The Evolution of State Quit Tobacco Services: Adaptation or Stagnation

1. The Evolution of State Quit Tobacco Services:  Adaptation or Stagnation ARE YOU READY?

2. Kathi Wilson Tobacco Cessation Coordinator Wyoming Department of Health Mental Health and Substance Abuse Services Division kathi.wilson@health.wyo.gov

3. I want it noted that the following presentation is strictly based on my experience supervising the Wyoming Tobacco Cessation Service, plus research that I have found on line and by talking with others who are the “experts” in the field of tobacco cessation. This presentation is to prompt discussion about tobacco cessation services and how our quitlines/web-based services need to adapt and grow with the ever changing tobacco/nicotine products and the consumers using them. Kathi Wilson

4. In the beginning….. In 1992 California was the first state quitline in the US, “California Smoker’s Helpline”

5. Seventeen years later we have 1-800-QUIT-NOW coverage in all 50 states.

6. Since tobacco cessation first began scientific research has continually uncovered data about the health effects of using tobacco. Combine this with new tobacco and nicotine products that are continually introduced to the consumer market, the emergence of dual or multi users, and possibly one day a consumer that is strongly addicted to nicotine who has never used a tobacco product = confusion…..

7. hat does this mean for state quitlines/web- based services or state tobacco cessation services? • As Quitlines/counselors/ educators are we researching how new products can influence our participants success rate within our programs?

8. Potential Adverse Effects Of Nicotine Nicotine Intoxication Delayed Wound Healing Low Birth weight Hypertension Stroke Peptic Ulcer Disease Sudden Death Fetal Neurotoxicity Esophageal Reflux • Symptoms of nicotine poisoning: • Abdominal cramps Coma • Agitation Confusion • Restlessness or excitement Convulsions • Muscular twitching Depression • Rapid breathing Difficulty breathing • Breathing stops Drooling • Burning sensation in mouth Headache • Fainting High Blood Pressure • Heartbeat-pounding Vomiting and weakness. • http://health.nytimes.com/health/guides/poison/nicotine/overview.html

9. Nicotine is such a poisonous substance that one drop of pure nicotine would kill a grown person. It is so poisonous that it can be used as a pesticide on plants. http://www.adapp.org/Documents/nicotine and Tobacco... If you dip, 2.0 mg. - 3.5 mg of nicotine per dip enters your bloodstream, twice the dose delivered by a standard 1mg cigarette. Users who consume 8 to 10 dips or chews per day (one-third-1/2 of a can of snuff or 1.3 - 1.2 of a pouch per day) receive a NICOTINE DOSE equal to that taken by a heavy cigarette smoker (30-40 cigarettes daily). A recent report indicates that users who went through two cans of snuff per week had a saliva nicotine level equal that of people smoking two packs of cigarettes per day. http://www.trytostop.org/quitting-smoking/products.html

10. These are only some of the new products that can be found….. Camel Snus: RJ Reynolds Tobacco Co., available in three flavors, attractive cans (cell phone shaped), sold cold for “freshness”, 8 mg of nicotine in each pouch and does not have to be spit out. Camel Sticks/Orbs/Strips: "It's meeting the needs of smokers," says Rob Dunham, of R.J. Reynolds, maker of Orb and Camel cigarettes. With lozenge-like Orb, he says there's no smoke, no spit, no litter.” Made from finely ground flavored tobacco, the products melt in the mouth within 3 to 30 minutes. Camel dissolvables are said to deliver about 0.6 to 3.1 mg of nicotine each.

