Whereas much is known about the effects of tobacco use, the current state of knowledge regarding non-cigarette nicotine products, such as electronic nicotine delivery systems (e-cigarettes and other vaping devices), water pipe/hookah, smokeless tobacco, pipes, cigars, little cigars, and cigarillos, that do not contain tobacco is not robust enough to yield a definitive consensus regarding their relative risks and benefits.

1. BEYOND CIGARETTES
The Risks of Non-Cigarette Nicotine Products
and Implications for Tobacco Control
March 2017

2. Types of Nicotine Products
2
Smoked
Tobacco
Smokeless
Tobacco
Electronic Nicotine
Delivery Systems (ENDS)
Cigarettes Chewing tobacco Electronic cigarettes
(e-cigarettes; cigalikes)
Cigars
(large cigars, little cigars,
cigarillos)
Dry snuff/pouch Vape pens
Pipes Moist snuff Modified e-cigarettes
Advanced personal
vaporizers
‘MODS’
Water pipe/hookah Snus Electronic water
pipe/hookah
Dissolvables

3. Non-Cigarette Nicotine Products:
Mixed Messages
• Although not risk-free, non-cigarette nicotine products
that do not have tobacco (such as ENDS) may be less
harmful alternatives to cigarettes for smokers who cannot
or will not quit by using approved smoking cessation aids
• BUT, they are addictive due to nicotine, have toxic
ingredients, and may encourage or perpetuate cigarette
smoking and other substance use and addiction
3

4. Nicotine is Not Harmless
• Increase in blood pressure, respiration, and heart rate
• Adversely affects nervous, cardiovascular, respiratory,
and reproductive systems
• May contribute to cancerous tumor development
• Can be lethal if orally ingested
• Associated with poor reproductive health outcomes
4

5. Nicotine is Not Harmless
• Early exposure can produce lasting effects on brain and
lung development
• Early exposure is associated with cognitive, emotional,
and behavioral deficits
• Perpetuates the use of harmful tobacco products
• Increases the risk of nicotine addiction and alcohol and
other drug use and addiction
5

6. Data Analysis
• To explore prevalence and patterns of nicotine product
use among youth and adults
• Analyses of recent, publicly available, nationally
representative data from the U.S. Centers for Disease
Control and Prevention (CDC) on nicotine product use in
the United States
• Middle and high school students (2014 data)
• Adults aged 18 and older (2013-2014 data)
6

7. Prevalence
• Approximately 26% of adults and 16% of middle and
high school students reported current use of at least
one nicotine product
– Approximately 16% of adults and 15% of middle and
high school students reported current use of at least one
non-cigarette nicotine product
– Young adults, aged 18 to 24, were the age group most
likely to report current use of a non-cigarette nicotine
product (37%)
7

8. Prevalence Among Adults
by Key Demographics
8

9. Prevalence Among Youth
by Key Demographics
9

10. Most Commonly Used Products
• Among Adults
– Cigarettes (18%)
– Cigars (7%)
– E-cigarettes (7%)
• Among Middle and High School Students
– E-cigarettes (9%)
– Water pipe/hookah (6%)
– Cigarettes (6%)
10

11. Multiple Nicotine Product Use
is Common
• 38% of adults and 50% of middle and high school
students who engaged in current use of nicotine
products used more than one nicotine product
• Among current users of nicotine products, 8% of adults
and 20% of middle and high school students reported
using more than one non-cigarette nicotine product
• Multiple nicotine product use elevates the risks of
nicotine addiction, alcohol and other drug use, and other
harmful consequences
11

12. Nicotine Addiction
• An estimated 4.5% of adults and less than 1% of middle
and high school students who reported current use of
non-cigarette nicotine products (and not cigarettes) met
criteria for nicotine addiction
• More than half of adults and half of middle and high
school students who only used non-cigarette nicotine
products reported at least one symptom of nicotine
addiction
12

13. Nicotine Addiction by Type of Product:
Adults
13
20.2
12.3 12.6
8.0
19.3
13.5
16.1
Cigarettes Cigars Pipes Hookah ENDS Chewing
tobacco
Snus
Nicotine Addiction Among Adults who Reported Current Nicotine Product
Use by Type of Product Used 2013-2014 (Percent)

14. Nicotine Addiction by Type of Product:
Youth
14

15. Quit Attempts and Former Use
• Quit Attempts
– Nearly half of adults and nearly one-third of middle and
high school students who reported current use of nicotine
products also reported attempting to quit using them in the
past year
• Former Use
– Approximately one-half of adults and middle and high
school students who reported ever having used a nicotine
product indicated that they were no longer using them
15

16. Most of the Controversy is Around
ENDS Products
• Questionable safety due to nicotine and toxic ingredients
in flavorings, liquids, and aerosols
• Use is skyrocketing among youth, even those who never
smoked or intended to smoke a cigarette
• Efficacy in aiding smoking cessation is questionable
• May be renormalizing smoking and reversing years of
progress in improving the public health
16

17. Summary of Risks and Benefits of
ENDS Products
17
Risks Benefits
For Nonsmoking Youth
Increased exposure to nicotine
Nicotine addiction
Increased risk of initiation of smoked cigarettes
Adverse effects on brain development
Future disease
For Current Smokers
Slower or delayed tobacco cessation Reduced tobacco-related disease morbidity and mortality for those who switch
to ENDS and significantly reduce or quit smoking cigarettes
Increased risk of nicotine exposure and addiction with continued dual use of
ENDS and smoked cigarettes
For Former Smokers
Re-initiation of cigarette smoking
Nicotine addiction
For Nonsmokers and Society
Secondhand aerosol exposure and associated health risks and costs Reduced costs associated with tobacco-related disease morbidity and mortality
Re-normalization of smoking
Accidental/unintentional poisoning

