E-cigarettes and personal vapourisers: current research and policy

Declaration of interest

• I have no links with any e-cigarette manufacturers

• I have received no funding from the tobacco or pharmaceutical industries

• My research is funded by Cancer Research UK, National Institute of Health Research, Roy Castle, Chief Scientist’s Office, the EU and other government and charitable bodies.

Outline

• Context

• Our Reports

• Tobacco Dependence & Nicotine

• E-cigarette use

• Safety

• Smoking cessation

• Harm perceptions

• Conclusions

Source: Jonathan Gornall BMJ 2015;350:bmj.h2052

Health Secretary Vini Mhajan reacted: “Having done well

in the field of tobacco control in general, Punjab, with this conviction, has shown the way to the entire country to end the nicotine-delivery devices sold in the form of

e-cigarettes”

The international context

E-cigarettes are illegal in more than 50 countries

In India, 900,000 people die prematurely from tobacco use each year

Where we are now in the UK…

September 2015: The UK public health community issues a joint statement making clear that all the evidence suggests that e-cigarettes are significantly less harmful than smoking and current smokers should not be discouraged from using them. Some of the organisations who endorsed this have a UK wide remit, others just England. However, the differences between England & Scotland are small compared with the contrast between the UK & other countries. Research has played a very large part in shaping our policy context and current policies on e-cigarettes.

We had furthest to go

In the UK (and Scotland) in the 1950s 80% of men smoked. Now it is fewer than one in five, but still far too many.

“Smokers smoke for the nicotine, but die from the tar”

Professor Mike Russell, Maudsley Smokers Clinic, 1979

Michael Russell’s legacy

The UK’s approach to nicotine & tobacco harm reduction has its origins in the work of Professor Mike Russell, who trained some of our leading researchers

Harm reduction

• By 2006, smoking rates were falling steadily, we had smokefree legislation in Scotland and smoking cessation service uptake was good

• But something was missing. The Royal College of Physicians made the case for tobacco harm reduction (THR) as part of comprehensive tobacco control.

NICE Guidance

• This was followed by NICE guidance on THR

• Our committee met for two years to review all the evidence

• We produced practical guidance for the NHS and others

• We remain the only country in the world with a formal policy on THR

• Key elements of the NICE guidance were adapted by Health Scotland and informed smoking cessation service guidance here.

What did the guidance say?

• Stopping smoking is a priority but for those who struggle…

• Cutting down to quit is a valid approach, when combined with nicotine containing products (at the time, just NRT)

• NRT can be used for temporary abstinence

• Longer term nicotine use (i.e NRT use after cessation, even for years) is far safer than continued smoking.

E-cigarettes

• When we developed the NICE guidance, e-cigarettes were just emerging

• We used the term ‘nicotine containing products’ in the guidance, because we knew they may act like NRT and could become licensed

• Then their use escalated, none were licensed (despite hopes, medicine regulation could not be adapted to be ‘light touch’) and the guidance was quickly outdated

• New evidence reviews & recommendations were urgently needed

Some of our reports

Tobacco Dependence

Benowitz et al. (1982). Clin Pharmacol Ther, 32, 758-764.

Nicotine Delivery

E-cigarette use

Current Figures in Scotland

• The Scottish Health Survey is conducted by ScotCen Social Research. They added a question on e-cigarette use in 2014.

• In the 2015 survey 5000 adults were surveyed. • 7% of adults said they currently use e-cigarettes,

compared with 5% in 2014. • Current use of e-cigarettes was most common

among adults aged 25-64 (7-9%), although those aged 16-34 were the most likely to have ever tried e-cigarettes (22-26% compared with 4-10% of those aged 65 and over).

Current Smokers

The next four slides show more detailed analysis from the Smoking Toolkit Study in England, conducted by Jamie Brown, Robert West + colleagues at UCL and UKCTAS. We used these data in our RCP report ‘Nicotine without smoke’

Former Smokers (recent)

Former Smokers (long term)

Never Smokers

Safety

Defining safety

• Are electronic cigarettes safer than tobacco cigarettes?

