4/17/17
E-Cigarettes
+
Marijuana
Brian Tiep, M.D.
Pulmonary Rehabilitation
Smoking Cessation
City of Hope
Disclosures
Consultant: CHAD Therapeutics, Drive Medical
Nonin Medical
History of Cigarettes
l 5000 BC Babylonians, Chinese, Indians
l James Buchanan Duke: Mass produced/Marketed
l Cigarettes to soldiers WWI: Free and addicting
l Lung Cancer 20th Century
l Surgeon Generals: 1963-4
l Medications for withdrawal: NRT, Varenicline, Bupropion
l E-Cigarettes: 2003 . . . .
James Duke Licensed James Bonsack
1881
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What is Tobacco Dependency
l Tobacco dependency is nicotine addiction
l A disease of the brain that causes its victim
to inject 7000 TOXIC chemicals into its
body over 200 times a day
l And find it a pleasurable experience.
What is Tobacco Dependency
l Chronic Disease
l Chronic Disease of the brain
l Chronic Relapsing Disease of the Brain
l A very strong addiction
l Changes way the victim thinks and acts.
What is Tobacco Dependency
l Like any addiction, the brain focuses energy
on obtaining its drug
l After it obtains its drug: Rush and Pleasure
l Minimum nicotine level to maintain addiction
l Deprived: Physiological + Mental
disturbances set in.
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When you smoke nicotine reaches the
brain in 7 Seconds
Nicotine Fix
lI Feel Good
lI feel Centered
lI feel Reassured
Dopamine Reward Pathway
PreFrontal
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Brain Links Habits to Procure Nicotine
Habits = Autopilot
Withdrawal Symptoms
> 2 Hours
l Depressed mood
l Insomnia
l Irritability, frustration, anger, anxiety
l Difficulty concentrating, Restlessness
l Decreased heart rate
l Increased appetite – Weight gain
l Craving for NICOTINE!
Reversible by nicotine = dose dependent
Rat Studies on Nicotine Addiction
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Rat Studies
l Normal behavior when receiving nicotine
l Slows when deprived of nicotine or receives nicotine
blocker
l Stops sniffing
l Teeth chatter, shakes
l Eyes half closed
l Dose of nicotine:
l Normal behavior
- Within seconds
Quit Smoking Tools
Medications
l NRT
l Long acting: Patch
l Rapid Acting: Inhalers, lozenges, gum
l Varenicline
l Bupropion
l Combinations of above
Behavior Therapy
l Dose dependent.
Lobeline and Cytosine
Tobacco Dependency
Summary
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E-Cigarettes
E-Cigarettes
l Neat invention by Herbert Gilbert 1963
l Modern E-cigarette re-invented by Hon Lik 2003
l Probably safer than tobacco cigarettes – no combustion
l Patients take to it – Vibrant vape support systems
l Considered “harm reduction” for those who will not quit
via NRT or Varenicline
l Tends to the tactile and psychosocial part of addiction
l Some evidence that patients can quit via E-cigarettes
l Inexpensive and accessible.
E-Cigarette Herbert Gilbert 1963
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Hon Lik 2003
After his father died of lung cancer – deliver smoke free nicotine vapor
ENDS (electronic Nicotine
Delivery Systems)
Electronic Nicotine Delivery System
ENDS
l Personal vaporizer
l Handheld often looks like cigarettes
l E-liquid or E juice
l forms an aerosol when E-liquid heated boiling point
l Pushing a button heats the battery-powered device
l This is called
vaping
l Use:
l Recreational: less harm, more socially acceptable places
l Smoking Cessation
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E-Cigarette Charger
Kinds of ENDS
Kinds of ENDS
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466 brands of E-cigarettes
2014 = 7 Billion Dollars
E-cigarette Build it yourself
E-Cigarettes
l E-Cigarettes
vaporized nicotine solution
l Liquid Solution Composition (variable)
l Propylene glycol (90%)
l Nicotine (2%)
l Tobacco Essence (4.5%)
l Vegetable glycerin
l Essence (1%)
l Organic acid (2%) + Nitrosamines
En.-wikepdia.org
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E-Cigarette Liquid
E-Cigarette Liquid
Many Brands / Multiple Options
E- Flavors
Vapor Devices
Tanks and Coils
Accessories
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E-cigarette Support System
l On-line
l E-cigarette Forum:
l Response to threatening regulations
l Positive direction rather than – quit something
l Vibrant and Vocal
American Vaping Association
Greg Conley - President
FDA to Regulate E-Cigarettes
MedWatch program at 1-800-FDA-1088.
