Quick facts about E-cigarettes for mental health and addiction clinicians and administrators Mary.f.brunette@dartmouth.edu Associate Professor of Psychiatry, Geisel School of Medicine 2015

What are E-Cigarettes? Plastic or metal device that delivers vapor Sensor detects when smoker takes a drag Heater vaporizes liquid and nicotine Microprocessor controls heater and light Cartridge holds nicotine dissolved in propylene glycol LED lights up when smoker inhales Battery Stream inhalation Plastic or metal device that delivers vapor Many types and brands, new ones emerging all the time E-juice has varying strengths from 0 nicotine to high levels of nicotine Typical cartridge = about 2 packs of cigarettes worth of nicotine Other substances can be added to tank style cigarettes First manufactured in China in 2003. Device resembling cigarette with a battery, microchip, red LED tip, cartridge with liquid (nicotine in propylene glycol), vaporization chamber (produces an aerosol) Mechanical sensor detects inhalation and triggers the microchip controlling the heater which raises the temp in the vaporization chamber, which generates the aerosol (vapor), which condenses quickly in ambient air into visible fog Size of the aerosol particles in ecigs is bigger so often is absorbed in the mouth, not the alvioli in the lungs

E-cigarette safety As of 2015, toxins in vapor of tested brands of e-cigarettes were 8-600 times lower than levels of toxins in cigarette smoke (Goniewitz, 2014; Rabinowitz 2014) Nicotine is addictive but not toxic in cigarettes doses Nicotine e-juice is concentrated – an irritant and harmful if taken as overdose Most e-cigarette products have not been tested for safety Some of the flavorings added to e-juice are toxic Like alcohol and cigarettes, the FDA does not yet monitor the safety of these products

Who is using e-cigarettes and what are the implications? In children, use of e-cigarettes is associated with using other combustible tobacco products (Collaco 2015) In adults, use of e-cigarettes is most common among cigarette smokers who wish to cut down/quit/be healthier (Cummins 2014; Wang 2016) Naturalistic use of e-cigarettes was not associated with different cessation outcomes in studies of people with mental illness who were trying to quit - didn’t help or harm outcomes (Prochaska 2014; Brunette 2016) Controlled trials suggest that e-cigarettes are equivalent to NRT for smoking cessation (McRobbie 2014)

What should clinicians do? Find out people’s reasons for using e-cigarettes Educate people using e-cigarettes about the facts Support people’s efforts to quit smoking with evidence-based cessation treatments Teach people behavioral cessation strategies Ebbert, 2015

Summary: 4 facts about e-cigarettes E-cigarettes are devices that can deliver nicotine in vapor Kids are experimenting with e-cigs before combustible cigarettes; adult chronic smokers are using e-cigarettes to cut down, avoid toxins in smoke, and to quit Some brands of E-cigarette vapor have lower levels of toxins than cigarette smoke, but some flavorings are clearly toxic. Overall safety is unknown as of January 2016 Clinicians can provide education and evidence based cessation treatment to smokers who are using e-cigarettes to try to cut down and quit

references Ebbert JO, Agunwamba AA, Rutten LJ. Counseling patients on the use of electronic cigarettes. Mayo Clin Proc. 2015;90(1):128-34. PMID: 25572196. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014; PMID: 25515689. Prochaska JJ, Grana RA. E-Cigarette Use among Smokers with Serious Mental Illness. PloS one. 2014;9(11):e113013. PMCID: Pmc4242512. Wang M, Wang JW, Cao SS, Wang HQ, Hu RY. Cigarette Smoking and Electronic Cigarettes Use: A Meta-Analysis. Int J Environ Res Public Health. 2016;13(1). PMID: 26771624.