E-Cigarettes - How should Public Health respond? - Linda Bauld. Presented on Thursday 5th June 2014.

1. Electronic cigarettes:Electronic cigarettes:
how should public healthhow should public health
respond?respond?
Linda BauldLinda Bauld
With thanks to
Maciej L. Goniewicz,
John Britton, Robert West
& Martin Dockrell

2. BackgroundBackground
 In order to consider how and where e-cigarettesIn order to consider how and where e-cigarettes
feature in the current public health landscape,feature in the current public health landscape,
it’s important to take into account recentit’s important to take into account recent
developments indevelopments in tobacco harm reductiontobacco harm reduction
 Harm reduction measures are aimed at thoseHarm reduction measures are aimed at those
smokers who, for whatever reason, are not ablesmokers who, for whatever reason, are not able
or willing toor willing to stop using tobaccostop using tobacco oror stop using nicotine.stop using nicotine.

3. BackgroundBackground

4. NICE & Licensed Nicotine Products
 The harm reduction approaches in the NICE guidanceThe harm reduction approaches in the NICE guidance
can involve substituting the nicotine in tobacco withcan involve substituting the nicotine in tobacco with
nicotine from less harmful, nicotine-containing products.nicotine from less harmful, nicotine-containing products.
 These include NRT products that are licensed by theThese include NRT products that are licensed by the
MHRA as pharmaceutical treatments for smoking.MHRA as pharmaceutical treatments for smoking.
 There are also unregulated products such as electronicThere are also unregulated products such as electronic
cigarettes. The guidance only recommends use of licensedcigarettes. The guidance only recommends use of licensed
products recognising that when electronic cigarettesproducts recognising that when electronic cigarettes
become licensed, they can be recommended for use.become licensed, they can be recommended for use.
 Nicotine-containing products might be used eitherNicotine-containing products might be used either
temporarily or indefinitely and as a partial or completetemporarily or indefinitely and as a partial or complete
substitute for tobaccosubstitute for tobacco

5. NICE & Nicotine-containing productsNICE & Nicotine-containing products
The guidance states that:The guidance states that:
There is reason to believe that lifetime use of licensedThere is reason to believe that lifetime use of licensed
nicotine-containing products will be considerably lessnicotine-containing products will be considerably less
harmful than smokingharmful than smoking
There is little direct evidence on the effectiveness, qualityThere is little direct evidence on the effectiveness, quality
and safety of nicotine-containing products that are notand safety of nicotine-containing products that are not
regulated by the MHRA. However, they are expected to beregulated by the MHRA. However, they are expected to be
less harmful than tobacco.less harmful than tobacco.

6. Hon Lik: inventor of the Ruyan (“Hon Lik: inventor of the Ruyan (“resembling smoking”resembling smoking” ))
e-cigarette, marketed 2004e-cigarette, marketed 2004

7. Anatomy ofAnatomy of anan e-cigarettee-cigarette

8. Development of devicesDevelopment of devices

9. Growth in useGrowth in use
 There are now an estimated 2.1 million users in the UKThere are now an estimated 2.1 million users in the UK
 In the Republic of Ireland in 2012 the EurobarometerIn the Republic of Ireland in 2012 the Eurobarometer
survey found that 3% of the Irish population had eversurvey found that 3% of the Irish population had ever
tried e-cigarettes and 1% used them regularlytried e-cigarettes and 1% used them regularly
 In the UK by 2014 ever use rose by a factor of 1.9 andIn the UK by 2014 ever use rose by a factor of 1.9 and
current use by 1.7. If a similar rise happened in Ireland,current use by 1.7. If a similar rise happened in Ireland,
we can assume 1.7% of the population regularly use ecigswe can assume 1.7% of the population regularly use ecigs
and 5.6% have ever tried themand 5.6% have ever tried them
 Amongst smokers in Ireland, we can estimate that aroundAmongst smokers in Ireland, we can estimate that around
1/3 (34%) have tried them but the figure may now be1/3 (34%) have tried them but the figure may now be
higher.higher.
Source: Eurobarometer and personal correspondence with Fenton Howell

10. Stop smoking aids (England)Stop smoking aids (England)
Source: West et al (2014)
www.smokinginengland.info/lateststatistics
20% use NRT from store
25% use e-cig
40% use nothing

11. • nicotine
• propylen glycol
• glycerin
• water
• flavourings
What is in a cartridge ?

