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Prof Jean Francois Etter 
Professor of Public Health 
University of Geneva
Prof. Jean-François ETTER, PhD Faculty of Medicine University of Geneva, Switzerland 
E-cigarette Summit, London 
November 13, 2014 
Product diversity, user behavior, players in the e-cig market
Conflicts of Interest 
Tobacco industry: - never received any funding, no CoI 
Pharmaceutical industry - no funding in past 8 years, no CoI 
E-cigarette industry - plane ticket + hotel (London + China, 2013) - no honorarium
3 broad types of e-cigarettes, but no distinction is made in many sales statistics, user surveys 
Cig-alike: 
Tanks, vaporizers: 
Mods:
Speed of nicotine delivery to the blood: 1st generation e-cig, 2nd generation e-cig, tobacco cigarettes 
Source: Farsalinos et al Sci Rep. 2014; 4: 4133
Machine tests: depending on puff conditions and product features, 
ECIG can provide far less or far more nicotine than a tobacco 
cigarette (50-fold variation). 
Talih et al. Nicotine & Tobacco Research, Sept 2014
E-cig global sales, $ million 2014: probably $5 billion <1% of tobacco cigarette market 
190 
350 
700 
1200 
240 
160 
150 
100 
480 
770 
950 
1200 
0 
500 
1000 
1500 
2000 
2500 
2010 
2011 
2012 
2013 
USA 
China 
International 
(source: Philip Morris)
England: prevalence of electronic cigarette use: smokers and recent ex-smokers 
8 
0 
5 
10 
15 
20 
25 
30 
35 
40 
45 
50 
Percent of smokers and recent ex- smokers 
Any 
Daily 
Growth in prevalence of e-cigarette use has not increased since Q3 2013 
N=14490 adults who smoke or who stopped in the past year; increase p<0.001 
Source: STS - Smoking Toolkit Study
= cig-alike
USA: dollar share by company: convenience stores 
and XAOC = expanded all outlets combined 
(Nielsen bar code data) 
Lorillard 
Reynolds 
Logic 
NJoy 
Altria
UK e-cigarette retail market share (%) Total U.K. retail market, including U.K. Major Multiples, Household, Impulse and Chemist Channels, 52 weeks ending Sept 2014. Source: Wells Fargo 
33.6 
32.8 
11 
6.7 
3.3 
2.1 
1.9 
1.4 
1.4 
1 
0.9 
0.9 
3 
UK 2014 
Ecig Group (FIN, VIP, Ten Motives) 
Nicocig - PMI 
E-Lites - Japan Tob 
Halco 
blu - Lorillard 
Gamucci 
BAT 
Vapouriz 
Dekang 
NJOY 
Vapourlites 
Supreme Imports 
Other
Tobacco company 
Brands of e-cigarette / vaporizers 
Altria 
MarkTen 
Green Smoke 
Reynolds + Lorillard, merged July 2014 
Vuse 
SkyCigs 
Imperial Tobacco 
Blu (sold by Lorillard) 
Puritane 
+ intellectual rights on Dragonite 
Japan Tobacco 
Ploom (tobacco vaporizer) 
E-Lites 
Philip Morris 
Nicolite 
iQos (heat not burn) 
+ partners with Altria / MarkTen 
British American Tobacco 
Vype 
Intellicig (CNCreative) 
Voke (Nicoventures) 
ITC (Imperial Tobacco Company of India) 
Eon 
NTC (National Tobacco Company, distributor of Zig-Zag cig. paper) 
V2 Cig
New nicotine + tobacco vaporizers: no combustion of tobacco 
Nicotine vaporizers, without tobacco: 
1.E-cigarettes (3 broad categories: cig-alike, tank, mod) 
2.Nicotine vaporizer using the technology of asthma vaporizers VOKE (Nicoventures = BAT: British American Tobacco): 
3.Nicotine pyruvate (chemical reaction that vaporizes nicotine, Jed Rose) (PMI: Philip Morris, under development) 
Tobacco vaporizers: 
1.Heated tobacco products, «heat not burn»: - electric heating (e.g. iQos by PMI, Chinese models) - charcoal heating (ember) 
2.Hot air flow - Nespresso-like cartridge (Ploom: distributed by Japan Tobacco) - loose tobacco (various brands of vaporizers)
iQos = Philip Morris 
heated tobacco product
Pharmacokinetics: Philip Morris iQos 
Same speed as tobacco cigarette 
= iQos
Voke = Nicoventures (BAT)
Voke: pharmacokinetics 
Delivery twice as quick as for Nicorette inhalator
Ploom: tobacco vaporizer commercialized by Japan Tobacco
Snus: first FDA application as reduced risk product (Swedish Match) 
For FDA registration as reduced risk product, applicant must show that: - the product is less harmful to the individual user - the total effect on the population is beneficial 
Very costly process, very long 
Will e-cig / vaporizers follow ?
