15/10/2014
Pro:
EͲCigarettescan
assist patients
assistpatients
withsmoking
cessation
DisclosureofCommercialSupport
• Thisprogramhasreceivednofinancialsupport .
• ThisprogramhasreceivednoinͲkindsupport.
Faculty/PresenterDisclosure
• Faculty:AlanKaplanMDCCFP(EM)FCFP
• ChairFamilyPhysicianAirwaysGroupofCanada
• ChairofSpecialInterestFocusedPractice,CollegeofFamilyPhysiciansin
RespiratoryMedicine.
Relationships with commercial interests:
• Relationshipswithcommercialinterests:
– Grants/ResearchSupport:none
– SpeakersBureau/Honoraria:AstraZeneca,BoehringerIngelheim,Griffols,Pfizer,
Purdue,JohnsonandJohnsonMerckFrosst,Novartis,Sanofi,Takeda.
– ConsultingFees:Aerocrine,Novartis,Takeda,Purdue,Pfizer
– Other:
MemberofHealthCanadaSectiononAllergyandRespiratoryTherapeutics.
MemberofPublicHealthAgencyofCanadasectiononRespiratorySurveillance
MemberofMetropolitanTBsubcommitteeoftheCTS
EditorialboardofthePrimaryCareRespiratoryJournal
MitigatingPotentialBias
• MybiasisthatsmokingisBADandisthemajorcauseof
preventabledeaths
• Potentialforconflict(s)ofinterest:
– A)
A)thereareno
there are no organizationssupportingthisprogram
organizations supporting this program
– B)IhaveNOrelationshiptocompaniesmakingtobaccoproductsor
companiesmakingelectroniccigarettes.
Taxrevenuetoourgov’tfrom
tobacco:TalkaboutBIAS???
Deaths Attributable
to smoking
Other Deaths
SmokingaffectsthewellͲbeingofthefetusand
thepregnantwoman.
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15/10/2014
What’sinaCigarette?
iTobacco smoke: t 4000 chemicals1, t 50
carcinogenic2
Chemicals in
Tobacco Smoke1
Acetone
Butane
Arsenic
Cadmium
Carbon monoxide
Toluene
Also Found In…
Paint stripper
Lighter fluid
Ant poison
Car batteries
Car exhaust fumes
Industrial solvent
WhatisanEͲCigarette?
• DesignedbyChinesepharmacistHonLikin
2003
• Electronicdevicesthatreplicateacigarette,
cigar or other smoking pipes are called "eeͲ
cigarorothersmokingpipesarecalled
cigs"or"eͲcigarettes".
• Nicotineisresponsiblefortheaddiction,butotherchemicals
arealsoinvolved.2
• Smokingcigaretteswithlowertarandnicotineprovidesnohealth
benefit.2
1. World Health Organization. Tobacco: deadly in any form or disguise, 2006.
2. Health Canada. What’s in Cigarette smoke?, August 2005.
Howdoesitwork?
• Userinhalesonthemouthpiece,triggering
theliquidtobeheatedbyalithiumbattery
withamicrochip,andtheatomizerturnsthe
eeͲliquid
liquidintoavapor
into a vapor
• Thevaporisinhaledbytheuser,whichgives
theeffectofsmokingarealcigarette
• Usersare"vaping,"notsmoking
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15/10/2014
BenefitsofeͲcigarettes
• Notar,tobacco,carbonmonoxide,orash
• Eachcartridgecostslessthan$2andisequivalenttoan
entirepackofcigarettes(possiblesavingsofover$1000a
year)
• Moreeconomical(usercantakeasmany"hits"asdesired
and need not smoke the entire thing in one sitting)
andneednotsmoketheentirethinginonesitting)
• Don'tgetthesame"smoke"smellbecausethere'sno
smoke
• Nosecondhandsmoke
Inecigwithnicotine:
• Deliversnicotineeffectively,
• Significantlyreducescigarettecravingandnumberof
cigarettessmokedatalevelsimilartothatofnicotineͲ
replacementproducts
It takes 14-20 seconds for heroin to reach the
addiction centers when injected intravenously
It takes nicotine, approximately 4-7 seconds to reach
addiction centers when smoked!!
