Reframing the E-cigarette Debate To Address Genuine Harm Reduction

Transcription

1 Reframing the E-cigarette Debate To Address Genuine Harm Reduction Michael J. Thun, M.D., M.S. National Tobacco Control Conference Washington DC December 2, 2014

2 Debates over regulation of E-cigarettes and other ENDS often framed as the Purists vs. the Pragmatists

3 False Construct - Those who favor regulation are labeled Purists (i.e. fanatics who consider any form of nicotine addiction to be evil ). - Those who dispute the need for regulation characterize themselves as Pragmatists (i.e. those who accept the inevitability of nicotine addiction and contend that e-cigarettes will displace more harmful combustible products).

4 The pragmatists contend that whatever toxicity e-cigarettes have cannot possibly be as bad as conventional cigarettes.

5 But The real issue is how to develop prudent & effective public health policy in the context of important unknowns

6 What Are the Most Important Unresolved Questions? 1. Are e-cigarettes better than existing cessation therapies to help smokers quit? 2. What are the long-term health problems from using ENDS? 3. Are e-cigarettes a gateway to (or a replacement for) cigarette smoking among non-smoking youth?

7 I will discuss briefly: - The criteria for true Harm Reduction - The disconnect between the stated goal of harm reduction and the current marketing of e-cigarettes. - A recent example of harm reduction gone terribly awry

8 Part I Criteria for Harm Reduction The product must: - Reduce risks for individual smokers & - Reduce harms from tobacco use in the overall population

9 Do E-Cigarettes Reduce the Risks for Individual Smokers? Only if: - E-cigarettes are more effective than established cessation therapies in helping smokers quit. & - Smokers quit entirely or use e-cigarettes exclusively.

10 Otherwise - Smokers who continue to smoke but also use E-cigarettes (dual use) will increase their individual risk if this delays cessation. - Dual use ( For when you can t smoke ) was once the industry rationale for marketing e-cigarettes.

11 How Might E-cigarettes Adversely Affect Health at the Population Level? If they: - Increase uptake among adolescents who would not otherwise use tobacco. - Renormalize cigarette smoking - Have unanticipated health effects - Provide a gateway to smoking combustible tobacco products

12 Part 2 The disconnect between the goal of Harm Reduction and the current marketing of e-cigarettes

13 Much of the advertising and promotion of e-cigarettes is aimed at the youth market, not smokers

14 E-cigarette Flavors

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16 E-cigarette Flavors

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23 ports Illustrated Swimsuit Edition

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25 Cautionary Tale of Harm Reduction Gone Terribly Awry

26 Tar (mg) Nicotine (mg) Decrease in Average Machine-Measured Tar and Nicotine in US Cigarettes s Cellulose acetate filters 1959 More porous cigarette paper Late 1960s Expanded tobacco TAR 1970s Air ventilation holes NICOTINE Values before 1968 are estimated from available data D. Hoffman personal communication Year Source: Modified from NCI Smoking and Tobacco Control Monograph 1997, p

27 Smoking Machines - Developed by tobacco industry in 1930s. - Adopted by FTC in 1967/1968.

28 Many studies conducted since the 1960s reportedly showed lower lung cancer risk with lower tar yield.

29 Epidemiologic studies of Low yield, cigarettes & lung cancer and lung cancer, Bross 1969 Hammond 1977 (M) Hammond 1977 (W) Hawthorne 1978 Todd 1978 Wynder 1979 (M) Wynder 1979 (W) Rimington 1981 Lee 1981 (M) Lee 1981 (W) Vutuc 1982 (W) Borland 1983 Vutuc 1983 (M) Lubin 1984 (M) Lubin 1984 (W) Benhamou 1985 Alderson 1985 (M) Alderson 1985 (W) Pettiti 1985 Buffer 1986 Pathak 1986 Benhamou

30 American Cancer Society Public Relations Ad

31 What epidemiologists weren t aware of: Barclay Grooved Filter We seem to have found a cigarette that shows low deliveries on machine smoking and much higher deliveries when people smoke it memo from filter inventor RR Johnson to Brown & Williamson executives - not recorded in Johnson s official laboratory notebook. Source: Kozlowski et al Tob Control 2005;14:64-70.

32 Tar (mg) Nicotine (mg) Epidemiologists largely unaware of the distinction between ventilated & unventilated filter tip cigarettes s Cellulose acetate filters 1959 More porous cigarette paper Late 1960s Expanded tobacco TAR 1970s Air ventilation holes NICOTINE Values before 1968 are estimated from available data D. Hoffman personal communication Year Source: Modified from NCI Smoking and Tobacco Control Monograph 1997, p

33 Smoking machines do not accurately simulate humans smoking modern cigarettes Smoking machine protocol * Actual yield to smoker * Puff volume 35 ml ml Puff frequency Amount of cigarette smoked Every 60 sec. Stops at specified length sec. Every 30 All Machines also do not capture deeper inhalation, length of retention, and greater surface area of lung tissue being exposed. * Hammond D et al, Lancet 2006

34 We expected lung cancer risk to decrease over this period in smokers. 34

35 Contrary to expectation Our analyses found that lung cancer risks in smokers increased from CPS-I to CPS-II in men & women. 35

36 Rate per 100,000 Age-specific lung cancer mortality increases among women who smoke across all three time periods Contemporary CPS-II CPS-I Attained Age 36

37 Rate per 100,000 Age-specific lung cancer death rates continue to increase in male smokers until the 1980s Current Smokers Contemporary CPS-II CPS-I Attained Age 37

38 Conclusions - True Harm reduction is defined by the outcome, not by enthusiasm for the concept. - Current promotion of e-cigarettes is aimed at maximizing sales, not at harm reduction. - There are major uncertainties about the ultimate effect of e-cigarettes on both individual and population risk. - What is certain is that unregulated marketing is detrimental. 38

39 What Would He Do? 39

40 Thank You