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E-Cigarettes: An Evidence Update

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A public lecture on Electronic Cigarettes delivered by Dr Lynne Dawkins of the Centre for Addictive Behaviours Research, London South Bank University on 14th November 2018.

A recording of the talk can be found here: https://youtu.be/VpetvlAmIaU

Following her successful public lecture on E-Cigarettes in 2013, Dr Dawkins re-visits the subject of e-cigarettes and vaping, drawing on the most recent evidence and updates since 2013. She describes the development in e-cigarette technology and current regulation and then brings the audience up to date with the latest research on usage patterns, smoking cessation and safety issues, addressing some of the common myths held around e-cigarettes and vaping.


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E-Cigarettes: An Evidence Update

  1. 1. E-cigarettes: An Evidence Update Dr Lynne Dawkins Associate Professor Centre for Addictive Behaviours Research London South Bank University dawkinl3@lsbu.ac.uk @lynnedawkins
  2. 2. Disclosures • Pharmaceutical industry: consultancy (2014; 2017) • Law/Litigation: expert witness/consultant (2014) • E-cigarette companies: research grants, honorarium (2010-2013) • Tobacco Industry: no funding
  3. 3. What I’m going to talk about: • Brief introduction to E-cigarettes • Regulation • Who’s using them & why • Nicotine & addiction • Fires & explosions • Potential harms & effects on health • E-cigarettes and quitting smoking • Gateway effects • Summary & conclusions Common myths & concerns Followed by research evidence
  4. 4. E-cigarettes: What are they? vaporisers
  5. 5. “ We don’t know anything about them” “There’s been no research on them”
  6. 6. E-cigarette research studies published since 2009 0 100 200 300 400 500 600 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Numberofarticlespublished Year Over 2000 research articles on e-cigarettes published since 2008 Pubmed year by year search using ‘E-cigarette’ in title or abstract
  7. 7. “ They’re not regulated”
  8. 8. UK E-Cig Policy 1. Consumer route • Notification process • Minimum standards for safety, quality, nicotine and size limits • Standard packaging & labelling requirements • Advertising regulations • Yellow card system for side effects & safety reporting 2. Medicinal licensing route • Different standards for safety and quality, higher nicotine levels allowed • Advertising allowed • But none yet marketed EU Tobacco Products Directive translated into UK law: UK Tobacco and Related Product Regulations 2016 2 routes to market (Both overseen by Medicines Healthcare products Regulatory Agency (MHRA): Slide adapted from McNeill, Evidence review of e-cigarettes (SRNT-E Munich 2018) Source: https://www.gov.uk/government/collections/e-cigarettes- and-vaping-policy-regulation-and-guidance
  9. 9. Some issues with E-cig regulations • No advertising = less presence, less reach = more smoking • Addiction warning labels: intimidating message; may put smokers off (Cox et al. 2018, Addict Beh Reports) • Caps on nicotine content: may not relieve cravings for the heaviest smokers; encourages more use & compensatory puffing (Dawkins et al. 2016, Psychopharm) • Limits on tanks and bottle sizes = more refills, more hassle, more to remember = easier to smoke. • US – limits on change to products = improvements (including safety) restricted = unnecessary harm THIS PRODUCT CONTAINS NICOTINE WHICH IS A HIGHLY ADDICTIVE SUBSTANCE
  10. 10. “Young people are using them” “Non-smokers are using them” “Everyone’s using them”
  11. 11. Who uses them? An estimated 3.2 million (6.2%) adults in Great Britain currently use e- cigarettes, up from 700,000 in 2012. Source: http://ash.org.uk/information-and-resources/fact-sheets/use-of-e-cigarettes-among-adults-in-great-britain-2017/ Most people who vape are ex- smokers or current smokers. Use among never smokers is low
  12. 12. Nicotine use by never smokers and long-term ex-smokers 12 E-cigarette use by never smokers is low and similar to rates of NRT use N=71732 never and long-term ex-smokers from Nov 2013 0 5 10 15 Percent Never: E-cigs Long-term ex: E-cigs Never: NRT Long-term ex: NRT Source: www.smokinginengland.info
