FORMS of TOBACCO

1. FORMS of TOBACCO

2. FORMS of TOBACCO Cigarettes Smokeless tobacco (chewing tobacco, oral snuff) Pipes Cigars Clove cigarettes Bidis Hookah (waterpipe smoking) Electronic cigarettes (“e-cigarettes”)* *e-cigarettes are devices that deliver nicotine and are not a form of tobacco. Image courtesy of the Centers for Disease Control and Prevention / Rick Ward

3. AMERICAN CIGARETTES Most common form of tobacco used in U.S. Sold in packs (20 cigarettes/pack) Total nicotine content, per cigarette: - Average 13.5 mg (range, 11.9 to 14.5 mg) Machine-measured nicotine yield: Smoker’s nicotine yield, per cigarette: - Approximately 1 to 2 mg Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc.

4. SMOKELESS TOBACCO Chewing tobacco Looseleaf Plug Twist Snuff Moist Dry The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

5. SMOKELESS FORMS of TOBACCO Estimated 9.0 million users in the U.S. in 2012 (3.5%) Adult males (6.7%) more likely than adult females (0.4%) to be current users Prevalence highest among Young adults aged 18-25 years Residents of the Midwest and Southern U.S. Residents of nonmetropolitan areas Significant health risks Numerous carcinogens Nicotine exposure comparable to that of smokers, leading to Physical dependence Withdrawal symptoms after abstinence

6. NICOTINE CONTENT in SMOKELESS TOBACCO PRODUCTS Data from Hatsukami et al. (2007). Am J Prev Med 33(6S):S368–78.

7. HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE Periodontal effects Gingival recession Bone attachment loss Dental caries Oral leukoplakia Cancer Oral cancer Pharyngeal cancer Oral Leukoplakia Image courtesy of Dr. Sol Silverman - University of California San Francisco

8. PIPE TOBACCO Prevalence of pipe smoking in the U.S. is less than 1% Pipe smokers have an increased risk of death due to: Cancer (lung, oral cavity, esophagus, larynx) Chronic obstructive pulmonary disease Risk of smoking tobacco-related death: cigarettes > pipes ≈ cigars

9. CIGARS Estimated 13.4 million cigar smokers in the U.S. in 2012 Tobacco content of cigars varies greatly One cigar can deliver enough nicotine to establish and maintain dependence Cigar smoking is not a safe alternative to cigarette smoking

10. CLOVE CIGARETTES (also known as KRETEKS) • Mixture of tobacco and cloves • Imported from Indonesia • In 2012, an estimated 3.0% of 12th graders in the U.S. reported smoking kreteks in the past year • Two times the tar and nicotine content of standard cigarettes

11. BIDIS Imported from India Resemble marijuana joints Available in candy flavors In 2010, an estimated 1.4% of 12th graders in the U.S. reported smoking bidis in the past year Deliver 3-fold higher levels of carbon monoxide and nicotine and 5-fold higher levels of tar when compared to standard cigarettes Image courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson

12. HOOKAH (WATERPIPE SMOKING) Also known as Shisha, Narghile, Goza, Hubble bubble Tobacco flavored with fruit pulp, honey, and molasses Increasingly popular among young adults in coffee houses, bars, and lounges In 2012, 18.3% of 12th graders and 25.7% of U.S. college students had smoked hookah in the past year Nicotine, tar and carbon monoxide levels comparable to or higher than those in cigarette smoke Image courtesy of Mr. Sami Romman / www.hookah-shisha.com

13. POTENTIALLY REDUCED-EXPOSURE PRODUCTS (PREPs) Tobacco formulations altered to minimize exposure to harmful chemicals in tobacco Cigarette-like delivery devices Eclipse, Heatbar Oral noncombustible tobacco products Ariva, Marlboro Snus, Stonewall, Camel Snus No evidence to prove that PREPs reduce the risk of developing tobacco-related disease

14. ELECTRONIC CIGARETTES • Battery operated devices that deliver vaporized nicotine • Cartridges contain nicotine, flavoring agents, and other chemicals • Battery warms cartridge; user inhales nicotine vapor or ‘smoke’ • Available on-line and in shopping malls • Not labeled with health warnings • Preliminary FDA testing found some cartridges contain carcinogens and impurities (e.g., diethylene glycol) • No data to support claims that these products are a safe alternative to smoking

16. ELECTRONIC CIGARETTES: Awareness and Use* among U.S. Adults (2010-2011) Percent King et al., Nicotine Tob Res 2013;15:1623–1627. *Use defined as having ever tried electronic cigarettes, even just one time.