Philip Morris: 
4 new reduced risk products 
See presentation on PM Investor’s day 2014: 
https://www.media-server.com/m/instances/8hjnb6wm/items/29n825fv/assets/75ngrwuk/0/file.pdf 
iQos Coal ember Nicotine pyruvate E-cig ‘cig-alike’
Science + regulation are part of the tobacco industry’s business model
Regulation: part of the tobacco 
industry business model
Tobacco industry involvement 
New situation: tobacco industry sells reduced risk vaporizers 
Science 
Huge investments in R&D on vaporizers ($2bn for PMI only) 
Regulation 
Intense lobbying (EU, US, nationally) 
Large numbers of experienced, professional lobbyists 
Long tradition, historically strong influence on tobacco laws 
Suspicion that aim of tobacco industry involvement in regulation is to: . avoid “unfriendly” rules . raise technical + legal barriers at entry in this market . eliminate (Chinese) competitors + small players
Tobacco industry: history 
Denied - that nicotine is addictive - risks of smoking - risks of passive smoking 
Produced bogus science 
Artificially created controversy, confusion 
Deception campaign to block smoking bans 
Will e-cig / vaporizers enable the tobacco industry to re-emerge as a legitimate stakeholder ?
How to react to tobacco industry involvement ? 
Science: 
Need for independent research, not just research conducted by tobacco industry + its subsidiaries 
If collaborations emerge between academy + industry, there is a need to define conditions / limits 
Transparency is crucial 
Follow example of guidelines for academic collaboration with pharma industry 
A framework is needed to manage conflicts of interest
Management of conflicts of interest 
Goals = protect the integrity of research, = preserve public trust 
Core principle = transparency 
Declaration of conflict of interest + registration of studies = insufficient 
Define policies, rules and restrictions, code of practice 
Rely on organizations / institutions that define + enforce + monitor these policies (national academy of sciences, ethics committees, etc.)
Perspectives 
New situation: are we prepared ? 
We have no choice but to rethink academic + political interactions with the industries that produce nicotine + tobacco vaporizers 
Need for transparency 
Need to develop rules, policies 
Need for a debate involving all stakeholders

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Professor J.F. Etter - E-Cigarette Summit 2014

  • 1. Prof Jean Francois Etter Professor of Public Health University of Geneva
  • 2. Prof. Jean-François ETTER, PhD Faculty of Medicine University of Geneva, Switzerland E-cigarette Summit, London November 13, 2014 Product diversity, user behavior, players in the e-cig market
  • 3. Conflicts of Interest Tobacco industry: - never received any funding, no CoI Pharmaceutical industry - no funding in past 8 years, no CoI E-cigarette industry - plane ticket + hotel (London + China, 2013) - no honorarium
  • 4. 3 broad types of e-cigarettes, but no distinction is made in many sales statistics, user surveys Cig-alike: Tanks, vaporizers: Mods:
  • 5. Speed of nicotine delivery to the blood: 1st generation e-cig, 2nd generation e-cig, tobacco cigarettes Source: Farsalinos et al Sci Rep. 2014; 4: 4133
  • 6. Machine tests: depending on puff conditions and product features, ECIG can provide far less or far more nicotine than a tobacco cigarette (50-fold variation). Talih et al. Nicotine & Tobacco Research, Sept 2014
  • 7. E-cig global sales, $ million 2014: probably $5 billion <1% of tobacco cigarette market 190 350 700 1200 240 160 150 100 480 770 950 1200 0 500 1000 1500 2000 2500 2010 2011 2012 2013 USA China International (source: Philip Morris)
  • 8. England: prevalence of electronic cigarette use: smokers and recent ex-smokers 8 0 5 10 15 20 25 30 35 40 45 50 Percent of smokers and recent ex- smokers Any Daily Growth in prevalence of e-cigarette use has not increased since Q3 2013 N=14490 adults who smoke or who stopped in the past year; increase p<0.001 Source: STS - Smoking Toolkit Study
  • 10. USA: dollar share by company: convenience stores and XAOC = expanded all outlets combined (Nielsen bar code data) Lorillard Reynolds Logic NJoy Altria
  • 11. UK e-cigarette retail market share (%) Total U.K. retail market, including U.K. Major Multiples, Household, Impulse and Chemist Channels, 52 weeks ending Sept 2014. Source: Wells Fargo 33.6 32.8 11 6.7 3.3 2.1 1.9 1.4 1.4 1 0.9 0.9 3 UK 2014 Ecig Group (FIN, VIP, Ten Motives) Nicocig - PMI E-Lites - Japan Tob Halco blu - Lorillard Gamucci BAT Vapouriz Dekang NJOY Vapourlites Supreme Imports Other
  • 12. Tobacco company Brands of e-cigarette / vaporizers Altria MarkTen Green Smoke Reynolds + Lorillard, merged July 2014 Vuse SkyCigs Imperial Tobacco Blu (sold by Lorillard) Puritane + intellectual rights on Dragonite Japan Tobacco Ploom (tobacco vaporizer) E-Lites Philip Morris Nicolite iQos (heat not burn) + partners with Altria / MarkTen British American Tobacco Vype Intellicig (CNCreative) Voke (Nicoventures) ITC (Imperial Tobacco Company of India) Eon NTC (National Tobacco Company, distributor of Zig-Zag cig. paper) V2 Cig
  • 13.