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Harm Reversal
Polosa
Hazards of Exploding
Will chronic e-cigarette use
cause lung disease?
•
•
•
•
•
throat burning
mucus secretion
cough reflex
wound healing
heavy lung
Rowell. Am J Physiol
2015
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Toxicology
l Propylene Glycol – Long term exposure
l Flavorings Cinnamonaldehyde, Cherry - Benzaldehyde
l Diacetyl Popcorn lung BOS
l Acrolein (aldehyde) from heated glycerin
l Nitrosamines Potent carcinogens
l Ethylene glycol, coumarin and acetamide, formaldehyde,
acetaldehyde, propionaldehyde
l Less free radicals
l Metals chromium and Nickel (not in tobacco).
E-Cigarettes
l Inhale heated, vaporized chemicals of unknown composition
l Manufactured by unknown and unregulated manufacturers
l Including 3 tobacco companies
l Heating tip is nichrom/Kanthal heating element with a wick
l The tip temps between 300 o and 700 o C.
l Boils very rapidly – upon inhalation. 3 watts 1-3 ohms 3-6 V
l Boiling point of propylene glycol =188.2o C (370.8 F)
l Studies underway on temperature and formaldehyde.
Temperature of Atomizer
l Information not available
l Estimated between 130 C0 and 7000
l Depends on Voltage and resistance of atomizer
l Some brands allow control of watts / volts.
l Higher temperatures can create toxic chemicals
l Formaldehyde
l Acetaldehyde
l Ethylene Glycol.
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Temperature of Atomizer
Boiling point Propylene Glycol: 370.8°F
Boiling point Glycerin: 544.8°F
Boiling point Water: 212°F
Vaping Power Chart
Resistance vs Volts
Children
l Vape Shops everywhere:
l Near Schools
l E-cigarettes at school
l Increased use increased X 3
l Includes never smokers
l E-cigarettes delivering
l Vaping drugs at school
l Does not smell
l Overdose – ER’s
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Children
l Looks cool
l Flavors are fruity – candy
l Vaping can be hidden
l Can be used for drugs.
Kids
Youth
UAB Study
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E-cigarette
CDC: National Youth Tobacco Survey
E-Cigarette Nicotine Poisoning
Compared to Tobacco Cigarettes
l Kids <5y/o poisoning up 15X in 3 years
l 44% poison control calls for kids < 2y/o
l Hospitalizations 5X more likely
l Most due to E-Juice.
Kamboj Pediatrics 2016
National Institute on Drug Abuse
l Study teens using E-Cigarettes more likely to start
smoking tobacco cigarettes
l Nicotine exposure causes neuroplastic changes in brain
l Prime the brain for rewarding by other chemicals
l Or combustible tobacco
Nora Volkow Teens Using E-cigarettes More Likely to Start Smoking Tobacco.gov.
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Gateway To Cigarette
Adolescents who had ever used
e-cigarettes at baseline compared
with nonusers are 3X more likely
to smoke combustible tobacco
use over the next year.
Leventhal AM et al Association of Electronic cigarettes
use with initiation of combustible tobacco product
smoking in early adolescents JAMA 2015;314(7):700-7.
Reduction in Nicotine Withdrawal
Comparison Nicotine Levels between
Tobacco Cigarettes and E-Cigarettes
Van Sickel et al, Konstantinos 2014
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E-Cigarette Summit – Hajek 2012
Hajek. Adding E-Cigarettes to Specialist StopSmoking Treatment: City of London Pilot Project .
J Addict Res Ther. 2015
Recommended combining with Varenicline
E-cigarettes and smoking cessation in realworld and clinical settings: a systematic
review and meta-analysis
E-Cigarettes for smoking cessation
l Less harmful than tobacco cigarettes ?
l Get patients started on a track to quit
For
l Better tactile – behavioral substitute?
l Harm reduction
l Efficacy not yet determined
l Unsafe substances
l May end up smoking AND vaping
Against
l We have proven methods to quit
l Nicotine Replacement; Varenicline
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International Forum of
Respiratory Societies Oslo
l Weigh benefits vs potential harm: Ban until
more information is available
l Safety
l Benefits / Harm
l Individual
l Society
l If allowed: Regulate as medicine or tobacco product.
Schraufnagel AJRCCM 2014
Summary
l E-Cigarettes increase in popularity
l Safer, cheaper, versatile, available
l Smoking Cessation
l Some able to quit combustible
l Some use both
l Most not helped
l More safe than cigarettes? – but not safe!
Thank You
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