17. ELECTRONIC CIGARETTES: Use* Among Middle and High School Students—U.S., 2011-2012 *Statistically significant difference between 2011 and 2012 (p<0.05). * * Percent * Centers for Disease Control and Prevention (CDC). (2013). MMWR 62:729–730. *Use defined as having ever used electronic cigarettes, even just one time.

18. ELECTRONIC CIGARETTES: Potential health risks – Propylene glycol • Primary ingredient in e-cigarettes for producing vapor • FDA has classified propylene glycol as“generally recognized as safe” for oral intake • Long-term effects associated with pulmonary inhalation are unknown • Limited studies suggest adverse effects on airways: • Short- and long-term exposure has been associated with respiratory tract irritation1,2 • Long-term indoor air exposure might exacerbate and/or induce asthma and rhinitis in children3 1Wieslander et al., Occup Environ Med 2001;58:649-655. 2 Moline et al., Equity-League Pension & Health Trust Funds 2000, pp 1-180. 3Choi et al., PLoS ONE 2010;5:e13423.

19. ELECTRONIC CIGARETTES: Potential health risks – Glycerin • Common ingredient in e-cigarettes for aerosol production • The FDA has classified glycerin as“generally recognized as safe” for oral intake • Long-term effects associated with pulmonary inhalation are unknown • Case report of exogenous lipoid pneumonia caused by glycerin-based e-cigarettes1 • 7-month h/o dyspnea, productive cough, fevers with 7-month history of e-cigarette use • Symptoms resolved following discontinuation of e-cigarettes 1McCauley et al., Chest 2012;141:1110-1113.

20. ELECTRONIC CIGARETTES: Potential health risks – Nicotine • Nicotine is highly addictive • Nicotine may cause adverse cardiovascular effects (increased HR, BP) and may impair endothelial function • Likely less harmful than nicotine delivered via combustion • Accidental poisoning, especially in children • Liquids in e-cigarettes typically contain 6-36 mg nicotine per mL • Lethal adult oral dose (40-60 mg); in children, 6 mg may be life-threatening • Calls to U.S. poison control centers for e-cigarette liquid exposures increased to 1,351 cases in 2013 (up 300% from 2012) with 365 hospital referrals; on pace to double in 2014.1 1http://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html

21. ELECTRONIC CIGARETTES: Potential health risks – Carcinogens1,2 • E-cigarette liquids contain small amounts of nitrosamines • E-cigarette aerosols contain the following carcinogens: • Formaldehyde, Acetaldehyde • Acrolein • Chromium, Nickel • Levels of most substances lower than found in conventional cigarettes • No safe level of exposure has been determined 1German Cancer Research Center (Ed). Electronic Cigarettes—An Overview. Heidelberg, 2013. 2Willams M et al., PLoS ONE 2013;8:e57987.

22. ELECTRONIC CIGARETTES: Potential health risks – Indoor air pollution1,2 • E-cigarettes are not emission-free • During vaping sessions, compounds and particles emitted into the indoor air include • Nicotine • Flavoring agents • Propylene glycol, glycerin • Heavy metals • Polycyclic aromatic hydrocarbons • Levels of most substances lower than conventional cigarettes • Long-term safety of second-hand exposure to e-cigarette aerosols is unknown 1German Cancer Research Center (Ed). Electronic Cigarettes—An Overview. Heidelberg, 2013. 2Schober et al., Int J Hyg Environ Health 2013: Dec 6 Epub ahead of print.

