OCTOBER 2014 DELHI PSYCHIATRY JOURNAL Vol. 17 No. 2 Commentary E-Cigarette in Tobacco Cessation — A misnomer ‘Shruti Srivastava, M.S. Bhatia Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Ditshad Garden, Deihi-110095 Contact: Shruti Srivastava, Email: srivastava_shruti@ hotmail.com Background WHO Framework Convention On Tobacco Control (2013) reports that 63% of all deaths worldwide, are due to Non-communicable diseases (NCD), killing 36 million people each year 86% of premature deaths from NCD occurs in developing countries, tobacco being a significant contributor. One third of world population-2.3 billion people are covered by at-least one effective tobacco control measure, additional three billion are covered by national mass media campaign. Tobacco kills six million people and more than half a trillion dollar of economic damage each year. WHO Framework Convention of Tobacco Control recognizes the substantial harm caused by tobacco use and need to prevent it. Tobacco will kill one billion people in this century if not prevented. The Report focuses on enforcing ban on tobacco advertising, promotion and sponsorship. ‘There are growing deleterious health concerns related to the use of smoked and smokeless products of tobacco Electronic cigarettes(e-cigarettes) is anew introduction in the recent years which claims to be less hazardous than the otherwise existing co. The liquid in e-cigarettes (commonly referred to as ‘e-liquid’ or ‘e-juice’) is forms of toba formulated to contain a mixture of chemicals, nicotine in some products. Nicotine used for e-cigarettes can be chemically extracted from tobacco plants or tobacco dust." ‘An e-cigarette generally contains a battery, an atomiser and a cartridge. Typically, the cartridge is ‘wrapped in a plastic bag. The sale of e-cigarettes has grown world- wide in general population. Advertising claims on branded e cigarettes retail websites from United States show that Ninety-five percent of the websites made explicit or implicit health-related claims, 64% had a smoking cessation-related claim, 22% featured doctors, and 76% claimed that the product does not produce secondhand smoke. Comparisons to cigarettes included claims that e-cigarettes were cleaner (95%) and cheaper (93%).* No studies formally evaluated the environmental impacts of the manufacturing process or disposal of components, including batteries. Some e-cigarette manufacturers claim their e-cigarettes are ‘eco- friendly’ or ‘green’, despite the lack of any supporting data or environmental impact studies as reviewed recently.” In India, there is easy availability of e cigarettes from retailers and also online through several websites, They often attract the young population by advertisements promoting them to be smokeless and some sites even offering free trials Current Scientific evidence on electronic cigarettes A recent study on 1074 participants included smokers (patients with cancer) who recently enrolled in a tobacco treatment program at a comprehensive cancer center found 3-fold increase in E-cigarette use was observed from 2012 to 2013, E-cigarette users were more nicotine dependent than nonusers, had more prior quit attempts, and were more likely to be diagnosed with thoracic and head or neck cancers. Using an intention-to-treat analysis, E-cigarette users were twice as likely to be smoking at the time of follow-up as nonusers." A recent review article reported limited evidence for the effectiveness on the use of €- cigarettes on tobacco cessation on compiling data from 1946 till March 2014.In small studies, e- cigarettes significantly decreased desire to smoke, Delhi Psychiatry Journal 2074; 17:(2) © Delhi Poychiatris Society ‘BIDELHI PSYCHIATRY JOURNAL Vol. 17 No. 2 OCTOBER 2014 number of cigarettes smoked per day, and exhaled carbon monoxide levels. Symptoms of nicotine withdrawal and adverse effects were variable. The most common adverse effects were nausea, headache, cough, and mouth/throat irritation, Compared with nicotine patches, e-cigarettes were associated with fewer adverse effects and higher adherence. Most studies showed a significant decrease in cigarette use acutely; however, long- term cessation was not sustained at 6 months.” A research article examined if e-cigarette liquid alters human young subject airway epithelial functions such as inflammatory response (IL-6) and host defense against respiratory viral (ie., human thinovirus, HRV) infection. The study found that nicotine-free ¢-liquid promoted IL-6 production and HRV infection. Addition of nicotine into -liquid further amplified the effects of nicotine-tree e- liquid.” Glycerin (VG) and propylene glycol (PG) are the most