Evidence:
15
ElectronicCigarettes&SmokingCessation
• Methods:
ElectronicCigarettes&Smoking
Cessation
Polosa,BMCPublicHealth,2011
Polosa, BMC Public Health, 2011
– 5visits:baselineandfourfollowupvisitsatweek
4,8,12,and24
– BaselineMeasurements:
li
• Demographicsanddetailedsmokinghistory
• Levelofcarbonmonoxideinexhaledbreath(eCO)
– 4weeksupplyof7.4mgnicotinecartridgesgiven
– Maxuseof4cartridges/day
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15/10/2014
ElectronicCigarettes&SmokingCessation
ElectronicCigarettes&SmokingCessation
Polosa, BMC Public Health, 2011
Reducers
Heavy Reducers
Quitters
Smoking Failure
50% reduction in
number of cig/day
compared to
baseline
80% reduction in
number of cig/day
compared to
baseline
Smoking
abstinence at 24
weeks
< 50% reduction in
number of cig/day
compared to
baseline
• Results:
– 50%reductionshownin13/40subjects
– Combinedsustained50%reductionandsmoking
p
abstinencein22/40(pч0.001)
• Conclusions:
– ReductionincigarettesmokingwitheͲcigarettes
mayincreasemotivationtoquit
– Gradualreductionsincigarettesmokingcan
increasecessation
Polosa, BMC Public Health, 2011
CaseSeriesonSmokingCessationUtilizing
EͲcigs
• Threechronicsmokers(twomale,onefemale)
CaseSeriesonSmoking
CessationUtilizingEͲcigs
g
g
Caponnetto,JournalofMedicalCaseReports,2011
• Severedependencetonicotine
– FagerstromTestofNicotineDependence(FTND)
– ExhaledBreathCarbonMonoxideConcentration
(eCO)
• Previouscessationefforts(patches&group
counseling)
Caponnetto, Journal of Medical Case
Reports, 2011.
CaseSeriesonSmokingCessationUtilizing
EͲcigs
ElectronicCigarettesforSmokingCessation:A
RandomizedControlledTrial
• Purpose:
• Results:
– CessationstatusfollowingtheusageofEͲcigs
• Norelapse6monthsfollowingstudy
– ReductionineCO
– ToassesswhetherEͲcigarettescontainingnicotine
weremoreeffectiveforsmokingcessationthan
nicotinepatches
p
• Methods:
• Limitation– Smallsamplesize!
• But:isthatnotwhatwewant,individualize
ourtreatments??
– 657subjectswereselectedforthestudy
– Randomizedbycomputerizedblockrandomization
– 4:4:1ratio
Bullen, Nat Inst Health Innov, 2013
Caponnetto, Journal of Medical Case
Reports, 2011.
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15/10/2014
ElectronicCigarettesforSmokingCessation:A
RandomizedControlledTrial
• Procedures:
ElectronicCigarettesforSmokingCessation:
ARandomizedControlledTrial
• Results:
– Subjectsusedrespectivesmokingcessation
productsfor12weeksbeforeaspecific“quitting
day
day”
– Theprimaryoutcomemeasuredwassmoking
abstinencesixmonthsafter“quittingday”
– VerifiedbyselfͲreportandcarbonmonoxide
measurement
– Abstinenceratesaftersixmonths
• NicotineEͲcigarette7.3%
• NicotinePatches
Ni i P h
5 8%
5.8%
• PlaceboEͲcigarette 4.1%
– Studywasunderpoweredduetolowabstinence
ratesandcouldnotconcludeifEͲcigaretteswere
superiortonicotinepatchesorplacebo
Bullen, Nat Inst Health Innov, 2013
PublicHealthreviewingthis
Bullen, Nat Inst Health Innov, 2013
CPHAsupport…but…
Downsides
Societyissues
• Yes,thereareissues.
• Suzannewillgo
throughthemin
detail
• ‘HarmReduction’is
whatweas
physiciansdoallday
• Patientsmake
choices
• Nitrosamine(carcinogen)present(butat
levels100Ͳ1000xlessthancigarettes!)
• Propyleneglycol(alsoinMDIs!)
• QualityControl(nicotinelevels)
• Shorttermphysiologiceffectsonairways
controversial;Yes(1)No(2,3)
• Recreationaluse/gatewaydrugtosmoking
• Nicotinetoxicity(4)
• Soldbytobaccocompanies!!
1.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. 2012 Jun;141(6):1400-6. doi: 10.1378/chest.11-2443. Epub 2011 Dec 22.
2. Hollander, Catherine. “Is Nicotine Really Any Different Than Caffeine?” National Journal, 26 June, 2013. Available at:
http://www.nationaljournal.com/magazine/is-nicotine-really-any-different-than-caffeine-20130620?mrefid=site_search
3. Flouris AD, Chorti1 MS, Poulianiti KP, Jamurtas AZ, Kostikas K, Tzatzarakis MN, Hayes AW, Tsatsakis AM, and Koutedakis Y. ‘Acute impact of active and
passive electronic cigarette smoking on serum cotinine and lung function.” Inhal Toxicol, 2013; 25(2): 91–101.
4. Robert A Bassett DO. E cig, big threat for little kids. Medscape May 27, 2014.
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15/10/2014
ThisisNOTarecreationalproduct
forouryouth!
Whereweshouldgo
• NicotinefreeECigarettes(thatiswhatis
‘legal’currentlyinCanada)
• NoflavouredEcigarettes;thisisnotasocial
recreational product but a smoking cessation
recreationalproduct,butasmokingcessation
product
• Whenitisasmokingreplacementproduct,I
amnotthrilled,butthealternative??
• NOsalestominors!
• Governmentcontrol?
Donotmakeittooeasy!!
Besides,youreaditinthe
newspaper!
