E-cigarettesThe future of smoking?

Hayden McRobbie

Reader in Public Health InterventionsHealth and Lifestyle Unit

Wolfson Institute of Preventive Medicine

• 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

Declaration of Competing Interests

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 consumptionIncreased production

Increased consumption

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)

0.5% of never

smokers

0.7% of never

smokers

COREY et al. (2013), Morbidity and Mortality Weekly Report, 62, 729-30.

EVER use of electronic cigarettes – data from the National Youth Tobacco Survey

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

0

0.5

1

1.5

2

2.5

3

3.5

E-cig NRT

Smoking Toolkit Studywww.smokinginengland.infoN=8,380 from Nov 2013

Nicotine use by never and ex smokers

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 HealthGoniewizc 2013 Tobacco Control

EC nicotine delivery

2.4%

2.4%

18mg

Not all products are the same

Goniewicz, Hajek & McRobbie, 2014

Nicotine delivery in users

Vansickel et al Addiction 2012

• 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

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

N=4,935 adults who smoke and tried to stop or who stopped in the past year

(smokinginengland.info/latest-statistic)

Real-world effectiveness

E-cigarette OTC NRT No aid0%

5%

10%

15%

20%

25%

20.0%

10.1%

15.4%

Self reported abstinence

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]

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)

User experience

Yes76%

Maybe8%

No16%

Would use an elec-tronic cigarette to quit

smoking

Yes24%

Maybe

12%

No64%

Would use an nicotine inhalator to quit smok-

ing

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

Lechner W V et al. Nicotine Tob Res 2014;ntr.ntu061

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

MAKING SENSE OF IT ALL

Evaluating harm

Estimating the Harms of Nicotine-Containing Products Using the MCDA ApproachNutt, Phillips, Balfour, Curran, Dockrell, Foulds, Fagerstrom, Letlape, Milton, Polosa, Ramsey, Sweanor.Eur Addict Res 2014;20:218-225

• 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 ApproachNutt, 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

European Commission (2000) Communication from the Commission on the precautionary principlehttp://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2000:0001:FIN:EN:PDF

When the facts change, I change my mind. What do

you do, Sir?

John Maynard Keynes

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