12. • The Food and Drug Administration (FDA) has classified PG as an additive
that is “generally recognized as safe” for use in food.
• It is used to absorb extra water
and maintain moisture in certain
medicines, cosmetics, or food
products.
• PG is also used to create
artificial smoke or fog used
in theatrical productions.
• PG is practically odorless
and tasteless.
PropylenPropylenee GlycolGlycol

13. Current e-cigarette use amongCurrent e-cigarette use among
adults in England 2014adults in England 2014
13
ASH/YouGov March April 2014, Sample in England 10,112

14. Nicotine use by never smokersNicotine use by never smokers
and long-term ex-smokersand long-term ex-smokers
Source: West et al, 2014 N=5,272 from Nov 2013
E-cigarette use by never smokers is negligible

15. Use by children?Use by children?

16. Survey of children in GB 2013Survey of children in GB 2013
95%
90%
4%
8%
1%
1%
0%
1%
0% 25% 50% 75% 100%
11to15(N=804)16to18(N=624)
I use them often
(more than once a
week)
I use them sometimes
(more than once a
month)
I have tried them once
or twice
I have never used
them
99%
92%
82%
74%
59%
39%
8%
7%
18%
37%
48%
6%
4%
7%4%
5%
0%
25%
50%
75%
100%
Never
smoked
Tried smoking
once
Used to
smoke
Smoke <1 a
week
Smoke 1-6 a
week
Smoke 6+ a
week
Don't know/
Wouldn't say
I use them often
(more than once a
week)
I use them
sometimes (more
than once a month)
I have tried them
once or twice
I have never used
them
Source: ASH, 2014
Frequency of e-cigarette
use amongst 11-18 year olds
who had ever heard of
e-cigs
E-cigarette use by smoking
status, 11-18 year olds

17. E-cigarette/smoking by children: USAE-cigarette/smoking by children: USA
Source: US CDC data from National Youth Tobacco Survey 2011 and 2012. Graph from Bates & Rodu

18. E-cigarette marketingE-cigarette marketing

19. E-cigarette marketingE-cigarette marketing

20. Do e-cigarettes deliver nicotine?
E-cigarettes generate vapor that contains nicotine, but e-cigarettes brands
and models differ in efficacy and consistency of nicotine vaporization.
In e-cigarettes that vaporize nicotine effectively, the amount inhaled from
15 puffs is lower than smoking a conventional cigarette.

21. Toxicants in e-cigarettes?Toxicants in e-cigarettes?
 Other than nicotine, whatOther than nicotine, what
else do e-cigarettes deliver?else do e-cigarettes deliver?
 A number of studies haveA number of studies have
looked at this, with at least 8looked at this, with at least 8
toxic compounds identifiedtoxic compounds identified
 However all of these were atHowever all of these were at
significantly lower levels thansignificantly lower levels than
in conventional cigarettesin conventional cigarettes

22. • Small study conducted by Goniewcz and colleagues involving 20 tobacco cigarette
smokers
• Subjects were provided with electronic cigarettes with cartridges containing nicotine
• Subjects were asked to substitute their regular cigarettes with e-cigarettes for 2 weeks
• Researchers measured nicotine and selected carcinogens in their bodies
Exposure to toxicantsExposure to toxicants
after switchingafter switching

23. Nicotine & Tobacco-specificNicotine & Tobacco-specific
NitrosaminesNitrosamines

24. What about the vapour?What about the vapour?
 Should we be concerned about e-cigaretteShould we be concerned about e-cigarette
vapour in enclosed public places?vapour in enclosed public places?
 Lab studies suggest that the vapour containsLab studies suggest that the vapour contains
nicotine and some toxic metals such as cadium,nicotine and some toxic metals such as cadium,
nickel and lead, but levels are much lower thannickel and lead, but levels are much lower than
in second hand smokein second hand smoke
 No current evidence of health harms fromNo current evidence of health harms from
occasional exposureoccasional exposure
 However the effects of regular exposure overHowever the effects of regular exposure over
many years is unknown.many years is unknown.