• Safer = less harmful

• In discussions of safety the appropriate comparator is tobacco – both harm to users and bystanders

E-cigarettes as a harm reduction strategy

• In contrast to ‘reduced risk’ cigarettes no combustion takes place in e-cigarettes

• In contrast to smokeless tobacco, e-cigarettes are not tobacco products

• They contain nicotine and flavourings which can be toxicants, but toxicants present are at much lower levels than in tobacco

• All the evidence suggests e-cigarettes are safer than tobacco cigarettes

No Harm = no use at all

EXTREME

Toxicity Cigs - Combustibles

MUCH Less Harm Non combustible

Nutt DJ et al Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach – European Addiction Research March 2014

Not harmless but around 5% of the risks of smoking

• No differences in nicotine intake among users of any product, irrespective of smoking status

5. Study results Most recent study: Nicotine metabolites

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

0

50

100

150

200

250

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte-

on

ly s

mo

ker

leve

ls*

Total nicotine equivalents (95% CI)

0

20

40

60

80

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120

140

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

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leve

ls*

NNK (NNAL) (95% CI)

• Significant reduction in NRT/EC-only users compared with cigarette smokers

5. Study results Nitrosamines

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

97.5%

0

20

40

60

80

100

120

140

160

180

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*

Acrolein (3-HPMA) (95% CI)

• Significant reduction in NRT/EC-only users compared with cigarette smokers

5. Study results

Selected toxic volatile organic compounds

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

66.6%

0

20

40

60

80

100

120

140

160

180

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*

Acrylonitrile (CYMA) (95% CI)

• Significant reduction in NRT/EC-only users compared with cigarette smokers

5. Study results

Selected toxic volatile organic compounds

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

97.1%

0

20

40

60

80

100

120

140

160

180

200

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*

1,3-Butadiene (MHBMA3) (95% CI)

• Significant reduction in NRT/EC-only users compared with cigarette smokers

5. Study results

Selected toxic volatile organic compounds

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

89%

1) E-cigarettes are good nicotine delivery devices – Intake similar to combustible cigarettes > likely to be

effective for helping people stop smoking

2) Long-term use of e-cigarettes only is associated with reduced exposure to known smoking-related toxicants/carcinogens – Intake similar to NRT, a safe product > likely to result in

significantly reduced cancer (health) risks long-term

3) Dual use of e-cigarettes or NRT with combustible cigarettes does not appreciably reduce exposure to known smoking-related toxicants/carcinogens – Long-term health benefits of e-cigarette use only likely

following complete cessation of combustible cigarettes

6. Study conclusions

Take home messages

Toxicants in vapour

Source: Goniewicz et al, Tobacco Control, 2013

Risks to bystanders

• Several studies now exist comparing second hand smoke to second hand vapour

• Overall they show that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxicants

Earlier studies have focused on vapour exhaled by users but an additional recent one measured PM2.5 levels in vaping, smoking & non smoking homes. PM2.5 levels were similar between non smoking & vaping homes but much higher in the homes of smokers. However, newer studies suggest we might need to find different ways of assessing particulate matter exposure from e-cigs.

Smoking Cessation

Aids used in most recent quit attempt

38

0

5

10

15

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25

30

35

40

45

50

Perc

ent

of

smo

kers

try

ing

to s

top

E-cigs

NRT OTC

NRT Rx

Champix

Beh'l supp

N=11375 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 is still increasing

UK observational studies (use during quit attempts)

1. Cross-sectional study, smokers in England who used e-cigarettes to quit were significantly more likely to quit than smokers using no help or OTC NRT (Brown et al, Addiction, 2014)

2. Cohort study, International Tobacco Control Policy Evaluation Study, smokers in England and US who used e-cigarettes to quit were more likely to quit than smokers using no help or NRT but no more or less likely than using varenicline/bupropion (Hitchman et al, 2015)

3. New study, 18,000 smokers quit in England using e-cigarettes who would not otherwise have done so (Brown et al, BMJ, 2016)

Advising on E-cigarette Use

NICE Recommendation 5: Advising on licensed nicotine containing products

PHE and Health

Scotland agree that

cessation services

can offer

behavioural support

to those using e-cigs

in a quit attempt

NCSCT Recommendations: • Be open to e-cig use • Provide advice & support • Be positive about e-cigs • Many cessation services in Scotland now adopting this approach.