23. ELECTRONIC CIGARETTES: Potential health risks – Conclusions • Propylene glycol may cause respiratory irritation and increase the risk for asthma • Glycerin may cause lipoid pneumonia on inhalation • Nicotine is highly addictive and can be dangerous • Refill cartridges with high concentrations of nicotine are a poisoning risk, especially in children • Carcinogenic substances are found in some aerosols • Use of e-cigarettes leads to emission of propylene glycol, particles, nicotine, and carcinogens into indoor air Electronic cigarettes are not proven to be safe.

24. ELECTRONIC CIGARETTES: FDA Position

25. ELECTRONIC CIGARETTES: FDA Position • E-cigarettes have not been fully studied so consumers currently don’t know: • the potential risks of e-cigarettes when used as intended • how much nicotine or other potentially harmful chemicals are being inhaled during use • if there are any benefits associated with using these products • Additionally, it is not known if e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm

26. ELECTRONIC CIGARETTES: FDA Position, cont’d • FDA Regulation of e-Cigarettes • Only e-cigarettes that are marketed for therapeutic purposes are currently regulated by the FDA Center for Drug Evaluation and Research. The FDA Center for Tobacco Products currently regulates • cigarettes • cigarette tobacco • roll-your-own tobacco • smokeless tobacco • FDA intends to issue a proposed rule extending FDA’s tobacco product authorities beyond the above products to include other products like e-cigarettes. http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm

27. ELECTRONIC CIGARETTES: Summary of Current Evidence • E-cigarettes are predominantly used by smokers and smokers who are considering quitting • E-cigarettes are used as an alternative to cigarette smoking and as cessation aids because they are perceived as less harmful than conventional cigarettes • E-cigarette use by adolescents is increasing

28. ELECTRONIC CIGARETTES: Summary of Current Evidence, cont’d • E-cigarettes are not proven to be safe • Quality control for many products is lacking; consumers do not have reliable product information • E-cigarette liquids contain ingredients that may irritate airways and may be harmful when inhaled repeatedly over prolonged periods of time • Nicotine delivery with e-cigarettes is highly variable • Adverse health effects associated with second-hand vapor exposure cannot be excluded because e-cigarettes emit ultrafine inhalable particles and carcinogens into indoor air • Nicotine solutions used in e-cigarettes increase the risk of accidental nicotine poisoning

29. ELECTRONIC CIGARETTES: Summary of Current Evidence, cont’d • E-cigarettes can reduce the desire to smoke (craving) and reduce nicotine withdrawal symptoms • Some smokers reduce the number of cigarettes smoked or quit smoking as a result of using e-cigarettes • The efficacy of e-cigarettes as an aid for sustained smoking cessation has not been established

30. ELECTRONIC CIGARETTES: Possible Pros and Cons • PROS • Large proportion of current smokers switch andvaping is less harmful • Current smokers completely switch to vaping, then quit vaping • CONS • Gateway to smoking • Dual use (smoking + vaping) • Reduced quitting • Smoking is “normalized”

31. ELECTRONIC CIGARETTES: Recommendations for Clinicians • E-cigarette use by adolescents and adults who are current non-smokers should be discouraged • Until more is known about the potential risks, e-cigarettes should not be promoted as a safe alternative to smoking • Until long-term safety and efficacy data are available, recommend evidence-based, FDA-approved treatments (NRT, bupropion SR, varenicline, combination therapy) for cessation

32. ELECTRONIC CIGARETTES: Recommendations for Clinicians, cont’d • For smokers who are unable to quit using proven effective therapies, non-combusted nicotine-containing products (e-cigarettes) may be appropriate after patient-specific discussion of risks and benefits • In the absence of sufficient data, support legislative actions that: • include e-cigarettes in clean indoor air regulations • prohibit advertising that claims or suggests that e-cigarettes are effective smoking cessation devices

33. FORMS of TOBACCO: SUMMARY Cigarettes are, by far, the most common form of tobacco used in the U.S. Other forms of tobacco and nicotine delivery devices exist, and some are increasing in popularity. All forms of tobacco are harmful. The safety/efficacy of e-cigarettes is not established. Attention to all forms of tobacco is needed.