Alison B. Breland

Electronic cigarette nicotine delivery can exceed that of combustible cigarettes: a preliminary report

Introduction Electronic cigarettes (ECIGs) aerosolise a liquid that usually contains propylene glycol and/or vegetable glycerine, flavourants and the dependence-producing drug, nicotine, in various concentrations. This laboratory study examined the relationship between liquid nicotine concentration and plasma nicotine concentration and puffing behaviour in experienced ECIG users. Methods Sixteen ECIG-experienced participants used a 3.3-Volt ECIG battery attached to a 1.5-Ohm dual-coil ‘cartomiser’ loaded with 1 mL of a flavoured propylene glycol/vegetable glycerine liquid to complete four sessions, at least 2 days apart, that differed by nicotine concentration (0, 8, 18 or 36 mg/mL). In each session, participants completed two 10-puff ECIG-use bouts (30 s puff interval) separated by 60 min. Venous blood was sampled to determine plasma nicotine concentration. Puff duration, volume and average flow rate were measured. Results Immediately after bout 1, mean plasma nicotine concentration was 5.5 ng/mL (SD=7.7) for 0 mg/mL liquid, with significantly (p<0.05) higher mean concentrations observed for the 8 (mean=17.8 ng/mL, SD=14.6), 18 (mean=25.9 ng/mL, SD=17.5) and 36 mg/mL (mean=30.2 ng/mL; SD=20.0) concentrations; a similar pattern was observed for bout 2. For bout 1, at 36 mg/mL, the mean post- minus pre-bout difference was 24.1 ng/mL (SD=18.3). Puff topography data were consistent with previous results and revealed few reliable differences across conditions. Discussion This study demonstrates a relationship between ECIG liquid nicotine concentration and user plasma nicotine concentration in experienced ECIG users. Nicotine delivery from some ECIGs may exceed that of a combustible cigarette. The rationale for this higher level of nicotine delivery is uncertain.

Electronic cigarettes: what are they and what do they do?

Electronic cigarettes (ECIGs) use electricity to power a heating element that aerosolizes a liquid containing solvents, flavorants, and the dependence‐producing drug nicotine for user inhalation. ECIGs have evolved rapidly in the past 8 years, and the changes in product design and liquid constituents affect the resulting toxicant yield in the aerosol and delivery to the user. This rapid evolution has been accompanied by dramatic increases in ECIG use prevalence in many countries among adults and, especially, adolescents in the United States. The increased prevalence of ECIGs that deliver nicotine and other toxicants to users’ lungs drives a rapidly growing research effort. This review highlights the most recent information regarding the design of ECIGs and their liquid and aerosol constituents, the epidemiology of ECIG use among adolescents and adults (including correlates of ECIG use), and preclinical and clinical research regarding ECIG effects. The current literature suggests a strong rationale for an empirical regulatory approach toward ECIGs that balances any potential ECIG‐mediated decreases in health risks for smokers who use them as substitutes for tobacco cigarettes against any increased risks for nonsmokers who may be attracted to them.

Science and electronic cigarettes: current data, future needs.

Electronic cigarettes (ECIGs), also referred to as electronic nicotine delivery systems or “e-cigarettes,” generally consist of a power source (usually a battery) and heating element (commonly referred to as an atomizer) that vaporizes a solution (e-liquid). The user inhales the resulting vapor. Electronic cigarettes have been increasing in popularity since they were introduced into the US market in 2007. Many questions remain about these products, and limited research has been conducted. This review describes the available research on what ECIGs are, effects of use, survey data on awareness and use, and the utility of ECIGs to help smokers quit using tobacco cigarettes. This review also describes arguments for and against ECIGs and concludes with steps to move research on ECIGs forward.

