Lauren Meltzer, MPH Research Project Manager

2017 Current Perspectives in Oncology Nursing

E-cigarettes

Study I: Dual Users of E-cigarettes and

Tobacco Cigarettes Study II: E-cigarettes and Cancer Patients

CDC, 2012; Jamal et al., 2014; Pepper & Eissenberg, 2014; USDHHS, 2014

One of the leading causes of death and disability in the United States and is responsible for 30% of cancer deaths

However, smoking rates have been decreasing

The introduction of electronic cigarettes [e-cigarettes] has shifted the landscape of tobacco use

• Battery-powered heating devices, often resembling cigarettes, cigars or pipes

• Designed to deliver nicotine to users in the form of a vapor (instead of

smoke) • 3 Main Components of the E-Cigarette:

• Battery • Atomizer • Inhaler

First invented in the 1960’s

• E-cigarette first entered the market in China in 2004

• Currently over 250 brands available

• Designed to look and feel like traditional cigarettes

• Sometimes referred to as “cigalikes”

• Battery-operated, initially composed of 3 pieces

• Battery (provides power)

• Atomizer (produces heat)

• Cartridge (holds liquid/flavoring)

• Atomizer and cartridge now typically replaced by a combined “cartomizer”

• Disposable, designed for 1-time use

• Available in various nicotine concentrations and flavorings

• Devices are larger and typically do not resemble a cigarette

• Sizes, shapes, and colors vary widely

• Large, separate cartridges (“tanks”) for liquids and flavorings

• Sold separately

• Larger-capacity and rechargeable batteries, larger atomizers, and more powerful electronic circuits

• Some allow manual control of both puff length and frequency

• Similar to the second generation, but are usually larger and more customizable

• Contain a range of different cartridge, atomizer, and battery options

• Low-resistance cartomizers produce higher heating element temperatures, generating more heat and affecting the amount and quantity of the aerosol

• Potentially problematic in that components are not tested to work with each other

• Overheating has been a problem

Propylene Glycol Vegetable Glycerin

Nicotine Flavoring Chemicals

http://twitter.com/BullSmoke/status/378292255687065600/photo/1

• Less harmful than smoking

• Harm reduction

• Vaping instead of

smoking

• Aid to smoking cessation

(Nicotine Replacement

Therapy - NRT)

• Unknown dangers

• Re-normalizes smoking

behavior

• Gateway to smoking

Facilitates maintenance of

smoking

Syamlal G, Jamal A, King BA, Mazurek JM. Electronic Cigarette Use Among Working Adults — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:557–561. DOI: http://dx.doi.org/10.15585/mmwr.mm6522a1.

3.7% of U.S. Adults (5.5 million): Current E-cig Users

Reasons for Using — Adults

Primarily to quit or reduce

smoking (84% in our survey)

Efficacy for Smoking

Cessation • Largely unknown.

Few RCTs

• Mixed retrospective evidence

Adult Users • Highest prevalence among current smokers (dual users), followed by

exsmokers, with little use among never smokers

• About 77% of vapers also use cigarettes (dual users)

• Most dual users (89%) remain dual users 1 year later

Smoking Cessation Self-help for Dual Users of Tobacco

Cigarettes and E-cigarettes

PI: Dr. Thomas Brandon

Department Chair and Program Leader, Health Outcomes and Behavior Director, Tobacco Research & Intervention Program

(R01 DA037961)

2015-2020

vs.

Extended Self-Help for Smoking Cessation R01 CA134347

2009-2014 American Journal of Preventative Medicine

Traditional Self-Help

1 booklet (NCI)

Extended Self-Help

10 booklets & 9 pamphlets over 18 months

Month

Per

cent

Abs

tinen

t

Extended

Aim 1: To create a minimal smoking-cessation intervention for current dual users of tobacco cigarettes and e-cigarettes (Study I)

Aim 2: To evaluate the efficacy of the intervention via a randomized, controlled trial of current dual users (Study II)

Vs. Vs.

