E-cigarettes
The future of smoking?
Hayden McRobbie
Reader in Public Health Interventions
Health and Lifestyle Unit
Wolfson Institute of Preventive Medicine
Declaration of Competing
Interests
• I am employed as a Reader in Public Health Interventions
at Queen Mary University of London
• I have received research funding from, and provided
consultancy to manufacturers of smoking cessation
medications
• I was an co-investigator in a public-good funded
ASCEND e-cigarette trial for which PGM
International provided products at no cost, and have
undertaken research on Ruyan e-cigarettes, for
which the University of Auckland was funded by
Health New Zealand, independently of Ruyan
The current state of play
• The majority of
smokers want to quit
• Smokers make
frequent quit
attempts
• Smokers are looking
for the next
innovation to help
them quit
ARE E-CIGARETTES A
GAME CHANGER?
1800’s
Disruptive technology
Pre-1880
1880
Gerry Stimson, Disruptive innovations: The rise of the electronic cigarette, International Journal of Drug Policy, May 2014
Increased consumption
Increased
production
Increased
consumption
EC as a disruptive
technology
The survey conducted in 2014 found that electronic cigarette use amongst never smokers
remains negligible. Only 1.1 per cent of never smokers have ever tried electronic cigarettes and
virtually
continue
use them.
Among former
ASH Fact
Sheet none
(2014).
Use of to
electronic
cigarettes
in Greatsmokers,
Britain 11.8 per cent have tried electronic
CONCERN: UPTAKE IN
CHILDREN AND NONSMOKERS
Use by children (US)
EVER use of electronic cigarettes – data from the
National Youth Tobacco Survey
0.7% of
never
smokers
0.5% of
never
smokers
COREY et al. (2013), Morbidity and Mortality Weekly
Report, 62, 729-30.
Use by children (UK)
Electr
oni
c cg
are
tte u
s a
m
og ch
i
lre
n In 2013, two thirds of 11-18 year olds and
f 83%
eof 16-18 year
aolds had heard
g of electronic
r
n
cigarettes.
• Among
children
that
have
heard
of
electronic
• Understa
nding o e
lc
tro
nic c
i
g
r
ettes a
m
o
n chi
l
den is g
e
er
a
ly g
oo
d
.
Children
who have heard of electronic cigarettes believe correctly that they are less harmful than
cigarettes,
use
rare
and
confined
to
cigarettes to the regular
user (74%) and those
aroundis
them
(79%). Most
(51%) 16-18
year olds r
who have h
heard of electronic
o
e cigarettes
d
believe
l o that they contain
t
t
nicotine.
d
• A mongo
cil
d
re
d
n w h currently
h
a
d
v h
e
a
rc
o
f ee
c
t
rnic c
ig
e
a
r
e
t
e
e
s , y
su
sta
i
n
e u
se is a
re
children
who
or
use
to
smoke
a
nd cnfine t
och
i
lre
n who
urr
e
nly or h
a
v p
rviou
sl sm
ok
ed
.
Of those
who had heard of electronic cigarettes, 7% (10% among 16-18 year olds) had tried
at least once.
Two percent reported
using them monthlyhaving
or weekly .
• Onlyelectronic
1%cigarettes
of never
smokers
reported
Among the 7% of children who reported some use of electronic cigarettes, only 28%
used them in the last month. Of those who had never smoked a cigarette, 99%
triedhad
them
“once or twice”
reported never having tried electronic cigarettes and 1% reported having tried them
“once or twice”. There is no evidence of regular electronic cigarette use among children
who have never smoked or who have only tried smoking once.
ASH Fact Sheet (2014). Use of electronic cigarettes in Great Britain
A gateway to smoking?
It’s difficult to
make that
conclusion
when smoking
prevalence is
DECREASING
US data show
that around
40% of
children try
regular
cigarettes.*
*Johnston et al. Monitoring the Future national survey results on drug use, 1975-2012. Ann Arbor: Institute for Social
Research, The University of Michigan; 2013; 2013. Report No.: Volume I: Secondary school student
Nicotine use by never and
ex smokers
The survey conducted in 2014 found that electronic cigarette use amongst never smokers
remains negligible. Only 1.1 per cent of never smokers have ever tried electronic cigarettes and
virtually none continue to use them. Among former smokers, 11.8 per cent have tried electronic
cigarettes but only 4.7 per cent use them on a regular basis.