  • 14. New nicotine + tobacco vaporizers: no combustion of tobacco Nicotine vaporizers, without tobacco: 1.E-cigarettes (3 broad categories: cig-alike, tank, mod) 2.Nicotine vaporizer using the technology of asthma vaporizers VOKE (Nicoventures = BAT: British American Tobacco): 3.Nicotine pyruvate (chemical reaction that vaporizes nicotine, Jed Rose) (PMI: Philip Morris, under development) Tobacco vaporizers: 1.Heated tobacco products, «heat not burn»: - electric heating (e.g. iQos by PMI, Chinese models) - charcoal heating (ember) 2.Hot air flow - Nespresso-like cartridge (Ploom: distributed by Japan Tobacco) - loose tobacco (various brands of vaporizers)
  • 15. iQos = Philip Morris heated tobacco product
  • 16. Pharmacokinetics: Philip Morris iQos Same speed as tobacco cigarette = iQos
  • 18. Voke: pharmacokinetics Delivery twice as quick as for Nicorette inhalator
  • 19. Ploom: tobacco vaporizer commercialized by Japan Tobacco
  • 20. Snus: first FDA application as reduced risk product (Swedish Match) For FDA registration as reduced risk product, applicant must show that: - the product is less harmful to the individual user - the total effect on the population is beneficial Very costly process, very long Will e-cig / vaporizers follow ?
  • 21. Philip Morris: 4 new reduced risk products See presentation on PM Investor’s day 2014: https://www.media-server.com/m/instances/8hjnb6wm/items/29n825fv/assets/75ngrwuk/0/file.pdf iQos Coal ember Nicotine pyruvate E-cig ‘cig-alike’
  • 22. Science + regulation are part of the tobacco industry’s business model
  • 23. Regulation: part of the tobacco industry business model
  • 24. Tobacco industry involvement New situation: tobacco industry sells reduced risk vaporizers Science Huge investments in R&D on vaporizers ($2bn for PMI only) Regulation Intense lobbying (EU, US, nationally) Large numbers of experienced, professional lobbyists Long tradition, historically strong influence on tobacco laws Suspicion that aim of tobacco industry involvement in regulation is to: . avoid “unfriendly” rules . raise technical + legal barriers at entry in this market . eliminate (Chinese) competitors + small players
  • 25. Tobacco industry: history Denied - that nicotine is addictive - risks of smoking - risks of passive smoking Produced bogus science Artificially created controversy, confusion Deception campaign to block smoking bans Will e-cig / vaporizers enable the tobacco industry to re-emerge as a legitimate stakeholder ?
  • 26. How to react to tobacco industry involvement ? Science: Need for independent research, not just research conducted by tobacco industry + its subsidiaries If collaborations emerge between academy + industry, there is a need to define conditions / limits Transparency is crucial Follow example of guidelines for academic collaboration with pharma industry A framework is needed to manage conflicts of interest
  • 27. Management of conflicts of interest Goals = protect the integrity of research, = preserve public trust Core principle = transparency Declaration of conflict of interest + registration of studies = insufficient Define policies, rules and restrictions, code of practice Rely on organizations / institutions that define + enforce + monitor these policies (national academy of sciences, ethics committees, etc.)
  • 28. Perspectives New situation: are we prepared ? We have no choice but to rethink academic + political interactions with the industries that produce nicotine + tobacco vaporizers Need for transparency Need to develop rules, policies Need for a debate involving all stakeholders