Assessment Only Generic smoking-cessation booklets (SSFG)

New Targeted “E-Target” booklets

? ?

? ?

One-on-one interviews with current or former dual-users (n = 28)

E-cigarette specific strategies for quitting smoking • Gradually reduce the nicotine level in your juice over time • Start with a tobacco flavored juice and the switch to an alternative flavor (e.g.

fruit, herbal) over time • Only use e-cig in places where you would normally smoke tobacco cigarettes

(i.e., do not expand your use)

Strategies for coping with stress • “If I didn’t have any regular cigarettes, that would be my next thing [using an

e-cig]. That’s not the first thing that comes into my head.”

Should e-cigs be viewed as a quit aid like NRT? • “I think e-cigarettes need to be in their own separate category. Because it’s

different because just like I said it’s not FDA approved.”

Learner verification interviews with dual-users (n = 20)

Increase the visual appeal for a younger

demographic More tips for quitting smoking

using ECIGS

More variety of terms for ECIG devices

Introductory brochure, 10 Booklets, and 9 My Story pamphlets

Recruited Nationwide

≥ 18 years old

≥1 tobacco cigarette/week past year

e-cigarettes use ≥ 1/week over past month

Not currently enrolled in formal treatment

National Recruitment

Randomized and Consented (N = 2500)

Assessment Only

(n = 500)

Generic Booklets

(n = 1000)

eTargeted Booklets

(n = 1000)

6-Month Assessment

24-Month Assessment

3-Month Assessment

9-Month Assessment

15-Month Assessment

21-Month Assessment

12-Month Assessment

18-Month Assessment

N=2418

1. 2. 3. Treatment

To capitalize upon the exponential rise in e-cigarettes to reduce the prevalence of smoking and smoking-related mortality and morbidity.

Electronic Cigarette Use in Cancer Patients: A Pilot Study

PI: Dr. Vani Simmons Associate Member, Department of Health Outcomes and Behavior

Moffitt Foundation – Merit Foundation

Risks of Continued Smoking in

Cancer Patients

Other smoking-related diseases

Cancer reoccurrence

Second primary tumors

Treatment complications

• Infection • Poor wound healing

Reduced treatment efficacy

• Radiation • Chemotherapy

Mortality

o Special population with unique challenges and motivations • Highly nicotine dependent • High levels of stress and negative affect • Unique smoking relapse risk factors such as fear of cancer

recurrence • Highly motivated to quit smoking

o E-cigarette use among cancer patients = as high as 40% o Not clear whether e-cigarette findings from the general population

are generalizable to cancer patients; thus additional research is needed with this population

o Users of both e-cigs and tobacco cigarettes: different beliefs

about e-cigs compared to tobacco cigarettes and compared to nicotine replacement therapy (NRT)

o E-cigarettes = fewer health risks, better tasting, less negative

physical feeling BUT tobacco cigs better at reducing stress and negative affect

o Compared to NRT = e-cigarettes cheaper, more satisfying, better at

reducing craving, negative affect, and stress

o Do these results generalize to cancer patients???

Examine patient beliefs and behaviors about e-cigs

Why they use them?

How do their thoughts about e-cigs differ from tobacco cigarettes and NRT?

What conversations they are having with their providers about e-cigs?

Cancer Patients

≥ 18 years old

Smoked at least 100 cigs in lifetime

Used e-cig past 30 days

18+

One time, electronic survey on e-cigarette use 15-20 minutes demographics, smoking history, and

use of and expectancies towards e-cigarettes, tobacco cigarettes, and nicotine replacement therapies (NRTs).