  13. 13. Why do people use them? The main reason given for using an e- cigarette is to quit smoking Source: http://ash.org.uk/information-and- resources/fact-sheets/use-of-e-cigarettes- among-adults-in-great-britain-2017/
  14. 14. “They contain nicotine so it’s just swapping one addiction for another”
  15. 15. What’s wrong with nicotine? Prof Michael Russell: “People smoke for nicotine but they die from the tar” (1976) Components of Tobacco Smoke: Nicotine: main active ingredient = addiction Tar: Sticks to lungs/airways allowing cancer- causing compounds to build up resulting in cancers & respiratory disease Carbon Monoxide: toxic gas prevents O2transport & produces cardiovascular disease TOBACCO HARM REDUCTION: Give smokers the nicotine they desire without the harmful effects of burning tobacco
  16. 16. None or very small 8% Some but well under half the risk 18% Around half the risk 20% Much more than half the risk 18% Nearly all the risk 20% Don't know 16% Source: East et al. (2018). Drug, Alc Depend. https://www.drugandalcoholdependence.com/article/ S0376-8716(18)30648-3/pdf Public perceptions of nicotine harms How much of the harm from smoking cigarettes comes from nicotine? 2,103 11-18 yr olds in Great Britain in 2016
  17. 17. Is continued nicotine addiction a problem? • Long term use of Nicotine Replacement Therapy (NRT) not shown to be harmful (Murray et al. 2009, Nicotine Tob Res) • A problem for whom? • Public health? – no as completely switching to vaping dramatically reduces the risk of smoking-related disease • The individual? - maybe if cost, others’ perceptions, enslavement etc. is an issue • Limited research but some evidence that nicotine via vaping is less ‘addictive’ than via smoking (e.g. Dawkins et al. 2013, Addiction; Foulds et al. 2017, Prev Med)
  18. 18. “My wife/boss/friend/agony aunt/dog etc. uses it constantly. S/he must be getting more nicotine ”
  19. 19. Nicotine delivery from smoking vs. vaping • Smokers smoke intermittently; vapers ‘graze’ • Less efficient nicotine delivery from vaping • Vapers puff more with lower nicotine strength liquids but maintain a steady nicotine intake (Soar et al. 2018) NRT Gum 2mg Cigarette Farsalinos et al, 2014 (Adapted)
  20. 20. “ They’re always exploding” “They catch fire”
  21. 21. Fires & explosions: Like other portable electrical devices, e-cigs use lithium-ion batteries which can fail and occasionally explode and cause fires 0 50 100 150 200 250 300 2015 2016 2017 (to August) Total Fire False alarms E-cig fires and false alarms recorded by 41 fire services in England between 2015-2017 Call outs increased from 2015 – 2016 but mostly due to false alarms. 24 casualties in total but no fatalities Similar numbers reported from mobile phones Slide adapted from Calder, SRNT-E Munich (2018) Source: McNeill et al. (2018). Evidence review of E- Cigarettes & heated tobacco products. A report commissioned by Public Health England (PHE). Chapter 8
  22. 22. • 49 case studies of e-cigarette related burns in the literature (PHE, 2018) • Explosions usually occur in trouser pockets, whilst charging and occasionally when being used • Far more fires caused by smoking Fires recorded in London Fires & explosions: E-cigs vs. smoking Adapted from Calder, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 8.
  23. 23. “They’re just as harmful as smoking” “We don’t know the long- term effects” “We used to think smoking was good for us”
  24. 24. Harm perceptions in adults in Great Britain 0 5 10 15 20 25 30 35 40 45 More/equally harmful Less harmful Lot less harmful completely harmless don't know 2013 2014 2015 2016 2017 2018 A quarter of adults currently think e-cigarettes are just as harmful as smoking. Almost another quarter don’t know. Correct answer
  25. 25. • Burning: combustion is key • Cigarette smoke: 7000+ compounds, including 70 carcinogens burnt at ~800 °C • E-cigarette vapour: mainly nicotine, PG/VG, flavourings, heated at ~200 °C E-cigarette health effects: some things to consider Need to ensure that research studies use realistic exposure & measured effects are actually a marker of risk/disease • Assessing harms is difficult • Any possible harms of vaping will take years to emerge • Hard to draw conclusions from animal studies • Are vapour exposure conditions realistic? • Human studies: most users are current/past smokers • Is the biomarker meaningful? Slide adapted from Shahab, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 9.
