E-cigarettes: Evidence, perceptions and misconceptions. Martin Dockrell, Tobacco Control Programme Lead

Transcription

1 E-cigarettes: Evidence, perceptions and misconceptions Martin Dockrell, Tobacco Control Programme Lead

2 Smoking causes the greatest number of preventable deaths Are EC less tightly regulated in the UK than elsewhere? Did PHE s 2015 report mark a new policy direction? Are EC contributing to an increase in youth smoking? Is use among youth increasing rapidly? Have EC proven a gateway to smoking? How toxic are EC? How harmful is passive exposure? How effective are EC in helping smokers to quit? Are non smokers increasingly using EC? 2

3 Percent First some good news! Smoking prevalence in England (N=22079)(N=18990)(N=21137)(N=24794)(N=21879)(N=21330)(N=22167)(N=20170)(N=20026)(N=20437) 2017 Feb (N=3360) 3 Smoking Toolkit Study

4 Percent First some good news! 35 Success in stopping among those who tried (N=2533) 2008 (N=1829) 2009 (N=1833) 2010 (N=2068) 2011 (N=1637) 2012 (N=1627) 2013 (N=1729) 2014 (N=1485) 2015 (N=1317) Feb (N=1226) (N=192) 4 Smoking Toolkit Study

5 Are EC less tightly regulated in the UK than elsewhere? WHO recommendation Prevent the initiation among non-smokers and youth Action in England Age of sale of 18. Packs must state the products not for use by nonsmokers or children Minimise health risks to EC users and Prior notification of all new e-cigarette products; protect non-users from exposure limits nicotine concentration and size of tamper proof/child resistant refill containers requires information on safe use, contraindications/adverse effects Warnings on packs protected from breakage and leakage ingredients to be of high purity and not a risk to health Removal of products that do not comply Prevent unproven health claims Banned from the outset. 5 The Tobacco and Related Products Regulations 2016

6 Are EC less tightly regulated in the UK than elsewhere? WHO recommendation Protect tobacco control activities from vested interests related to EC Consider prohibiting or regulating EC, including as tobacco products, medicinal products, consumer products Consider banning or restricting advertising, promotion and sponsorship Comprehensively monitor the use of EC, including the relevant questions in all appropriate surveys Action in England The UK is a signatory to the WHO Framework Convention on Tobacco Control and has policies and procedures in place to protect health policy from the vested interests of the tobacco industry The UK provides both medicinal and consumer product regulatory frameworks for e-cigarettes. From May 2016 advertising of unlicensed EC in print, broadcast, online and other electronic media and sponsorship of large events and broadcast programming are prohibited. EC use among adults and children is comprehensively monitored by several national Government surveys Additional national and local surveys are undertaken by other organisations 6 The Tobacco and Related Products Regulations 2016

7 Did PHE s 2015 report mark a new policy direction? 2007 RCP Tobacco Harm Reduction 2008 Beyond Smoking Kills 2013 NICE Harm Reduction Guidelines 2015 Smoking Still Kills 2016 RCP Nicotine without smoke 7

8 Evidence reviews: PHE 2014 & 2015 While not completely risk free, e-cigarette use carries a fraction of the risk of smoking, with no evidence of harm to bystanders Now the most popular quitting aid in England and can be effective in helping people to stop smoking 2017: Updated evidence review on EC and novel tobacco products No evidence as yet that e- cigarettes are acting as a route into smoking for children or non-smokers Public perceptions about the relative risks of e-cigarettes and smoking have become increasingly inaccurate 8

9 Seeks to identify research priorities, discuss funding opportunities, generate ideas for new projects and promote collaboration. Pooling academic knowledge, identifying research gaps, setting new priorities Developed by Cancer Research UK (CRUK) in partnership with Public Health England (PHE) and the UK Centre for Tobacco and Alcohol Studies (UKCTAS) Brings together policy makers, researchers, practitioners and the NGO community to discuss the emerging evidence and identify gaps in the evidence. Aims to develop knowledge and understanding, inform policy and practice, and share best practice.

10 Use among youth increasing rapidly? Youth using e-cigarettes Never-used EC 60.0 Experimenter 50.0 Monthly or more user ASH Smokefree Youth

11 Uses EC at least monthly Do non smoking youth vape? E Cigarette use (by smoking status) Never smoker Former smoker Current smoker 60 All youth ASH Smokefree Youth

12 How toxic are EC? We found that the e-cigarette vapors contained some toxic substances. The levels of the toxicants were 9 to 450 times lower than in cigarette smoke and were, in many cases, comparable to trace amounts found in the reference product. Our findings are consistent with the idea that substituting tobacco cigarettes with electronic cigarettes may substantially reduce exposure to selected tobacco-specific toxicants. E-cigarettes as a harm reduction strategy among smokers unwilling to quit warrants further study. 12 Goniewicz, Maciej Lukasz, et al. "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes." Tobacco control (2013): tobaccocontrol-2012.

13 How toxic are EC? 13 Polosa, Riccardo, et al. "Success rates with nicotine personal vaporizers: a prospective 6-month pilot study of smokers not intending to quit." BMC public health 14.1 (2014): 1159.

14 How toxic are EC? 14 Nutt, David J., et al. "Estimating the harms of nicotine-containing products using the MCDA approach." European addiction research 20.5 (2014):

15 How toxic are EC? Nicotine equivalence Toxins and carcinogens 15 Nicotine carcinogen and toxin exposure in long term e-cigarette and NRT users. Shahab et al 2017

16 How toxic are EC? From May 2017, every e-cigarette on the UK market has been tested for major toxicants. Mostly undetectable or near undetectable other than Formaldehyde Acetaldehyde Acrolein All at levels a small fraction of that of tobacco smoke 16

17 What risk of passive exposure? 17 Fernández, Esteve, et al. "Particulate Matter from Electronic Cigarettes and Conventional Cigarettes: a Systematic Review " Current Environmental Health Reports (2015): 1-7.