Tobacco specific nitrosamines and potential reduced exposure products for smokers: a preliminary evaluation of Advance™

Objective: To develop a method for evaluating the carcinogen delivery of potential reduced exposure products (PREPs) like Advance™, a PREP marketed to reduce smokers’ exposure to one tobacco specific nitrosamine (TSN), NNK, a potent lung carcinogen. Design, setting, and participants: Latin square ordered, three condition, outpatient, crossover design with 12 smokers of light or ultra-light cigarettes (15 or more cigarettes/day). In each five day condition, participants either smoked own brand, Advance™, or no cigarettes. Also, on the first and last day of each condition, participants smoked one cigarette in the laboratory. Main outcome measures: Subject rated measures of tobacco/nicotine withdrawal, expired air carbon monoxide, urine concentrations of cotinine and NNAL (one TSN biomarker), puff volume, duration, number, and interpuff interval. Results: Relative to own brand, Advance™ produced similar withdrawal suppression, slightly lower carbon monoxide, equivalent cotinine, and 51% lower NNAL concentrations. The lowest cotinine and NNAL concentrations were observed in the no cigarette condition. Participants took fewer puffs when smoking Advance™. Conclusions: Past experience with PREPs that failed to reduce smoking’s harm demonstrates the need for clinical methods in PREP evaluation. This study shows how assessing PREP induced changes in withdrawal and exposure to carbon monoxide, nicotine, and carcinogens may help predict PREP harm reduction potential. Adequate withdrawal suppression, slightly lower concentrations of carbon monoxide, and reduction of one TSN biomarker were observed for Advance™. In the future, clinical methods like those described here may be valuable for evaluating PREPs before they are marketed publicly.

Urine cotinine as an index of smoking status in smokers during 96-hr abstinence: Comparison between gas chromatography/mass spectrometry and immunoassay test strips

Biomarkers such as carbon monoxide (CO) and cotinine (a nicotine metabolite) are used in tobacco cessation studies to assess smoking status. CO is easy to assess, is inexpensive, and provides immediate results. However, the short half-life of CO may limit its ability to identify smokers who have abstained for several hours. Quantitative methods (e.g., gas chromatography/mass spectrometry, or GC/MS) for measuring urine cotinine, which has a longer half-life, are valid and reliable, though costly and time consuming. Recently developed semiquantitative urine cotinine measurement techniques (i.e., urine immunoassay test strips, or ITS) address these disadvantages, though the value of ITS as a means of identifying abstaining smokers has not been evaluated. The present study examined ITS as a measure of smoking status in temporarily abstaining smokers. A total of 236 breath and urine samples were collected from smokers who participated in two separate studies involving three independent, 96-hr (i.e., Monday-Friday), Latin-square-ordered, abstinence or smoking conditions; a minimum 72-hr washout separated each condition. Each urine sample was analyzed with GC/MS and ITS. Under these study conditions, CO demonstrated moderate sensitivity (83.1%) and strong specificity (100%), whereas ITS assessment showed strong sensitivity (98.5%) and weak specificity (58.5%). In this study of short-term abstinence, ITS classified as nonabstinent nearly half of the samples collected from abstaining smokers. However, it classified nearly all nonabstinent smokers as currently smoking. Validation of ITS using GC/MS results from smokers undergoing more than 96 hr of abstinence may be valuable.

Acute effects of Advance: a potential reduced exposure product for smokers.

Objective: To examine the acute effects of AdvanceTM, a potential reduced exposure product (PREP) for smokers marketed as a means to reduce exposure to toxic gases and tobacco specific nitrosamines. Design, setting, participants: Latin square ordered, three condition, laboratory based, crossover design with 20 smokers of light or ultra-light cigarettes (15 or more cigarettes/day). In each 2.5 hour condition, participants completed an 8-puff smoking bout from their own brand, AdvanceTM, or an unlit cigarette (that is, sham smoking) every 30 minutes for a total of four bouts. Main outcome measures: Subject rated measures of tobacco/nicotine withdrawal; carbon monoxide (CO), and heart rate; plasma nicotine concentrations. Results: Relative to own brand, AdvanceTM produced similar withdrawal suppression and heart rate increase, lower CO boost, and higher plasma nicotine concentrations. Conclusions: PREPs for smokers need to be evaluated using a comprehensive strategy that includes empirical examination of acute and long term effects. Adequate withdrawal suppression and potentially lower concentrations of CO associated with AdvanceTM use are positive factors, although higher nicotine concentrations do not constitute “reduced exposure”. Overall, longer exposure periods are necessary to determine carcinogen delivery. PREP evaluation is complex and should be completed objectively.