  26. 26. Using biomarkers to estimate harms • Biomarker – something that can be measured and which can be used as an indicator of a particular disease state. • Can be tested now • Short-term/reversible • Have to be reasonably specific and linked to disease (e.g. NNAL) NNAL Nitrosamine (NNK) Known lung carcinogen
  27. 27. • 10 published papers (8 studies) (2015-2017) with 658 participants Effects of E-cigarette use on NNAL 0 20 40 60 80 100 120 %ofcigarette-onlysmokerlevels 66.6% Randomised Controlled Trial Switch (baseline) Cross- sectional Historic Comparison 60.9% 64.4% 96.6% 96.7% 96.6% 95.8% 86.9% 91.4% Length of use of EC (abstinence from combustible tobacco use) Short >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Long Slide adapted from Shahab, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 9.
  28. 28. 0 20 40 60 80 100 120 %ofcigarette-onlysmokerlevels Effect of E-cigarette use on other biomarkers Cross- over Switch (baseline) Cross- sectional Generally see similar levels to non-smokers Pyrene (1-HOP) Cancer Acrolein (3-HPMA) Respiratory Diseases Carbon monoxide (expired air CO) Cardiovascular Diseases 69.3% 84.9% 41.3% 67.3% 84.1% 89.6% 71.7% Slide adapted from Shahab, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 9.
  29. 29. E-cigarettes are far less harmful than cigarette smoking
  30. 30. “They don’t help smokers to stop smoking”
  31. 31. Aids used in most recent quit attempt1 33 0 5 10 15 20 25 30 35 40 45 50 Percentofsmokerstryingtostop E-cigs NRT OTC NRT Rx Champix Beh'l supp N=13754 adults who smoke and tried to stop or who stopped in the past year; method is coded as any (not exclusive) use E-cigarette use for quitting has declined from a peak in 2016
  32. 32. E-cigarettes for quitting smoking: An overview of published reviews Since 2015: 7 reviews with meta-analysis. 3 different results Review Finding Rahman (2015) Nicotine E-cigs increased quitting Hartmann-Boyce (2016) Nicotine E-cigs increased quitting Khoudigian (2016) No effect of E-cigs on quitting Vanderkam (2016) No effect of E-cigs on quitting El Dib (2016) No effect of E-cigs on quitting Malas (2016) No effect of E-cigs on quitting Kalkhoran & Glantz (2016) E-cigs reduced quitting Reasons for inconsistencies: • Types of studies included • Types of participants included • Types of outcomes measured Studies including only RCTs generally find positive results but evolving E-cigs mean findings are out of date quickly Slide adapted from Robson, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 7.
  33. 33. 4-week quit rates by medication type in English Stop Smoking Services 25% 45% 46% 51% 53% 53% 57% 59% 60% 68% 0% 20% 40% 60% 80% 100% Unknown n=25, 409 NRT and/or Bupropion and/or Vareniciline consecutively n=14,867 Combination NRT n=228, 371 Single NRT n=168,965 No medication or EC n=46,728 Bupropion only n=2,584 Licensed medication and an EC concurrently n=15,971 EC only n=5,711 Varenicline only n=174,530 Licensed medication & an EC consecutively n=3,964 Self-reported4-weekquitrates(%) From: 4/2015 to 3/ 2017: 690,007 set a quit date & 51% quit Slide courtesy of Robson, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 7.
