.
HOW OR WHETHER THE GOVERNMENT
APPROACHES IT, THE FACT THAT THE
U.K. GOVERNMENT WAS OUT IN FRONT
EARLIER THAN OURS MAY HAVE HAD
AN IMPACT.
SECOND, RULES GOVERNING ITS
MARKETING HAS CLEARLY HAD AN
IMPACT ON HOW IT’S PERCEIVED
BOTH BY ADULTS AND YOUTH IN THE
U.K.
THE ULTIMATE ANSWER IS WE STILL
DON’T KNOW ABOUT LONG-TERM
IMPACTS IN THE U.K.
>>OKAY.
ANOTHER QUESTION FROM ON LINE.
>>I AM ON AN E-CIGARETTE AND
HAVE BEEN USING THEM FOR QUITE A
WHILE.
WHAT HARM AM I FACING?
>>DR. SALMON, IF YOU’D LIKE TO
TAKE THAT.
>>CERTAINLY, ONE HARM —
WITHOUT KNOWING FURTHER DETAILS
FROM THE QUESTION, I MEAN,
CERTAINLY ONE OBVIOUS HARM IS
CONTINUED ADDICTION TO NICOTINE.
[ INAUDIBLE ]
ADDICTIVE IF THERE’S ENOUGH
NICOTINE DELIVERABLE BY THE
DEVICES TO MAINTAIN NICOTINE
ADDICTION.
IF OUR QUESTIONER HAPPENS TO BE
AN ADOLESCENT, WE’VE HIGHLIGHTED
SOME OF THE CONCERNS ABOUT THE
EFFECT ON THE BRAIN.
AND THE WHAT ASPECT — IF THIS
WAS A INDIVIDUAL SMOKING REGULAR
COMBUSTIBLE CIGARETTES AT
PERHAPS 15 OR 20 A DAY, THEN I
THINK WE’VE HEARD THAT WE
ANTICIPATE, OF COURSE, LOWER
RISKS TO INDIVIDUALS WITH REGARD
TO THE LONG-TERM HEALTH
CONSEQUENCES.
THEN THERE ARE UNKNOWNS, THE
FLAVORINGS AND THINGS WE’VE
SPOKEN TO.
IT’S AN INCOMPLETE ANSWER TO A
VERY IMPORTANT QUESTION.
ONE, AGAIN, WHERE RESEARCH IS
DONE IS CLEAR.
>>OKAY.
>>ADDITIONAL QUESTIONS FROM ON
LINE IF THERE ARE NO OTHER IN
THE ROOM?
>>IS THERE ANY RESEARCH ON
LIPID INHALATION FOR STARTERS
ADMINISTRATION OR PROLONGED
EXPOSURE TO THE NON-NICOTINE
CONTENT?
CONTENT?
>>THERE’S BEEN SOME QUESTION
ABOUT LONG-TERM EXPOSURE TO THE
VEHICLE ITSELF AND WHETHER IT
COLD CAUSE LYMPH NODE PNEUMONIA
WHICH IS WHAT I THINK THE
QUESTION WAS REFERRING TO.
AND I THINK, AGAIN, I WOULD SAY
THAT THAT EVIDENCE IS VERY
FRAGMENTARY.
THAT SOME CLINICAL REPORTS NOT
RELATED TO E-CIGARETTES PER SE
OF EXPOSURE TO THE KINDS OF
THINGS WITH THE VEHICLE AND
CAUSATION OF SORT OF THE
CHEMICAL PNEUMONIA BUT
INFORMATION DIRECTLY RELATED TO
ELECTRONIC CIGARETTES I THINK IS
EITHER UNAVAILABLE OR
FRAGMENTARY.
>>WE HAVE ANOTHER QUESTION IN
THE ROOM.
YEAH?
>>HI, THANK YOU FOR YOUR VERY
JET LIGHTNING PRESENTATION.
WHAT ADVICE IS GIVEN TO TOBACCO
PREVENTION ORGANIZATIONS AND
STATES IN SHIFTING FOCUS FROM
COMBUSTIBLE CIGARETTES AND
TOBACCO TO E-CIGARETTES?
ESPECIALLY IN THE STATES THAT
HAVE THE HIGHEST PREVALENCE WITH
TOBACCO USE?
WHAT ADVICE ARE YOU GIVING OR
CAN YOU GIVE?
THANK YOU.
>>WOULD YOU LIKE TO START FROM
THE STATE EXPERIENCE?
>>I THINK FROM THE STATE
EXPERIENCE, THE ISSUE IS WE
CAN’T LOSE FOCUS OF EITHER.
WE ACTUALLY HAVE TO DO THESE
TOGETHER.
WE CAN’T LOSE FOCUS ON
COMBUSTIBLE TOBACCO, AND AT THE
SAME TIME WE’VE GOT TO MAKE SURE
THAT PEOPLE UNDERSTAND THE HARMS
OF ELECTRONIC CIGARETTES FOR
THOSE WHO HAVE NOT USED BEFORE.
I THINK IT’S BOTH.
FRANKLY, FOR A LOT OF US THE
CHALLENGE SIMPLY IS THE FUNDING.
WE KNOW THE BEST PRACTICES FOR
TOBACCO.
THEY’RE CLEAR.
WOOF BEEN SUCCESSFUL IN USING
THEM — WE’VE BEEN SUCCESSFUL IN
USING THEM AND DRIVEN DOWN
TOBACCO RATES.
YOU CAN’T DO THAT WITHOUT
PROGRAMS AND WITHOUT FUNDING.
>>I WOULD ADD THAT THE
EXPERIENCE IS PARALLEL AT THE
NATIONAL LEVEL.
THE 2014 SURGEON GENERAL’S
REPORT WAS CLEAR THAT THE
OVERWHELMING DEATH FROM
COMBUSTIBLE TOBACCO PRODUCTS IS
FROM CIGARETTES AND OTHER
COMBUSTIBLES.
WE DON’T WANT TO LOSE SIDE SIGHT
OF THE PRIZE.
WE KNOW COMBUSTIBLES IS PUBLIC
ENEMY NUMBER ONE.
IT’S IMPORTANT TO REMEMBER
E-CIGARETTES IN THAT CONTEXT AND
HOW IT COULD INFLUENCE PATTERNS
OF COMBUSTIBLE USE GOING
FORWARD.
IRRESPECTIVE OF WHERE A STATE
MAY BE ON THE CONTINUUM, WE
STILL NEED TO RESPECT THAT
E-CIGARETTES ARE NOT THE PRIMARY
FOCUS, AND COMBUSTIBLES ARE THE
PUBLIC HEALTH BURDEN.
WE CAN’T LOSE SIGHT OF EMERGING
PRODUCTS INCLUDING E-CIGARETTES
AND ANYTHING ELSE ON THE MARKET
AND HOW THAT COULD IMPACT OUR
ADDRESSING THING THAT WE KNOW
WILL WORK.
>>WITH THAT, I THINK WE ARE OUT
OF TIME FOR OUR Q&A.
>>YES.
THANK YOU VERY MUCH FOR JOINING
US.
AND THANK YOU T OUR SPEAKERS.
WE’LL SEE YOU NEXT MONTH FOR
PUBLIC HEALTH GRAND ROUNDS.
[ APPLAUSE ]