Potential reduced exposure products (PREPs) for smokeless tobacco users: Clinical evaluation methodology

Several potential reduced exposure products (PREPs) for smokeless tobacco (SLT) users are marketed in the United States, though their effects are largely unknown. These products include some that are low in tobacco-specific nitrosamines (TSNs), like Stonewall, a pressed tobacco tablet, and General snus, a moist snuff product produced in Sweden. Methodology assessing the toxicant exposure and effects of cigarette-like PREPs for smokers has been developed, and might be modified for use in evaluating PREPs for SLT users. This report describes two studies examining the toxicant exposure and effects of two PREPs for SLT users. Study 1 (n = 13) consisted of four 4.5-hr laboratory sessions where SLT products (own brand, Stonewall, General snus, and tobacco-free placebo) were used for four 30-min episodes and nicotine exposure and tobacco/nicotine abstinence symptoms were measured. Study 2 (n = 19) consisted of four 5-day ad libitum use periods when participants used own brand, Stonewall, General snus, or no SLT and urinary levels of metabolites of nicotine (cotinine) and the TSN 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNAL) and abstinence symptoms were measured. Compared with own brand, Stonewall was associated with lower levels of cotinine and NNAL, while General snus was associated with similar levels of cotinine and lower levels of NNAL. Abstinence symptoms generally did not differ across tobacco conditions. These results show that clinical laboratory methods can be used to evaluate the toxicant exposure and abstinence symptom suppression associated with PREPs for SLT users.

Electronic cigarettes: A review of safety and clinical issues

This clinical case conference discusses 3 cases of patients using electronic cigarettes. Electronic cigarettes, also referred to as electronic nicotine delivery systems or “e-cigarettes,” generally consist of a power source (usually a battery) and a heating element (commonly referred to as an atomizer) that vaporize a solution (e-liquid). The user inhales the resulting vapor. E-liquids contain humectants such as propylene glycol and/or vegetable glycerin, flavorings, and usually, but not always, nicotine. Each patients information is an amalgamation of actual patients and is presented and then followed by a discussion of clinical issues.

Assessing the Utility of Consumer Surveys for Improving the Quality of Behavioral Health Care Services

The development and implementation of provider performance and consumer outcome measures for behavioral health care have been growing over the last decade, presumably because they are useful tools for improving service quality. However, the extent to which providers have successfully used performance measurement results has not been adequately determined. To this end, two methods were used to better understand the use of data obtained from an annual survey of behavioral health care consumers: a cross-sectional survey of executive directors, clinical program directors, and quality improvement directors and follow-up interviews with a subsample of survey respondents. Results revealed information about the use of consumer survey data, factors that facilitate and hinder the use of results, as well as respondents’ opinions about consumer survey administration procedures. These findings provide valuable information for the application of performance measures and, ultimately, improving consumer outcomes.

Targeting tobacco in a community-based addiction recovery cohort: Results from a computerized, brief, randomized intervention trial

INTRODUCTION Nearly 80% of substance dependent individuals also use tobacco, and smoking cessation efforts during treatment for other substance use is associated with similar or even improved outcomes. However, smoking cessation is not routinely addressed during treatment for substance use disorders. The present study tested a computerized brief motivational intervention (C-BMI) for smoking cessation in an understudied population: a cohort recruited from a recovery community organization (RCO) center. METHODS Following baseline assessment, participants were randomly assigned to either a 30-minute C-BMI plus access to free nicotine replacement therapy (NRT), or an information-only control group plus NRT access. RESULTS Reductions in CO were observed for both groups. Quit rates in the C-BMI group (5%-7%, vs. 0% for the control group) approximated those observed elsewhere for physician advice and minimal counseling. Participants in the C-BMI group were also more likely to express a desire to quit. CONCLUSIONS Computer-delivered smoking cessation interventions within RCOs appear feasible. These organizations treat a wide variety of individuals, and C-BMIs for smoking in this context have the potential to reduce smoking-related morbidity and mortality.