common nicotine solvents used in c- It has been shown that at high temperatures both VG and PG undergo decompo- sition to low molecular carbonyl compounds, including the carcinogens formaldehyde and acetaldehyde. The authors after taking samples from commercially available e cigarettes found that vapors from EC contain toxic and carcinogenic carbonyl compounds, Both solvent and battery output voltage significantly affect levels of carbonyl compounds in EC vapors. High-voltage EC may expose users to high levels of carbonyl compounds." Another in vitro study demonstrated that menthol additives of e-smoking had harmful effects on human periodontal ligament fibroblasts."” A small retrospective study indicates that regular use of e-cigs to substitute smoking is associated with objective and subjective improve- ments in asthma outcomes.” A longitudinal study of electronic cigarette users based on internet survey from 2011 to 2013 was done to assess behavior change over 12 months in users of e-cigarettes (“vapers”). The authors assessed use of e-cigarettes and tobacco among the same cohort at baseline, after one month (n=477) and one year (n=367)."" 72% were former smokers, and 76% were using e-cigarettes daily. At baseline, current users had been using e-cigarettes for 3 months, took 150 puffs! cigarettes day on their e-cigarette and used refill liquids containing 16 mg/ml of nicotine, on average. Almost all the daily vapers at baseline were still vaping daily after one month (98%) and one year (89%). In daily vapers, the number of puffs/day on e-cigarettes remained unchanged between baseline and one year In dual users who were still smoking at follow-up, cigarette consumption decreased by 5.3 cig/day after ‘one month (from 11.3 to 6.0 cig /day, p=0,006), but remained unchanged between baseline and 1-year follow-up."* Awareness and determinants of electronic cigarette use among Finnish adolescents in 2013 in population-based National survey of 12-18- year-old. Finnish adolescents in 2013 (N=3535, response rate 38%).Of the respondents, 85.3% knew what € cigarettes were; 17.4% had tried them. E-liquids with nicotine were used most often (65.7%); also those who had never tried conventional cigarettes had used them. Of e-cigarette ever users, 8.3% had never tried smoking. Parents’ high level of education, being in employment, and intact family protected against children’s e-cigarette use. Daily smoking, snus use, water pipe use, children’s vocational education and poor school performance were associated with e-cigarette experimentation. Those smokers with most experience of e-cigarettes were least likely to consider smoking cessation. A randomized controlled trial (RCT) carried out in New Zealand, between 2011 and 2013 randomized 657 people (289 to nicotine e — cigarettes,295 to patches, and 73 to placebo e-cigarettes).At six months, abstinence was 7.3% with nicotine — cigarettes,5.8% with patches, and 4.1% with placebo e-cigarettes, no superiority observed, no significant adverse events." A US. population survey with 2 national probability sample (n=10,041) was used to assess ever use and current use of regular cigarettes, e- cigarettes, and U.S. Food and Drug Administration- approved pharmacotherapy for smoking cessation, Individuals with Mental Health Conditions (MHC) were more likely to have tried e-cigarettes (14.8%) and to be current users of e-cigarettes (3.1%) than those without MHC . Ever smokers with MHC were also more likely to have tried approved pharmacotherapy and to be currently using these products (9.9% vs. 3.5%, p<0.01) than those without ‘MHC. Additionally, current smokers with MHC were Be Dalhi Psychiatry Journal 2014; 17(2) © Dalhi Psychiatrie SocietyOCTOBER 2014 DELHI PSYCHIATRY JOURNAL Vol. 17 No. 2 more susceptible to future use of e-cigarettes than smokers without MHC.” In a prospective twelve month study on schizophrenic smokers, 50% reduction in the number of cigiday at week-52 was shown in 7/14 (50%) participants; their median of 30 cigiday decreasing significantly to 15 cigiday (p=0.018). The use of e- cigarette substantially decreased cigarette ‘consumption without causing significant side effects in chronic schizophrenic patients who smoke not intending to quit." A recent study provided the first evidence in a controlled setting that electronic cigarette exposure may evoke smoking urges in young adult daily smokers. Smoking desire and urge ratings were measured with visual analogue scale items for desire for a regular and an e-cigarette and the Brief Questionnaire of Smoking Urges.” Because e-cigarettes lack many of the sub- stances found in regular tobacco, they are often perceived