8 thoughts on “E-cigarettes: An Emerging Public Health Challenge

  • I'm an anecdote and have been for a year. Would you rather I went back to cigarettes? Precautionary principle in this case relegates smokers to quit or die, however it will certainly keep tax and MSA monies rolling in until they do, won't it.

  • Here's a tip from this former smoker:The gateway theory has no shred of proof.  The precautionary principle will cost smokers their lives.  E cigarettes are NOT tobacco products, NOT as addictive as cigarettes, NOT as harmful as cigarettes, and do NOT addict nonsmokers.My life has been saved in the way you suggest, and I am one of millions of anecdotes world wide.Stop lying to the public you are only pretending to serve.  We can do without your "help", which is so ill-informed it translates into HARM.We KNOW danged well what cigarettes will do, and children DO have parents.Vaping is NOT the tobacco industry, as you well know, nor does Big T own even CLOSE to all the e cig businesses.  They don't make any yummy flavors for adults like gummi bear or cotton candy, either.E cigarettes ALREADY stop tobacco.  CDC is undermining actual public health in favor of their prehistoric ideology.You are standing firmly on the wrong side of history, protecting the cigarettes you need to pretend to fight to justify your own existence over human lives.  Get a clue or go away.From a 55 year old who never would have quit smoking without delicious fruit and candy flavors.

  • There are a lot of false arguments and a lot of things that are assumed. It's assumed that teens will pick up these e-cigs and then move to cigarettes. it's assumed that smokers will dual use, and if they didn't have e-cigs, they'd just quit smoking.

    For one, from my personal observations, most teens don't want to pay 50-100 bucks for an e-cig that works. they want a cheap 5-10 dollar pack of smokes that if about to get caught, can throw away easy. They don't want to swap juices, they want to nick a quick smoke they can palm and throw away.

    For adults, the assumption that smokers would just quit if there were no e-cigs is just laughable. EVEN THE HEAD of the CDC admits compared to smoking combustible cigs, that e-cigs are safer. Even IF someone were to still smoke regular cigs and e-cigs, it's still an improvement over simply smoking alone.

    These arguments you use to disparage and condemn e-cigs as a "Public Health Challenge" when they should be seen as a wonderful way to put out combustible cigarettes. Might there be some health risks with e-cigs? Sure. But that's no different than eating bacon and eggs, or having some drinks. We're adults, and can take some reasonable risks if we choose.

    And the fact that you condemn nicotine, which without the carcinogens is actually not much more lethal than caffeine, and has a similar LD50. These specious arguments that do not bear up with actual facts smacks of the FDA doing Big tobacco's bidding, and needs to be seriously reconsidered.

  • And I live in Washington.  This guy's an insult to Washington State voters, small businesses, and PARENTS.If you want to educate the public, you have some serious remedial learning to do FIRST.Might want to check out the Public Health England report, too.  That one has actual facts in it.

  • It's 2018 and your fearmongering has amounted to nothing. Teens are not using them, only ex smokers and those trying to quit. Everyone else uses nicotine free. No you don't have to look at it through the lens of tobacco, there is no tobacco in this product, there is no burning plant matter in this product. No combustion is involved. Stop trying to regulate everything you money pit.

Leave a Reply

Leave a Reply

Your email address will not be published. Required fields are marked *