Implications of E-cigarettes for Behavioral Health: Insights and Guidelines

1. Implications of E-cigarette for Behavioral Health Populations Sharon Cummins, Ph.D. UCSD

2. Disclaimer • Not FDA approved • Unknown safety profile • Insufficient data on efficacy • Not endorsing or suggesting you recommend

3. 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

4. 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

5. 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”

6. Most Important reason? • Credibility

7. 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

8. 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

9. E-cigarettes and behavioral health • It’s already happening • High consumers of cigarettes • E-cigarettes are most salient to smokers • Bring data to bear

10. 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

11. Methods • Family Physicians (N=21) from Family Medicine Department at the UCSD School of Medicine • Cessation counselors (N=57)

12. Patient/client interest

13. Beliefs About Health Risks

14. Beliefs About Effectiveness

15. Beliefs About Regulation

16. 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

17. 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

18. 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?

19. 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

20. 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?

21. Implications • Beneficial? • Decrease cigarettes • Increase quitting • Detrimental? • Maintain smoking • Delay quitting • Tobacco Control Policy • Accessibility • Pricing • Advertising

22. 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

23. Mental Health Condition by Smoking Status

24. Use of E-cigarettes

25. Ever Use of E-cigarettes by Smoking Status † smokers who quit more than 12 months prior to survey ‡ smokers who quit within 12 months of taking the survey

26. Reasons for Using E-cigarettes

27. Susceptibility to Using E-cigarettes

28. 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

29. Clinical Implications • Encourage long-term use? • Encourage short-term use? • Discourage any use?

30. Things to think about • Absolute risk • Relative risk • Your own risk tolerance • Likelihood of quitting without it • Patient’s belief • Your goal

31. Questions? • scummins@ucsd.edu