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.

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. 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. 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. E-cigarettes: What are they?
vaporisers

5. “ We don’t know anything
about them”
“There’s been no research
on them”

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. “ They’re not regulated”

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. 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. “Young people
are using them”
“Non-smokers
are using them”
“Everyone’s
using them”

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. 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. 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. “They contain nicotine
so it’s just swapping one
addiction for another”

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. 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. 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. “My
wife/boss/friend/agony
aunt/dog etc. uses it
constantly. S/he must be
getting more nicotine ”

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. “ They’re always
exploding”
“They catch fire”

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. • 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. “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. 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

26. • 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.

27. 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

28. • 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.

29. 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.

30. E-cigarettes are
far less harmful
than cigarette
smoking

32. “They don’t help smokers to stop
smoking”

33. 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

34. 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.

35. 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.

36. 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

37. 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

38. “They may lead young
people to start smoking”

39. 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

40. 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

41. 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)

42. 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

43. No compelling evidence that EC are
attracting significant numbers of
young people who would not
otherwise have smoked.

44. 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

45. 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:

46. 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/

47. Questions?