1. Norris Cotton Cancer CenterJames Sargent MD Professor of Pediatrics Geisel School of Medicine at Dartmouth James Sargent MD Professor of Pediatrics Geisel School of Medicine at Dartmouth E-cigarettes for Physicians

2. Norris Cotton Cancer CenterJames Sargent MD Cigarette Smoking is Very, Very Bad Highlights of the 2014 Surgeon General's Report on Smoking and Health 20 million people have died since 1964 from smoking-related illnesses. 5.6 million children alive today will die prematurely from smoking if current smoking rates persist. That's 1 in 13 children in this country. Smokers today have a greater risk of developing lung cancer than they did in 1964, even though they smoke fewer cigarettes Because of changes in the design and composition of cigarettes Report calls for an end to the use of cigarettes How do we accomplish that?

3. Norris Cotton Cancer CenterJames Sargent MD William Dunn—Chief Scientist PM

4. Norris Cotton Cancer CenterJames Sargent MD

5. Norris Cotton Cancer CenterJames Sargent MD

6. Norris Cotton Cancer CenterJames Sargent MD E-cigs—Delivering Nicotine to Smokers

7. Norris Cotton Cancer CenterJames Sargent MD Vapor vs. Smoke—No Tar, No CO Electronic Cigarette Vapor Nicotine Vapor component Propylene glycol Glycerol Flavor components Contaminants e.g., oils, heavy metals Cigarette Smoke Nicotine Tar component Particulate matter Phenol Tobacco-specific nitrosamines Volatile chemicals Formaldahyde Benzene Heavy metals Gasses Carbon monoxide Hydrogen cyanide

8. Norris Cotton Cancer CenterJames Sargent MD Types of E-Cigs E-cigarettes are distinguished by the following features: How you refill them Disposable Rechargeable Technology Atomizer Microprocessor technology

9. Norris Cotton Cancer CenterJames Sargent MD Disposable

10. Norris Cotton Cancer CenterJames Sargent MD Rechargeable (Tanks) Small FirmsVape Shops

11. Norris Cotton Cancer CenterJames Sargent MD Studies—(of about 50 published) Chemical Juice Vapor Toxicological Behavioral Epidemiological

12. Norris Cotton Cancer CenterJames Sargent MD E-cig Levels of Various Toxic Substances 10-500 times Lower than Cigarettes Goniewicz et al, Tob Control 2013

13. Norris Cotton Cancer CenterJames Sargent MD Chemical studies Passive vaping Schripp et al, Indoor Air 2013

14. Norris Cotton Cancer CenterJames Sargent MD Nicotine Delivery

15. Norris Cotton Cancer CenterJames Sargent MD Quitting--Adults

16. Norris Cotton Cancer CenterJames Sargent MD Toxicity—Case Reports

17. Norris Cotton Cancer CenterJames Sargent MD Scenario – 15% global prevalence by 2050 The Public Health Endgame—Clive Bates Billon Adults >15 years

18. Norris Cotton Cancer CenterJames Sargent MD Scenario – 15% global prevalence by 2050 The Public Health Endgame—Clive Bates Billon Adults >15 years

19. Norris Cotton Cancer CenterJames Sargent MD HARM The Public Health Endgame—Clive Bates Billon Adults >15 years

20. Norris Cotton Cancer CenterJames Sargent MD The Public Health Endgame—Clive Bates Billon Adults >15 years

21. Norris Cotton Cancer CenterJames Sargent MD The endgame – a nicotine product contest? Billon Adults >15 years

22. Norris Cotton Cancer CenterJames Sargent MD The endgame – a nicotine product contest? Billon Adults >15 years Dual Use

23. Norris Cotton Cancer CenterJames Sargent MD The endgame – a nicotine product contest? Billon Adults >15 years Dual Use Recruitment of intermediate risk adolescents

24. Norris Cotton Cancer CenterJames Sargent MD Summary Statement Electronic cigarettes: here to stay They contain many fewer toxins than cigarettes The industry is rapidly evolving FDA has issued “deeming” documents for e-cigs They will eventually be regulated The big question is how?

25. Norris Cotton Cancer CenterJames Sargent MD E-CIGARETTES AND ACCOUNTABLE CARE Why ACOS Should Care How E-cigs Could Change the Game

26. Norris Cotton Cancer CenterJames Sargent MD ACO--Aim The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

27. Norris Cotton Cancer CenterJames Sargent MD ACO—Consequences of success When an ACO succeeds both in both delivering high- quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

28. Norris Cotton Cancer CenterJames Sargent MD

29. Norris Cotton Cancer CenterJames Sargent MD How Will ACOs Be Judged?

30. Norris Cotton Cancer CenterJames Sargent MD

31. Norris Cotton Cancer CenterJames Sargent MD

32. Norris Cotton Cancer CenterJames Sargent MD Harm Reduction—E-cigs could be a game-changer Certain patient groups stand to benefit greatly by switching to e-cigarettes Smokers with COPD Smokers with diabetes Smokers with coronary artery disease Smokers with cancer Smokers with lung nodules Testing aspirin as a tumor growth inhibiter Why not e-cigarettes? Cigarettes contain many cancer promoters

33. Norris Cotton Cancer CenterJames Sargent MD Problem—Nothing is known We need Phase 1 trials for to explore: The proportion of these patients that can successfully switch to e- cigarettes The short term effects on medical outcomes Lung function—COPD and Asthma Diabetes complications Cardiovascular function—Heart disease Tumor nodule growth—lung nodule patients The short term effects on health costs