Pregnancy

Resources available from: http://www.smokefreeaction.org.uk/SIP/index.html

Use in pregnancy

To date we only have small surveys and qualitative studies on vaping in pregnancy

Pregnant women who smoke, or used to smoke, are using these devices. Up to one in four in some areas

What risks should we be concerned about?

Use in pregnancy

Nicotine use in pregnancy is safe in the form of Nicotine Replacement Therapy (Cooper et al, 2014). NRT is licensed for use by pregnant smokers + widely used in the UK

Nicotine is therefore not the main concern

Vaping around babies and children is unlikely to confer significant risk but PHE advice, particularly for childcare establishments, can assist https://www.gov.uk/government/news/vaping-in-public-places-advice-for-employers-and-organisations

Use in pregnancy More evidence on use in pregnancy is needed

particularly on effectiveness for smoking cessation amongst pregnant women and any impact on their children

A large randomised controlled trial will start later this year funded by NIHR to assess this in England and Scotland

In the meantime, we need to use what we know about e-cigarettes generally and the harms from smoking in pregnancy specifically in order to best support women.

• Suggested responses to some frequently asked questions about their use during pregnancy.

• Background information for healthcare professionals on electronic cigarettes.

Available here http://www.smokefreeaction.org.uk/SIP/files/eCigSIP.pdf

Guide for midwives on use of e-cigarettes in pregnancy

Endorsed by:

• Provides key information for pregnant women who are considering using electronic cigarettes to help them quit smoking

• Designed to be used in face-to-face consultations with women.

• Supports the detailed briefing. Available here: http://www.smokefreeaction.org.uk/SIP/files/SIPe-cig%20infographic.pdf

Infographic for women on use of e-cigarettes in pregnancy

But… Harm Perceptions

Perception of harm is going the wrong way

ASH Fact Sheet on the use of electronic cigarettes among adults in Great Britain, May 2016

7

22 21

10

39

15

35

17

2

30

22

34

19

2

23 25 30

15

1

28

0 5

10 15 20 25 30 35 40 45

More or equally harmful

Less harmful Lot less harmful

Completely harmless

Don't know

% o

f ad

ult

s in

GB

Perception of harm relative to cigarettes

2013 (n=8936) 2014 (n=11307) 2015 (n=11340) 2016 (n=11489)

• The evidence on e-cigarettes is developing rapidly with new studies published almost every week

• Led by Cancer Research UK, we have formed a national forum to keep people up to date.

• We also provide a monthly evidence briefing of the latest studies from a range of countries. This can be sent to anyone, you can sign up here: http://www.cancerresearchuk.org/about-us/we-develop-policy/our-policy-on-tobacco-control-and-cancer/uk-e-cigarette-research-forum

Conclusions

• E-cigarette use is prevalent in the UK, including Scotland, but confined to current or ex smokers

• E-cigarettes are far safer than tobacco • There is growing evidence of effectiveness for smoking

cessation • Worryingly, the general population and smokers have

misperceptions regarding relative harms – this needs to change

• New studies on e-cigarettes are being published on an almost weekly basis, and keeping abreast of the evidence is challenging. However, networks and good information sharing both within Scotland, across the UK and between countries can help and can continue to inform policy and practice.

Acknowledgements:

Ann McNeill, Robert West, Marcus Munafo,

John Britton, Maciej Goniewicz & colleagues

Linda.Bauld@stir.ac.uk

Linda.Bauld@cancer.org.uk