as a safer smoking alternative, especially in high-risk situations such as pregnancy. However, studies suggest that itis exposure to nicotine that is most detrimental to prenatal development. The authors studied perceptions of tobacco and e- cigarette health risks using a multiple-choice survey. To study the perceived safety of e-cigarettes versus tobacco cigarettes, 184 modified Global Health ‘Youth Surveys (WHO, http:/Avww.who int/tobacco/ surveillance/gyts/en/) were completed electronically or on paper. Age range, smoking status, and perceptions about tobacco cigarettes and e- cigarettes were studied, The results vetified that younger people use e-cigarettes more than older people. Tobacco cigarettes were perceived as more harmful than e-cigarettes to health in general, including lung cancer and pregnancy. Although more research is necessary, the authors postulate that the perception that e-cigarettes are safer during pregnancy may induce pregnant women to use these devices more freely. Given that nicotine is known to cause fetal harm, pregnant mothers who smoke e-cigarettes could cause even greater harm to the fetus because e-cigarettes are perceived as being safer than tobacco cigarettes.”” A review of Forty-four articles about the effects of e-cigarettes on human health showed that E- cigarette aerosols may contain propylene glycol, alycerol, flavourings, other chemicals and, usually, nicotine. Aerosolised propylene glycol and glycerol produce mouth and throat irritation and dry cough. No data on the effects of flavouring inhalation were identified. Acrosol exposure may be associated with respiratory function impairment, and serum cotinine levels are similar to those in traditional cigarette smokers. The high nicotine concentrations of some products increase exposure risks for non-users, particularly children, The dangers of secondhand and third hand aerosol exposure have not been thoroughly evaluated.” Impact of tobacco via movies in India ‘Smoking/tobacco use has increased significantly to 89% among all movies released in 2004 and 2005, The brand placement has been also increased nearly three folds. Tobacco brands now appear in 46% of, movies having tobacco scenes. Cigarette companies have almost all the tobacco product placements with ‘two companies accounting for over 90% of the brand visibility. 75% of movies having tobacco also showed the main/lead character consuming tobacco. The instances of females consuming tobacco in movies has also increased in India pointing towards a specific market expansion strategy by tobacco companies using movies as a vehicle.” Influence of tobacco advertising from India Tobacco companies target middle and low income countries. Exposure to tobacco advertise- ments and receptivity to tobacco marketing were related to increase tobacco use among students in a questionnaire based study on 6% to 8® standard students from 2 cities (n=11642) from 32 schools in 20048 Perceptions about plain tobacco packs Plain packaging would reduce the appeal and promotional value of the tobacco pack (>80%), prevent initiation of tobacco use among children and youth (>60%), motivate tobacco users to quit (80%), increase notice ability, and effectiveness of pictorial health warnings on tobacco packs (290%), reduce tobacco usage (75% of key stakeholders) with 346 participants, Delhi. Promotion tactics of companies manufacturing e-cig Health claims and smoking-cessation messages Delhi Psychiatry Journal 2014; 17:(2) ® Delhi Poychiatris Society 3DELHI PSYCHIATRY JOURNAL Vol. 17 No. 2 OCTOBER 2014 that are unsupported by current scientific evidence are frequently used to sell e-cigarettes. The presence of doctors on websites, celebrity endorsements, and the use of characterizing flavors should be prohibited. E ~ Cigarettes launched in India Indian companies are witnessing loss in profits due to constant rise in prices of conventional cigarettes. They have started investments in E- cigarettes segment, will be rolled out pan-India in phases according to press release. The products are currently being manufactured in China.