Implications of E-cigarette for

Behavioral Health Populations

Sharon Cummins, Ph.D.

UCSD

Disclaimer• Not FDA approved

• Unknown safety profile

• Insufficient data on efficacy

• Not endorsing or suggesting you recommend

Acknowledgements

• Gary Tedeschi PhD

• Lesley Copeland MA

• Leslie Zoref PhD

• Shu-Hong Zhu PhD• Supported by a grant from the NIH/NCI #U01 CA154280

through the State and Community Tobacco Control (SCTC) initiative

Potential problems with e-cigarettes

• Possible gateway for nonsmokers to cigarettes

• Not safe—

▫ “Water vapor”

▫ Not all use good product manufacturing processes

▫ Calls to poison centers are up

• Could delay or prevent quitting among smokers—end up with dual use

Why consider e-cigarettes?

• E-cigarettes have the potential to act as a nicotine replacement therapy

▫ Could help individuals quit cigarettes

▫ Broader appeal = greater reach

▫ Potential population impact?

• There is no product likely to be deadlier than cigarettes

▫ Orders of magnitude

▫ Looking for “game changer”

Most Important reason?

• Credibility

Why consider the behavioral health

population in this discussion?• High rates of smoking

• Both greater uptake and less cessation

• High rates of morbidity and mortality from smoking

• A tobacco disparity population

▫ Important that regulations not result in disproportionate harm

Tobacco control among those with

behavioral health conditions• Many myths around quitting

• Excluded from much of the research

• Changing

▫ Smoke-free policies in facilities

▫ Recommendation of greater assistance

▫ Recognition

� Need to quit

� Want to quit

� Can quit

E-cigarettes and behavioral health

• It’s already happening

• High consumers of cigarettes

• E-cigarettes are most salient to smokers

• Bring data to bear

A way to view e-cigarettes• Perceptions from clinicians—what would you do

if someone wanted to quit using e-cigarettes?

▫ Physicians

▫ Paraprofessional cessation counselors

• Data from a national probability survey

▫ Focus on those with Mental Health Conditions

• Clinical practice implications

Methods

• Family Physicians (N=21) from Family Medicine Department at the UCSD School of Medicine

• Cessation counselors (N=57)

Patient/client interest

% Yesof MDs

% Yesof Cessation Counselors

Patients/clients asking 70.0 96.5

Physicians/coaches seeking advice

0 66.7

Beliefs About Health Risks

% of MDs % of Cessation Counselors

Riskier than NRT 14.3 40.4

Riskier than varenicline

33.3 49.1

% Strongly agree % Strongly agree

Exposure to secondhand e-cigarette vapor is harmful

5.0 14.3

E-cigarettes are highlyaddictive

30.0 33.9

Beliefs About Effectiveness

E-cigarettes are an effective quitting aid

% of MDs % of Cessation Counselors

Strongly agree 15.0 0

Somewhat agree 60.0 26.8

Somewhat disagree 15.0 60.7

Strongly disagree 10.0 12.5

Beliefs About Regulation

% of MDs

Strongly agree

% of Cessation Counselors

Strongly agree

Should be illegal in places where smoking is illegal

47.6 58.9

Use by minors should be illegal 57.1 73.7

Should be taxed like regularcigarettes

25.0 64.3

Advertisement should be banned like regular cigarettes

33.3 54.4

Summary of Perceptions

• E-cigarettes are relevant• See them as higher in health risks than NRT or

varenicline• See them as not very effective• Important to clinicians that FDA has not

approved them as quit aid• With little data to go on, they are erring on the

side of being against e-cigarettes▫ Treat like cigarettes—taxes, advertising, youth

access, use in smoking-restricted areas

Likely answer?

• If a smoker wanted to quit smoking by using e-cigarettes, what would you do?

▫ Most would discourage him from using e-cigarettes to quit smoking

▫ Offer alternative to e-cigarettes such as NRT, bupropion, varenicline

▫ Recommend and provide or refer to behavioral cessation counseling

What if…?