11. Marlboro Snus: Use “flavor strip technology” and dried tobacco. 6.33 mg up to 7.61 mg of nicotine with four flavors to choose from. Revved Up: Developed by two Marines, Revved Up is a smokeless tobacco infused with energy elements, similar to Red Bull. Developed to combat fatigue in troops, patented and sold by Southern Smokeless Tobacco. E-Cigarette: The Food and Drug Administration released an analysis of 19 varieties of electronic cigarettes that said half contained nitrosamines (the same carcinogen found in real cigarettes) and many contained diethylene glycol, the poisonous ingredient in antifreeze. Some that claimed to have no nicotine were found to have low levels of the drug. The devices are available in more than 4,000 retail outlets nationwide, as well as on many Web sites, with a starting cost of $40 to $70. Over the past year, sales have grown from about $10 million to $100 million, according to the Electronic Cigarette Association, the industry’s trade group. They also come in a variety of flavors, including chocolate, mint and apple, which make them appealing to children and adolescents. By THOMAS H. MAUGH II LOS ANGELES TIMES Aug. 19, 2009, 1:18PM

12. Nico-Water: "Nicotine water runs a serious potential of both being hazardous and serving as a first step into addiction with children," says Matthew Myers, president of the Campaign for Tobacco-Free Kids. 4 mg of nicotine per bottle. Nicoshot: Developed by a German Company, three cans of Nicoshot is comparable to an entire pack of conventional cigarettes. (3 cans = 1 pack of cigarettes) Larry Wald, the owner of the Cathode Ray Club, came up with the homemade brew as he searched for ways to help smokers cope with the new smoke-free atmosphere Florida voters ordered last fall. Soak tobacco leaves in vodka overnight, deaden the juice's harshness by adding a couple other liquors and voila: the nicotini of Las Olas. Nicotini:

13. xamples: 8-10 dips /day = ½ can = 40 mg nicotine = 2 packs of cigarettes (average) 1 can = 80 mg nicotine = 4 packs of cigarettes (average) Example One: If a person uses ½ can of tobacco/day (40 mg) of nicotine PLUS Camel stick (3.1mg) X 3/day = (9.3 mg) of nicotine TOTAL: 49.3 mg of nicotine per day (average) Example Two: Smokes one pack of cigarettes/day = (20 mg) of nicotine PLUS Marlboro Snus (6.33) X 2 pouches/day = (12.66 mg) of nicotine TOTAL: 32.66 mg of nicotine per day (average)

14. s Quitlines, if we do not gather the correct or enough information about ALL of the products people are using, we could be setting them up for relapse, nicotine toxicity and improper use of cessation medications. Plus, we loose an opportunity to educate about these “other” products and nicotine addiction.

15. hat does this mean for state quitlines/web-based services? • Are we excluding certain tobacco users from our programs by the images/wording we use? • (Are messages clear?)

16. “Smoke Free” vs. “Tobacco Free” In recent years we have recognized the need to replace the word “Smoke Free” with the word “Tobacco Free”, to cover all other forms of tobacco use…… In light of all the new laws that have passed prohibiting smoking in public areas, increased tobacco taxes and new products available at the consumer market………the new catch phrase may now need to be……. “Nicotine Free”

17. “Nicotine Free” nicotine and tobacco products “Tobacco Free” Accommodate for smokeless tobacco and other forms “SMOKE FREE” Smoking and secondhand smoke

25. This sign is still appropriate, but does not cover the use of all tobacco products. Would prefer it to say…”No Tobacco”. Logo may now be outdated ? How do we account for pouches or the cell phone shaped cans??

26. hat does this mean for state quitlines/web-based services? • As we provide these services are we matching the growth and knowledge of the tobacco companies, or are we still stagnant/out dated in our approach?

27. Recognizing state budget cuts and the challenges these restrictions impose on our quit services, we can and need to be creative to accommodate the needs of all of our tobacco/nicotine users. Wyoming has been taking a hard look at our services over the past months. We are interested to learn how other states are dealing with all these new challenges in the quest for the most comprehensive and effective quit tobacco program. In our efforts to adapt from Smoke Free to Tobacco Free in our scope of services, how or should we now move in the direction of Nicotine Free?

28. Throughout this presentation we have hinted about how messaging and promotion needs to fit the target population. “Tobacco is Tobacco”….”Nicotine is Nicotine”, no matter the package. So where is the universal “No Safe Tobacco icon?” Is this not the true message we want everyone to know?

29. Adaptation or Stagnation How are YOUR quitline/web based cessation services dealing with these new tobacco and nicotine products? How are you accommodating a consumer that is different from those of the past? How do we address new tobacco and nicotine products when talking about a quit attempt? Thank you