* ‘The main hurdle which is anticipated is that these new products are not subjected to regulations under the Cigarettes and Tobacco Products Act and can bbe consumed, marketed and sold like any consumer product Tobacco cessation and Total ban on e- cigarettes WHO (2008) identified six evidence-based tobacco control measures that are effective in reducing tobacco use abbreviated as “MPOWER”, M-’ Monitor tobacco use and prevention policies, P - Protect people from tobacco smoke © - Offer help to quit tobacco use W- Warn people about the dangers of tobacco use E -Enforce bans on tobacco advertising , promotion and sponsorship R - raise taxes on tobacco. ‘Tobacco cessation ~ Policies (WHO Framework Convention on Tobacco Control) Robust supporting data and evidence, the WHO FCTC recognizes that meaningful tobacco control must include + the elimination of all forms of tobacco adver- tising, promotion and sponsorship(TAPS). + This goal is so critical that Article 13 (Tobacco advertising, promotion and sponsorship) is one of only two provisions in the treaty that includes a mandatory timeframe for implementation. Tobacco cessation ~ Policies (WHO Framework Convention on Tobacco Control) All Parties must implement a comprehensive TAPS ban (or restrictions in accordance with its constitution if a comprehensive ban would violate its constitutional principles) within five years after the entry into force of the treaty for that Party. The requirement includes domestic TAPS activities, as ‘well as all cross-border TAPS activities that originate within a Party's territory. India regulations No brand names of tobacco products or tobacco product placement may be shown, close- ups of tobacco products and packaging are prohibited, and promotional materials such as movie posters may not depict tobacco use. These rules also assign responsibility for implementation to cinema owners or managers and television broadcasters, with penalties for violations including suspension or cancellation of licenses. National Tobacco Control Programme + Government of India initiated the National Tobacco Control Programme in 2007-08 as the first national program for tobacco control + The program mandates implementation of different tobacco control initiatives at the national, state and district levels, encompa- ssing law enforcement, awareness campaigns, training, and monitoring and evaluation, including surveillance. + Another component of the program is to provide tobacco cessation services in the primary health care system. + The district is the basic administrative unit for many public health services in the country and is responsible for the development of tobacco cessation services (with the state’s technical support) in general hospitals, TB hospitals, regional cancer centres, teaching colleges and other institutions.** 275 million adults(15 years and above) use tobacco in India.** Global Adult Tobacco Survey, India,2009-2010 reports cross-sectional data having 25,175 ever tobacco users aged 21 years and above, Of the ever tobacco users, 10,513 (42%) made an attempt to quit, 4395(42%) were successful, Significant associations were demonstrated between male gender, increasing Be Dalhi Psychiatry Journal 2014; 17:(2) © Delhi Psychiatric SociotyOCTOBER 2014 DELHI PSYCHIATRY JOURNAL Vol. 17 No. 2 educational attainment higher asset quintiles for both those who attempted to quit and those who were successful. Younger age groups had higher odds of quit attempts than all except the oldest age group, but also had the lowest odds of successful quitting.” Obstacles removed if the will is strong both political, professional and public will should be strong to eradicate harmful tobacco use, Legal challenges have been used to obstruct and delay tobacco control measures by a decade in implementation of “The Cigarettes and Other Tobacco Products Act” in India India according to WHO report, largest ptoducer of movies, have taken action ton to reduce tobacco imagery in films and television. Regulations put into effect in 2011, 2012 now require films and television programmes depicting tobacco use to show 2 30-second anti-tobacco spot at the beginning and middle, as well as a prominent static message at the bottom of the screen during scenes with tobacco use. New films and television programmes must justify depictions of tobacco use and include disclaimers at the beginning and middle of the film about the harmful effects of tobacco. Government of India is considering a ban on the sale of electronic cigarettes. An expert panel on e-cigarettes constituted by the health ministry has recommended a blanket ban on the product, saying its safety has not been established.” Banning ECs seems to be the most plausible approach at present.” However, in the long run, India should be open to new research.” References 1, World Health Organization Framework Con- vention on Tobacco Control. 2013. http:// ‘www.who.in/fctcfen/ (accessed 23 May 2013). 2. Tobacco Free Initiative. Tobacco: Deadly in Any 1m or Disguise. World Health Organisation; Geneva: 2006. at hitp://www.who.inttobacco/ communications/events/wntd/2006/ ‘Tii_Rapport pdf [25 March 2011] de Luca A, Cafiizares P, Garcia MA, et al. 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