• The patient had tried and been unsuccessful with all the recommended pharmacotherapies(as is true of many with behavioral health issues)?

• Insisted that he would only try to quit if he could use e-cigarettes?

• Was unwilling to give up smoking at all, but was willing to switch to e-cigarettes?

Then need to consider the likely

impact of e-cigarettes?• Need to weigh:

▫ Potential to prompt a quit attempt

▫ Ongoing nicotine addiction

▫ Potential to delay quitting cigarettes

Mental Health Conditions• High smoking prevalence

• More difficulty quitting

• Use of other tobacco products not known

• E-cigarettes

▫ Do they use them?

▫ If so, why?

▫ Are they likely to use them in the future?

Implications

• Beneficial? ▫ Decrease cigarettes▫ Increase quitting

• Detrimental?▫ Maintain smoking▫ Delay quitting

• Tobacco Control Policy▫ Accessibility▫ Pricing▫ Advertising

Methods

• Conducted through GfK’s Knowledge Panel

• National probability sample (N=10,041)

• Asked about diagnosis of Anxiety Disorder, Depression, or “Other Mental Health Condition”

• Early 2012

Mental Health Condition by Smoking

Status

13.4

16.4

26.027.8

0

5

10

15

20

25

30

Never smokers(N=3254)

Long-term formersmokers (N=3263)

Recent formersmokers (N=413)

Current smokers(N=3111)

Use of E-cigarettes

14.8

3.1

6.6

1.1

0

2

4

6

8

10

12

14

16

Ever e-cig Current e-cig

Pe

rc

en

t

Mental Health Condition No Mental Health Condition

Ever Use of E-cigarettes by Smoking Status

Never

smokers

(n=3,254)

Long-term

former

smokers†

(n=3,263)

Recent

former

smokers‡

(n=413)

Current

smokers

(n=3,111)

Mental

Health

Condition

0.5

(0-1.0)

3.3

1.1-5.6)

31.0

(19.2-42.8)

40.3

(34.6-46.0)

No Mental

Health

Condition

1.1

(0.6-1.6)

2.2

(1.6-2.9)

25.7

(19.6-31.9)

28.7

(25.5-31.9)

Over all

1.0

(0.6-1.5)

2.4

(1.7-3.1)

26.8

(21.4-32.4)

32.2

(29.3-35.0)

† smokers who quit more than 12 months prior to survey‡ smokers who quit within 12 months of taking the survey

Reasons for Using E-cigarettes

Product

Mental Health

Condition

(N=359)

No

Mental Health

Condition

(N=813)

Safer than cigarettes

54.6

(44.9-64.3)

48.5

(42.3-54.7)

Cheaper than cigarettes

36.7

(27.5-45.9)

27.9

(22.7-33.1)

Easy to use when I can’t

smoke

50.4

(40.6-60.2)

42.5

(36.6-48.4)

To try to quit smoking

cigarettes

59.6

(50.0-69.2)

52.9

(46.8-59.0)

Susceptibility to Using E-cigarettes

2.84.9

29.5

60.5

2.6 3.1

23.8

45.3

0

10

20

30

40

50

60

70

Never smokers Long-term formersmokers

Recent formersmokers

Current smokers

Pe

rc

en

t

Mental Health Condition No Mental Health Condition

Summary for Individuals with MHC

• They are using e-cigarettes

• Mostly appeals to smokers

• And for the same reason as other smokers

▫ To try and quit cigarettes

▫ Perceived as more safe than cigarettes

• MHC have tried many quitting aids

▫ May be looking to try something new

• MHC have higher susceptibility

▫ Appeals to smokers, not nonsmokers

Clinical Implications

• Encourage long-term use?

• Encourage short-term use?

• Discourage any use?

Things to think about

• Absolute risk

• Relative risk

• Your own risk tolerance

• Likelihood of quitting without it

• Patient’s belief

• Your goal

Questions?

• scummins@ucsd.edu