  34. 34. Estimates of the impact of E-cig use on the number of long-term quitters Year Ref Estimated number of additional long-term quitters Methods 2014 West et al. (2016) 16,000 – 22,000 Indirect method 2015 Beard et al. (2016) 18,000 Time series analysis 2016 PHE (2018) 22,000 – 29,000 As West et al. 2016 PHE (2018) 27,000 – 57,000 Varying 2 assumptions Slide adapted from Robson, SRNT-E Munich (2018). Source: McNeill et al. (2018). Chapter 7
  35. 35. Cigarette smoking prevalence 24.2 22.0 21.5 21.4 20.7 20.0 19.3 18.5 18.7 18.0 17.2 17.5 0 5 10 15 20 25 30 Percent 37Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: All adults The long-term decline in the prevalence of cigarette smoking continues
  36. 36. “They may lead young people to start smoking”
  37. 37. Surveys including over 60,000 young people: Source: Bauld, L, MacKintosh, A, Eastwood, B, Ford, A, Moore, G, Dockrell, M, Arnott, D, Cheeseman, H, McNeill, A. (2017) Int. J. Environ. Res. Public Health, 14, 973; doi:10.3390/ijerph14090973 Also see McNeill et al. (2018). Chapter 5 Regular e- cigarette use is confined to those who have smoked
  38. 38. 2015 (n=728) 2016 (n=814) 2017 (n=790) All: Ever Use 22.2% 25.2% 28.0% All: At least weekly 1.0% 1.3% 1.8% Never smokers: Ever use 5.7% 8.8% 8.5% Never smokers: Weekly use 0.3% 0.0% 0.0% Regular Smokers: Ever use 81.8% 74.2% 75.8% Regular Smoker: Weekly use 3.9% 9.6% 8.2% EC use among 17-18 year olds 2015-17 Slide adapted from Brose, SRNT-E Munich (2018). McNeill et al. (2018). Chapter 5 Source: ASH Smokefree GB Survey
  39. 39. Pathways of use • Two surveys from the UK and several US studies found that young people who have never smoked but have tried an e-cigarette at the beginning of the study are more likely to have gone on to try smoking several months or years later. • This suggests there may be an association but we cannot establish a cause based on these findings • ‘Common liability’ likely explains these findings (i.e risk taking behaviour) • Some data to suggest the opposite trend – i.e. that e-cigarettes may be a route out of smoking for some young people Slide adapted from Bauld, SRNT-E Munich (2018)
  40. 40. Take-up of smoking in young people 42 0 5 10 15 20 25 30 35 40 45 50 Percentwhoreporthavingever smokedregularly N=21889 people aged 16-24 Proportion of people aged 16-24 years who have ever smoked regularly has slowly declined
  41. 41. No compelling evidence that EC are attracting significant numbers of young people who would not otherwise have smoked.
  42. 42. Summary of myths/concerns • There hasn’t been enough research • They’re not regulated • Everyone’s using them • It’s just transferring an addiction to nicotine • People use them constantly – that must be bad • They’re always exploding / they catch fire • They’re just as harmful as smoking • They don’t help smokers to quit smoking • They may lead young people to start smoking Smoking kills approx. 260 people in the UK every day
  43. 43. Acknowledgements • Prof Linda Bauld • Dr Leonie Brose • Dr Jamie Brown • Dr Robert Calder • Dr Sharon Cox • Prof Ann McNeill • Dr Deborah Robson • Dr Lion Shahab • Prof Robert West Thanks to the following for contributing their slides, images and data for this presentation:
  44. 44. Key Information Sources • Smoking Toolkit Study: www.smokinginengland.info • McNeil, A., Brose, LS., Calder, R., Bauld, L. & Robson, D. (2018): Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England: https://www.gov.uk/government/publications/e-cigarettes-and-heated- tobacco-products-evidence-review • Gov.UK (2018): E-cigarettes & Vaping: Policy Regulations and Guidance: https://www.gov.uk/government/collections/e-cigarettes-and-vaping- policy-regulation-and-guidance • Action on Smoking and Health. Use of E-cigarettes among adults in Great Britain 2018: http://ash.org.uk/information-and-resources/fact- sheets/use-of-e-cigarettes-among-adults-in-great-britain-2017/
  45. 45. Questions?

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