James Sargent MD Professor of Pediatrics Geisel School of Medicine at Dartmouth

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

2. 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. William Dunn—Chief Scientist PM

6. E-cigs—Delivering Nicotine to Smokers

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

8. Types of E-Cigs • E-cigarettes are distinguished by the following features: • How you refill them • Disposable • Rechargeable • Technology • Atomizer • Microprocessor technology

9. Disposable

10. Rechargeable (Tanks) Small Firms Vape Shops

11. Studies—(of about 50 published) • Chemical • Juice • Vapor • Toxicological • Behavioral • Epidemiological

12. E-cig Levels of Various Toxic Substances10-500 times Lower than Cigarettes Goniewicz et al, Tob Control 2013

13. Chemical studies Passive vaping Schripp et al, Indoor Air 2013

14. Nicotine Delivery

15. Quitting--Adults

16. Toxicity—Case Reports

17. The Public Health Endgame—Clive Bates Billon Adults >15 years Scenario – 15% global prevalence by 2050

18. The Public Health Endgame—Clive Bates Billon Adults >15 years Scenario – 15% global prevalence by 2050

19. The Public Health Endgame—Clive Bates Billon Adults >15 years HARM

20. The Public Health Endgame—Clive Bates Billon Adults >15 years

21. The endgame – a nicotine product contest? Billon Adults >15 years

22. The endgame – a nicotine product contest? Billon Adults >15 years Dual Use

23. The endgame – a nicotine product contest? Recruitment of intermediate risk adolescents Billon Adults >15 years Dual Use

24. 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. E-cigarettes AND Accountable Care Why ACOS Should Care How E-cigs Could Change the Game

26. 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. 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.

29. How Will ACOs Be Judged?

32. 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. 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