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E-Cigarettes - How should Public Health respond? - Linda Bauld
The document discusses the role of electronic cigarettes in public health and their potential as a harm reduction tool for smokers unable or unwilling to quit tobacco. It highlights the increase in e-cigarette use in the UK and Ireland, emphasizing their lower toxicity compared to conventional cigarettes but also notes the lack of regulation for many products. The report outlines the effectiveness of e-cigarettes in smoking cessation compared to other methods and raises questions about regulation and public health responses.
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E-Cigarettes - How should Public Health respond? - Linda Bauld
- 1. Electronic cigarettes:Electronic cigarettes: howshould 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 orderto 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.
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- 4. NICE & LicensedNicotine 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-containingproductsNICE & 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: inventorof the Ruyan (“Hon Lik: inventor of the Ruyan (“resembling smoking”resembling smoking” )) e-cigarette, marketed 2004e-cigarette, marketed 2004
- 7. Anatomy ofAnatomy ofanan e-cigarettee-cigarette
- 8. Development of devicesDevelopmentof devices
- 9. Growth in useGrowthin 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 • propylenglycol • glycerin • water • flavourings What is in a cartridge ?
- 12. • The Foodand 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 useamongCurrent 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 bynever 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?Useby children?
- 16. Survey of childrenin 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
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- 20. Do e-cigarettes delivernicotine? 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?Toxicantsin 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 studyconducted 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 thevapour?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 ofE-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 EnglandEffectivenessin 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 fordifferencesAfter 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 ofdifferentSuccess 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 beenan 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 hasdecreased 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 prevalenceCigarettesmoking 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?Alicensed 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 discussionPointsfor 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?
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Editor's Notes
- #8 The device uses heat to vaporize a propylene glycol- or glycerin-based liquid solution into a mist, similar to the way a nebulizer or humidifier vaporizes solutions for inhalation. The device&apos;s components usually include a small liquid reservoir, a heating element, and a power source, normaly a battery
- #9 The device uses heat to vaporize a propylene glycol- or glycerin-based liquid solution into a mist, similar to the way a nebulizer or humidifier vaporizes solutions for inhalation. The device&apos;s components usually include a small liquid reservoir, a heating element, and a power source, normaly a battery
- #17 Use amongst 11-18 year-olds 7% had tried e-cigarettes at least once 2% reported using them ‘sometimes’ (more than once a month) or ‘often’ (more than once a week) 28% of those who had ever used e-cigarettes, had used them within the last month Use by age 16-18 years: 11% had tried e-cigarettes at least once; 8% reported using them sometimes; and 1% using them often 11-15 years: 4% had tried them at least once and 1% reported using them sometimes; none reported more frequent use. 95% 11-15 year-olds and 90% 16-18 year-olds had never used e-cigarettes
- #27 So, in our survey of just under 6,000 smokers we found that…A total of…
- #28 Therefore, the key finding is the result after we adjust for differences in a range of socio-demog and smoker characteristics. In these adjusted models, we found that…