Smoking Toolkit Study
www.smokinginengland.info
N=8,380 from Nov 2013
3.5
3
2.5
2
1.5
1
0.5
0
Never Long-term
smoker ex-smoker
E-cig
NRT
ASH Fact Sheet (2014). Use of electronic cigarettes in
2 ASH Fact Sheet onGreat
the use Britain
of electronic cigarettes in Great Britain
CONCERN: SAFETY
Toxicants
• A number of toxicants have been found in
EC liquid, e.g.
– acrolein and acetaldehyde
– metal and silicate particles
– tobacco-specific nitrosamines (TSNAs).
• These are either at lower levels than seen
in cigarette smoke or at levels that are not
associated with health risk
Burstyn 2014 BMC Public Health
Goniewizc 2013 Tobacco Control
EC nicotine delivery
Not all products are the same
2.4%
2.4%
18mg
Goniewicz, Hajek & McRobbie, 2014
Nicotine delivery in users
• 20 smokers completed 6 x 10puff bouts (separated by 30
minutes) on an 18 mg/ml e-cig
Vansickel et al Addiction 2012
• 8 experienced users (18-24
mg)
Vansickel & Eissenberg Nicotine & Tobacco
Research 2012
Different Devices
Farsalinos et al, Sci. Rep. 2014 http://dx.doi.org/10.1038/srep0413
Safety in users
• No SAEs related to EC in any study so far
• AEs mostly irritation and cough, same in
control conditions and in online forums on
adverse effects
• Several case reports (e.g. lipoid
pneumonia, atrial fibrillation)
• Increase in poison centre calls
– most related to unintentional exposure
– measures (e.g. childproof containers) to
prevent accidental poisoning are warranted
Exposures in perspective
http://www.clivebates.com/?p=2197#p22
So far, so good
• The general effects of long-term EC use
are not known
• There could be subtle chronic effects that
become apparent only some time
• We don’t know what these are or when they might
appear (so makes it hard to study)
• However any risks are likely to be a small
fraction of the risks of smoking
CONCERN: THEY MAY NOT
HELP PEOPLE TO STOP
SMOKING?
Effects on smoking
behaviour
• EC reduces urges to smoke
• EC use leads to reduced smoking and to
smoking cessation in healthy smokers,
even those not intending to quit; and in
smokers with schizophrenia
• EC with low nicotine vs. patches, no
support: Similar small effect on cessation,
but EC better on smoking reduction and
user approval
Smokers are already using them
for smoking cessation
(smokinginengland.info/latest-statistic)
N=4,935 adults who smoke and tried to stop or who stopped in the past year
Real-world effectiveness
5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that period
with either an e-cigarette only (n=464), NRT bought over-the-counter only (n=1922) or no aid in their most recent
quit attempt (n=3477)
25%
Self reported abstinence
20%
20.0%
adj OR=1.61 (95% CI: 1.19-2.18)
15%
15.4%
10.1%
10%
adj OR=1.63
(95% CI:
1.17-2.27)
5%
0%
E-cigarette
OTC NRT
No aid
Brown et al. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014 May 20. doi:
10.1111/add.12623. [Epub ahead of print]
User experience
Would use an electronic
cigarette to quit
smoking
Maybe
8%
Would use an nicotine
inhalator to quit
smoking
No
16%
Yes
24%
Yes
76%
No
64%
Maybe
12%
Steinberg et al (2014). E-Cigarette Versus Nicotine Inhaler: Comparing the Perceptions and Experiences of Inhaled Nicotine
Devices. J Gen Intern Med.
CONCERN: DUAL USE
Concerns: Dual Use
• Concern that dual use might
– Expose users to increased toxins
– People may not stop smoking conventional
cigarettes
Dual use and toxins
• In people who use both vape and smoke
there are significant reductions in
– Acrolein (a toxicant in tobacco smoke)
– Carbon monoxide
McRobbie H, Goniewicz M, Phillips A, Myers-Smith K, West O, Hajek P. Effects of the use of electronic cigarettes with and without concurrent
smoking on acrolein delivery. Society for Research on Nicotine and Tobacco, 20th Annual Meeting, Seattle, Washington; 2014.
