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 4 per min to 200 per min (James Bonsacks Smokinhg Machine) Pre-1880 1880 Gerry Stimson, Disruptive innovations: The rise of the electronic cigarette, International Journal of Drug Policy, May 2014

Increased consumption Increased production

EC as a disruptive technology ASH Fact Sheet (2014). Use of electronic cigarettes in Great Britain

Concern: Uptake in children and non-smokers

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 Recent US report: In 2012, never smokers who reported ever trying EC Middle School (aged 11-14): 0.5% High School (aged 14-18): 0.7% In 2011, 39.5% of US children tried cigarettes by the age of 18 Corey et al. (2013), Morbidity and Mortality Weekly Report, 62, 729-30.

Use by children (UK) Among children that have heard of electronic cigarettes, regular use is rare and confined to children who currently or use to smoke Only 1% of never smokers reported having tried them “once or twice” 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 Smoking Toolkit Study www.smokinginengland.info N=8,380 from Nov 2013 ASH Fact Sheet (2014). Use 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

Not all products are the same 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 10-puff bouts (separated by 30 minutes) on an 18 mg/ml e-cig 8 experienced users (18-24 mg) Vansickel & Eissenberg Nicotine & Tobacco Research 2012 Vansickel et al Addiction 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) adj OR=1.61 (95% CI: 1.19-2.18) adj OR=1.63 (95% CI: 1.17-2.27) 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 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 Increased duration of e-cigarette use increased the likelihood of being an ex-smoker (not dual use) Duration of e-cigarette use was not associated with addiction to e-cigarette 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

A change “…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 e-cigarettes 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