25. Cessation: RCTs of E-cigarettesCessation: RCTs of E-cigarettes
• ‘‘Categoria’ 7.2mg nicotine EC vs. 4.8mgCategoria’ 7.2mg nicotine EC vs. 4.8mg
nicotine EC vs. no nicotine ECnicotine EC vs. no nicotine EC
 300 smokers (unwilling to quit)300 smokers (unwilling to quit)
 1 year abstinence rates: 13%, 9% and 4%1 year abstinence rates: 13%, 9% and 4%
(Caponnetto et al. 2013)(Caponnetto et al. 2013)
• ‘‘Elusion’ 16mg nicotine EC vs. nicotineElusion’ 16mg nicotine EC vs. nicotine
patch vs. no nicotine ECpatch vs. no nicotine EC
 657 participants657 participants
 6 month abstinence rates: 7.3%, 5.8% and6 month abstinence rates: 7.3%, 5.8% and
4.1%4.1%
(Bullen et al. 2013)(Bullen et al. 2013)

26. Effectiveness in EnglandEffectiveness in England
Source: West et al (2014)
www.smokinginengland.info/lateststatistics
E-cigarette users were more likely
not to be smoking than those using
NRT bought from a store and those
using nothing
**
** Significantly different from both other groups

27. After adjusting for differencesAfter adjusting for differences
between groupsbetween groups
Source: West et al (2014)
www.smokinginengland.info/lateststatistics
The odds of e-cigarette users still
being abstinent were 61% greater
than those using nothing and 63%
greater than those using NRT

28. Success rates of differentSuccess rates of different
methods of quittingmethods of quitting LowestLowest
 Nothing or NRT bought from aNothing or NRT bought from a
storestore
 HigherHigher
 Prescription NRT/medicine or e-Prescription NRT/medicine or e-
cigarette from a store (about 50%cigarette from a store (about 50%
better)better)
 HighestHighest
 Specialist support from NHSSpecialist support from NHS
Stop-Smoking Service (aboutStop-Smoking Service (about
200% better)200% better)

29. There has been an increase in the
rate of quitting smoking
More smokers are quittingMore smokers are quitting
•Source: West et al, 2014 ENGLAND ONLY Base: All adults

30. Cigarette consumption has decreased
as has overall nicotine use
Fewer people are using nicotineFewer people are using nicotine
•Source: West et al, 2014 ENGLAND ONLY Base: All adults

31. Cigarette smoking prevalenceCigarette smoking prevalence
Source: West et al, 2014 ENGLAND ONLY Base: All adults
Prevalence is declining faster than in
previous years since 2008

32. A licensed product?A licensed product?
NicoventuresNicoventuresVokeVoke inhaled nicotineinhaled nicotine

33. RegulationRegulation
 Medicine’s “walledMedicine’s “walled
garden”?garden”?
• ““Safe” and “effective”Safe” and “effective”
• Therapeutic doseTherapeutic dose
• AdvertisingAdvertising
• VAT 5%VAT 5%
 EU’s “NicotineEU’s “Nicotine
Jungle”?Jungle”?
• Health warning on packHealth warning on pack
• Concentration capConcentration cap
• No health claimsNo health claims
• Ad banAd ban
• 20% VAT20% VAT
• Declaration of additivesDeclaration of additives

34. Points for discussionPoints for discussion
• In the struggle to reduce preventable mortality, how do weIn the struggle to reduce preventable mortality, how do we
balance the risks?balance the risks?
• What are the ongoing evidence needs and how do we addressWhat are the ongoing evidence needs and how do we address
them?them?
• Do we need to test diverse responses or do we need a “oneDo we need to test diverse responses or do we need a “one
size fits all” international response now?size fits all” international response now?
• How do we manage tobacco industry involvement and whatHow do we manage tobacco industry involvement and what
scope is there to use the Framework Convention on Tobaccoscope is there to use the Framework Convention on Tobacco
Control?Control?

35. Thank youThank you
Linda.Bauld@stir.ac.ukLinda.Bauld@stir.ac.uk