18 What risk of passive exposure? 18 Protano, C., et al. "Second-hand smoke exposure generated by new electronic devices (IQOS and e-cigs) and traditional cigarettes." Ann Ig 28.2 (2016):

19 RCP 2016 report The hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco. In the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK. 19

20 Percent of smokers trying to stop How effective are EC in helping smokers to quit? E-cigs NRT OTC NRT Rx Champix Beh'l supp N=12244 adults who smoke and tried to stop or who stopped in the past year 20 Smoking Toolkit Study

21 How successful are EC in local services? Four week quit rates in English stop smoking services by therapy type ( ) Licensed meds and U NCP consecutively Varenicline only U NCP Licensed meds and U NCP concurrently No medication or NCP Bupropion only All types L NCP / Bupropion / Vareniciline concecutively Single L NCP Combination of L NCPs concurrently Not Known week quit rate Note: Unlicensed Nicotine Containing Product (UNCP) are usually e-cigarettes 21 LSSS Quarterly Monitoring

22 How widely EC used in local services? Percentage of succcessful quits by therapy Licensed med + UNCP consecutively 1% UNCP 1% Not Known 2% Comb licensed med + UNCP concurrently 3% Licensed NCP +/- Bupropion +/- Vareniciline consecutively 2% None 6% Single NCP only 24% Varenicline only 30% Comb. licensed NCPs concurrently 31% Bupropion only 0% Note: Unlicensed Nicotine Containing Product (UNCP) are usually e-cigarettes 22 LSSS Quarterly Monitoring

23 How toxic are EC? Popcorn Lung Diacetyl inhalation is a suggested causes of severe bronchiolitis obliterans or Popcorn workers lung 1 Diacetyl is found in EC vapour but at levels 1/10 th to 1/100 th the level of cigarette smoke 2 BO is rare and smoking has not been found to be a risk 1 There are 2 case reports of BO in long term smokers who use EC 3 23 Pierce, Jennifer S., et al. "Diacetyl and 2, 3-pentanedione exposures associated with cigarette smoking: implications for risk assessment of food and flavoring workers." Critical reviews in toxicology 44.5 (2014): Farsalinos, Konstantinos E., et al. "Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins." Nicotine & Tobacco Research 17.2 (2014): Mantilla, Ronnie D., Robert T. Darnell, and Umar Sofi. "Vapor Lung: Bronchiolitis Obliterans Organizing Pneumonia (BOOP) In Patient With E- Cigarette Use." D22. REDUCING HARMS OF TOBACCO USE. American Thoracic Society, A6513-A6513.

24 How toxic are EC? Popcorn Lung Diacetyl inhalation is a suggested causes of severe bronchiolitis obliterans or Popcorn workers lung 1 Diacetyl is found in EC vapour but at levels 1/10 th to 1/100 th the level of cigarette smoke 2 BO is rare and smoking has not been found to be a risk 1 There are 2 case reports of BO in long term smokers who use EC 3 Today the top suggestion for Popcorn on google is Popcorn lung The second is Popcorn lung and vaping 24 Pierce, Jennifer S., et al. "Diacetyl and 2, 3-pentanedione exposures associated with cigarette smoking: implications for risk assessment of food and flavoring workers." Critical reviews in toxicology 44.5 (2014): Farsalinos, Konstantinos E., et al. "Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins." Nicotine & Tobacco Research 17.2 (2014): Mantilla, Ronnie D., Robert T. Darnell, and Umar Sofi. "Vapor Lung: Bronchiolitis Obliterans Organizing Pneumonia (BOOP) In Patient With E- Cigarette Use." D22. REDUCING HARMS OF TOBACCO USE. American Thoracic Society, A6513-A6513.

25 Addressing misperceptions 25 ASH Smokefree GB

26 Harmful misperceptions The two main reasons smokers give for not using EC are don t want to swap on addiction for another (28%) and concerned they are not safe enough (23%) The belief among smokers that EC are at least as harmful as smoking is correlated with not trying EC The belief among vapers that EC are at least as harmful as smoking is highly correlated with continuing to smoke 16% of non vaping smokers say they would try them if I had confidence that they are safe to use. 26 ASH Smokefree GB

27 Conclusions The UK already has some of the most rigorous regulations We have a long track record in THR UK products are all tested and have low levels of toxicants There is little risk of passive exposure EC are helping smokers to quit We risk scaring smokers out of quitting We are continuing to monitor the evidence as it emerges 27

28 PS: NICE and PHE "Stoptober advice is completely in line with the NICE draft guidance. These are new products and naturally results of long term studies are only now emerging - strongly reinforcing the view that e-cigarettes carry a fraction of the risk of smoking. "We promote e-cigarettes as aids to stop smoking and when used in conjunction with other support, smokers have some of the highest success rates. Our recommendation is that people should receive advice on e- cigarettes so that they can make informed decisions on how to stop smoking "E-cigarettes are now the most popular quitting aid in England with growing evidence of their effectiveness, with similar or better results than nicotine replacement therapies such as patches. A recent BMJ study estimated that, in England, e-cigarettes lead to 16,000-22,000 additional smokers quitting a year. Our guidance is draft and we are keen to get feedback on the use of e- cigarettes during the consultation. 28