18. A Closer Look at the Research
Evidence on ENDS
• Who are the main users of ENDS products?
– Youth or Adults? Youth, including young adults, generally
report higher rates of ENDS use than adults
– Cigarette Smokers or Nonsmokers? Most people who
use ENDS also smoke cigarettes; however, many people
who use ENDS, especially among youth, never smoked a
cigarette
18

19. A Closer Look at the Research
Evidence on ENDS
• Do nonsmokers who use ENDS products end up
smoking cigarettes?
– Non-cigarette smoking youth who use ENDS are
significantly more likely to report intentions to smoke and to
end up smoking cigarettes in the near future
– Even non-cigarette smoking youth who specifically
expressed no intention to smoke cigarettes in the future but
used ENDS products are significantly more likely to end up
smoking in the near future
19

20. A Closer Look at the Research
Evidence on ENDS
• Do cigarette smokers who start using ENDS
products reduce/quit smoking or do they continue to
use both types of nicotine products?
– Smokers who use ENDS generally are not more likely to
reduce or quit smoking cigarettes and many become ‘dual
users’ of cigarettes and ENDS
20

21. Government Regulation
• Federal Laws and Regulations
– The 2009 Family Smoking Prevention and Tobacco Control Act
• Only applied to cigarettes, loose tobacco, roll-your-own tobacco,
and smokeless tobacco
– The 2016 FDA Final Rule for all Tobacco Products
• Broadens FDA coverage to all tobacco products, including ENDS,
cigars, pipes, water pipe/hookah, and dissolvables
• Still does not restrict flavoring in non-cigarette products and does
not prohibit advertising these products to youth
21

22. Government Regulation
• State and Local Laws and Regulations
– State and local governments are allowed to enact more
stringent tobacco regulations than the federal government with
regard to:
• Sales and distribution restrictions (minimum legal age of sale, retail
and packaging requirements)
• Youth possession restrictions
• Smoke-free (clean air) laws and regulations
• Taxation
22

23. Barriers to Reducing Use
• Public Perceptions
– The risks and harms of non-cigarette nicotine products tend to be minimized or dismissed
• Addiction
– Nicotine is addictive, regardless of the delivery device
• Industry Practices
– Product marketing (e.g., healthier alternatives to cigarettes, useful for smoking cessation,
circumvent smoke-free laws)
– Product design (appealing flavors, packaging)
– Influence on science, policy, and government oversight (lobbying)
• Social Influences (Peers, Family, Media)
• Inconsistent Research Findings and Clinical Practice
23

24. Recommendations:
Policy
• Federal Government
– Ban all characterizing flavors in all nicotine products
– Restrict the advertising and marketing of all nicotine products
– Prohibit Internet sales of all nicotine products
– Prohibit “low-risk” or “reduced-harm” claims
– Control product design, packaging, and labeling
– Fund quality research
24

25. Recommendations:
Policy
• State and Local Government
– Increase minimum legal sale age to 21 for all nicotine products
– Broaden smoke-free clean indoor/outdoor air laws to include all
nicotine products
– Prohibit the sale of all flavored nicotine products
– Control nicotine product retail outlet density and location
– Tax tobacco products at a higher level than ENDS to discourage
youth from using and to encourage smokers to cut back or quit
– Expand tobacco cessation insurance coverage
25

26. Recommendations:
Practice
• Health Care Professionals
– Patient education, screening, brief intervention, treatment
• Educators
– Prevention programming that includes all nicotine products
– Include all nicotine products in tobacco-free campus policies
– Ban all nicotine product advertising and promotions in and near
schools
– Offer students (and staff) cessation services
26

27. Recommendations:
Practice
• Parents and Families
– Establish healthy relationships with open, honest communication
– Convey strong anti-use messages and set and enforce rules fairly and consistently
– Set a good example: do not use nicotine products and prohibit use at home and in cars
• Media
– Restrict advertising of non-cigarette nicotine products, especially to youth
– Integrate anti-nicotine messages into media programming
– Ban brand identification of all nicotine products in television shows and movies
– Include the presence of nicotine product use in determinations of ratings for movies,
television shows, and video games
27

28. Recommendations:
Research
• Improve Surveillance
– Conduct longitudinal surveys
– Assess prevalence via detailed measures of recency, frequency, and
intensity of use that are applicable to all nicotine products
– Include measures of alcohol and other drug use and addiction
– Include measures of treatment of nicotine addiction
• Improve Assessment of Nicotine Addiction so that it is Relevant to
All Types of Nicotine Products
• Improve Understanding and Documentation of the Contents (and
Toxicity) of Non-Cigarette Nicotine Products
28

29. Conclusions
• There remains considerable debate regarding the risks and potential benefits
of non-cigarette nicotine product use, especially ENDS
• There is a strong need to accumulate more definitive, unbiased evidence
regarding the risks and potential benefits of these products
• Emerging evidence is pointing to the conclusion that their risks and harms
generally outweigh their benefits
• The evidence is clear that nicotine use, regardless of the delivery device, can
lead to addiction and other adverse health effects
• Evidence-based government policies, health care practice, and prevention
initiatives can help to protect the public from the harms of nicotine products
• We must implement a comprehensive, research-based approach to curbing all
forms of tobacco and nicotine product use and their associated health effects
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30. www.centeronaddiction.org