Provider communication

Total Sample (N=122)

Age: M (SD) 55.54 (9.69)

Gender (% Female) 57%

Race (%) White/Caucasian 89%

Black/African American 4%

Other 7%

Married or living together (%) 60%

Education (%)

Less than HS diploma 9%

HS Diploma or GED 34%

Some college / Technical / Associates 38%

College degree or beyond 19%

Household Income <= $30,000 (%) 35%

Currently a dual-user 51%

N %

To use when I can't smoke cigarettes 8 7

To help me quit smoking tobacco cigarettes 87 71 To help me cut down the amount of tobacco cigarettes I smoke 4 3

To help control my cravings for tobacco cigarettes 4 3 Because of health concerns associated with tobacco cigarettes 5 5

Because of health concerns due to my cancer diagnosis 6 5

I was curious about them 1 1

Recommendations from family/friends 0 0

Recommendations from oncology provider 2 2

To deal with stress or to control my mood 1 1

Other 2 2

0 1 2 3 4 5 6

Recommended by Oncology Provider

Negatively Impact Cancer Treatment

Relieve Stress Related to CancerDiagnosis

Healthy Alternatives to Smoking

Less Addictive Than Cigarettes

Useful for Quitting Smoking

E-CigaretteNRT

***

***

***

*p<.05 , ***p<.001

*

0 1 2 3 4 5 6 7

Experience Cravings

Expensive

Addictive

Help with Anxiety/Worry

Good for Dealing w/ Stress

Taste Good

Satisfying

Satisfies Nicotine Cravings

Convenient

E-CigaretteNRT

***

***

***

***

***

***

***

***

***

*p<.05, **p<.01, ***p<.001

0 1 2 3 4 5 6 7

People Think Less of Me

Hazardous to Health

Experience Cravings

Expensive

Addictive

Help with Anxiety/Worry

Good for Dealing w/ Stress

Taste Good

Satisfying

Convenient

E-CigaretteCigarette

***

***

***

***

***

***

***

***

***

***

*p<.05, **p<.01, ***p<.001

Did your oncology provider… Did your primary care provider…

Ask whether you use e-cigs? 24% Ask whether you use e-cigs? 33%

Advise you to quit e-cigs? 17% Advise you to quit e-cigs? 22%

Ask if you wanted to quit e-cigs?

11% Ask if you wanted to quit e-cigs?

19%

ASK about tobacco USE

ADVISE tobacco users to QUIT

ASSESS readiness to make a QUIT ATTEMPT

ASSIST with the QUIT ATTEMPT

ARRANGE FOLLOW-UP care

5A’s of Tobacco Intervention

What is your oncology provider's perspective on the use of e-cigarettes to quit smoking?

70% - I don’t know, it was never discussed

1 .Comfortable talking to your oncology provider about e-cigs

2. Would like to learn more about e-cigs from your oncology provider

3. It’s important to discuss e-cigs with your oncology provider

If your patient is willing to quit…

Evidence-based cessation treatments should be

recommended and provided when possible.

If your patient is not willing to quit…

Urged to smoke combustibles as little as possible and recommend one of the many FDA-approved

NRTs

If your patient asks about e-cigarettes…

Let them know that the long term effects of e-cigs are unknown, but

they are likely much safer than combustible cigarettes.

“If you use e-cigs your health will likely improve if you significantly reduce combustible smoking and

eventually quit”

Fiore , M.C., Schroeder, S.A., & Baker, T.B. (2014) Smoke, the Chief Killer — Strategies for Targeting Combustible Tobacco Use. New England Journal of Medicine, 370 (4), 297-299.

Research is needed to evaluate the safety and efficacy of e-cigarettes as a cessation treatment in cancer patients to help guide clinical practice

• Thomas Brandon, PhD

• Vani Simmons, PhD

• David Drobes, PhD

• Steve Sutton, PhD

• Karen Brandon, PhD

• Marina Unrod, PhD

• Cathy Meade, PhD, RN

• Gwendolyn Quinn, PhD

• Lisa Sloan, TTS

• Chad Steen, BA

• Alina Hoehn, BA