Rebuttal
Smokingcessationissuesfor
patients
•
•
•
•
Nicotineaddiction
Habit
Stressrelief
Lifestyle
• Sowhatareourotheroptions,dotheywork?
Suzanne is my friend and a respected colleague, but even really
smart people can be WRONG!!
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15/10/2014
ComparingMedications:Hugefailurerates:we
havenotfoundthegoldensnitch!
Medication
Nicotine gum
Nicotine
patch
Nicotine
inhaler
Bupropion
Varenicline
Treatment
length
1-3 months
8-12 weeks
12-24
weeks
7-12
weeks
12 weeks
i
Headache
i Disturbed
sleep
i Site rash
i Irritation
of throat
and nasal
passages
i Sneezing
i
Coughing
Main side
effects
i Upset
stomach
i Hiccups
i
Insomnia
i Nausea
Dosage
2 mg, 4 mg
7 mg,
14 mg,
21 mg
6-12
cartridges
per day
150-300
mg/day
0.5 mg qd to
1 mg bid
Effectiveness
at six months
or longer
(OR [CI])
1.66
(1.52-1.81)
1.81
(1.63-2.02)
2.14
(1.44-3.18)
2.06
(1.77-2.40)
2.83*
(1.91-4.19)
*Represents results from Weeks nine through 24 follow-up
OR = odds ratio; CI = confidence interval
Hughes JR et al. Cochrane Database Syst Rev 2004; 4:CD000031; Jorenby DE et al. JAMA 2006; 296(1):56-63; Silagy C et al. Cochrane
Database Syst Rev 2004; 3:CD000146.
Dotheseproductshaveside
effects?
• Buproprion:Seizure,mania,insomnia
• NRT:insomnia,suicidality,nightmares
• Varenicline:suicidality,nightmares,nausea,
CVsafety(Idon’tthinkso)
f ( d ’ hi k )
• Again,wearetalkingaboutrelativesafeties
andharmreduction….vssmoking!!
Counsellingissafe,butefficacy?
Don’tthrowthebabyoutwiththe
bathwater!
• Smokingisahorrificpublichealthepidemic
• Smokingcessationisthekey
• Ecigaretteshaveaplaceinassistingpatients
tostopsmoking,withourrecommendation
ki
ih
d i
• Donotsellittokids!
• Ifwe,andourgovernment,useitproperly,we
canassistmanypatientstostopsmoking
cigarettes.
7
15/10/2014
QuittingSmoking:Let’sHELP
ALongandDifficultJourney!
• Themajorityofsmokersaremotivatedto
quit2
The Stages of Change Model1
• 87% ofcurrentsmokershavetriedto
of current smokers have tried to
quitsmokingatleastoncebefore4
Adapted from Prochaska et al.1
1.
2.
3.
4.
Prochaska JO et al. Am Psychol 1992;47:1102-1114.
Hughes JR. CA Cancer J Clin 2000;50:143-151.
.
O'Donnell DE et al. Can Respir J 2004;11(SupplB):3B-59B.
i Most smokers make 5-7
attempts before succeeding2
i Only ~5% succeed without help6
Balance
• Thispaperarguesthat,whilemoreresearchisneededonthecostͲbenefit
equationoftheseproductsandtheappropriatelevelandtypeof
regulationforthem,theharmshavetendedthusfartobeoverstated
relativetothepotentialbenefits.Inparticular:concernoverrepeated
inhalationofpropyleneglycolisnotborneoutbytoxicitystudies withthis
compound;riskofaccidentalpoisoningisnodifferentfrommany
p
;
householddevicesandchemicalsavailableinsupermarkets;concernthat
eͲcigarettesmaypromotecontinuedsmokingbyallowingsmokerstocope
withnoͲsmokingenvironmentsiscounteredbytheobservationthatmost
smokersusetheseproductstotrytoquitandtheiruseappearsto
enhancequittingmotivation;concernsoverlownicotinedeliveryare
counteredbyevidencethattheproductsprovidesignificantcraving
reductiondespitethisinsomecases;andeͲcigarettesmayhelpreduce
toxinexposuretononͲsmokers.
WagenerTL,SiegelM,Borrelli B.Electroniccigarettes:achievingabalancedperspective.Addiction 2012.DOI:10.1111/j.1360Ͳ
0443.2012.03826.x.
Inperspective
• “Ifwecouldgetallofthosepeople[who
smoke]tocompletelyswitchalloftheir
cigarettestononcombustiblecigarettes,it
would be good for public health ”
wouldbegoodforpublichealth,
!
for4kids@gmail.
com
www.fpagc.com
• MitchZeller,directoroftheFoodand
Drug Administration'sCenterforTobacco
Products
NewInitiative
• CollegeofFamilyPhysiciansSectionon
RespiratoryMedicine
• SpecialinterestgroupatCFPC
• Goals:
ͲIncreaselevelofcareforpatients
I
l l f
f
ti t
withrespiratorydiseases
ͲSupportfamilyphysicians
ingivingthiscare
ͲGPSIasperUK
ͲCME/Curriculum
8