Dual use and smoking
behaviour
1. Increased duration of e-cigarette use increased
the likelihood of being an ex-smoker (not dual
use)
2. Duration of e-cigarette use was not associated
with addiction to e-cigarette
3. The reported strength of e-cigarettes decreased
from initiation to current use (this was not affected
by duration of EC use of smoking history
Lechner W V et al. Nicotine Tob Res 2014;ntr.ntu061
MAKING SENSE OF IT ALL
Evaluating harm
•
•
•
•
•
•
•
•
•
•
•
Cigarettes
Cigars
Little and small cigars
Pipes
Water pipe
Smokeless (non-snus)
tobacco
Snus
E-cigarettes (ENDS)
Oral nicotine products
Patch
Nasal spray
Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach
Nutt, Phillips, Balfour, Curran, Dockrell, Foulds, Fagerstrom, Letlape, Milton, Polosa, Ramsey, Sweanor.
Eur Addict Res 2014;20:218-225
Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach
Nutt, Phillips, Balfour, Curran, Dockrell, Foulds, Fagerstrom, Letlape, Milton, Polosa, Ramsey, Sweanor.
Eur Addict Res 2014;20:218-225
The Precautionary Principle
• Based on an
examination of the
potential benefits
and costs of action
or lack of action
• Subject to review, in
the light of new
scientific data
When the facts
change, I change
my mind. What do
you do, Sir?
John Maynard Keynes
European Commission (2000) Communication from the Commission on the precautionary principle
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2000:0001:FIN:EN:PDF
CURRENT
RECOMMENDATIONS FOR
PRACTICE
Guidance
• Be open to electronic
cigarette use in people
keen to try them,
especially in those who
have tried and failed
using other aids
• Provide advice to
clients
http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf
Giving advice
• EC provide some of the nicotine that a smoker would
have otherwise obtained from smoking regular
cigarettes
• EC are not a magic cure, but some people find them
helpful
• There is a wide range of EC available and clients may
need to try various brands, flavours and nicotine
dosages before they find a brand that they like
• EC use is not exactly like smoking and users may
need to experiment and learn to use them effectively
• Although some health risks from EC use may yet
emerge, these are likely to be, at worst, only a small
fraction of the risks of smoking
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Health experts back e-cigarettes to quit
smoking
bbyy LLY
YN
ND
DS
SA
AY
YB
BU
UC
CK
KLLA
AN
ND
D
ELECTRONIC cigaret t es have been included for t he fi r st t im e in offi cial NHS Scot land guidance aim ed at helping sm okers
quit .
The new advice recognises the increased popularity of the sm oking simulators am ong people wishing to cut down their use of m ore
harm ful tobacco products.
It says that while those using NHS sm oking cessation services should be strongly encouraged to adopt licenced nicotine replacem ent
therapy (NRT), such as patches and gum , those wanting to use e-cigarettes should not be told to stop if there was a risk they would return
to tobacco.
• “…those wanting to
use e-cigarettes
should not be told to
stop if there was a
risk they would return
to tobacco. In the
past it is believed
some services have
turned away those
wanting to use ecigarettes as part of
their attempts to quit
smoking, meaning
they are denied other
forms of support
offered by the NHS
such as group
counselling.”
EC friendly services
• Leicester Stop
Smoking Service
supporting
people quitting
with the aid of EC
Concluding remarks
• We should not forget the goal of tobacco
control, which is ultimately to save lives
• Most people who smoke are desperate
to quit
• EC have become a popular stop
smoking aid
• So far there is little evidence for the
hypothetical risks and increasing
evidence for benefits
• Appropriate cautionary measures can be
still be applied (e.g. sales to minors,
consumer safety, surveillance) without
regulation that would impede further
development
Fanaticism consists
of redoubling your
effort when you
have forgotten your
aim.
(George Santayana)
Concluding remarks
• Stop smoking services still provide the best
support for stopping smoking
• Stop smoking practitioners now have an
opportunity to
– support people using EC through their quit
attempt
– provide advice based on the current evidence
– collect information that may inform future policy
– learn from clients using these devices