E-cigarettes: pros, cons and controversy

Dr Laura-Jane SmithNon-smoker, Non-vaper

SpR Respiratory and General MedicineTraining Day, North East Thames Respiratory Medicine

Whittington HealthJune 2015

e-cigarettes: pros, cons and controversy

CaseNick, a 48 year old politician, attends clinic for follow-up after an admission for flu. He is well and his chest x-ray is normal.

He has a 35 pack year history. During his inpatient stay he met a smoking cessation counselor and expressed a wish to quit. He went home on NRT but, after a stressful time at work, he went back to smoking.

Dr, I was thinking about trying those e-cigarettes. What

do you think?

Vote

Know your enemy/friend

Reasons to be cautious

Reasons to be cheerful

Hard evidence

Soft recommendations

What are e-cigarettes?

An electronic cigarette that is rechargeable and has a tank or reservoir which has to be filledwith liquid nicotine/vapour

Disposable products (non-rechargeable)

An electronic cigarette kit that is rechargeable with replaceable pre-filled cartridges

HISTORICAL CONTEXT

Quiz

1572

• Sir Francis Drake introduces pipe smoking to Britain

1600s

• Pope bans smoking in holy places

1605

• First RCP debate on smoking. Concerns of King James I dismissed

1761

• London physician, John Hill, performs possibly first clinical study on tobacco. Warns snuff users at risk of nasal cancer

1908

• Children’s Act bans sale of tobacco to under-16s

1939

• “Tobacco misuse and lung carcinoma” Franz Herman Muller. First major report to find strong link between smoking & lung cancer

1947

• A 43% increase in tax on cigarettes results in a 14% drop in consumption amongst British men

1951

• Doll &Bradford-Hill epidemiological study of smoking and lung cancer. Of 1357 men with lung cancer 99.5% were smokers

1958

• First smoking cessation clinic established in Salford

1962

• RCP report “Smoking and Health”

1963

• First patent for an e-cigarette

1965

• Cigarette advertising banned on TV

1971

• First government health warning on cigarette packs

1988

• BA bans smoking on domestic flights

1992

• Sales of tobacco products in hospital shops ceases

1994

• Latest figures from Doll study shows ½ smokers die from smoking-related diseases

1997

• Sponsorship of sporting events banned

2004

• Ireland is first place to ban smoking in workplaces and public places

2007

• Scotland and England go smoke free in public places. Age raised to 18.

2013

• E-cigarettes are advertised on TV

2014

• Ban on smoking in cars with children

2015

• Plain packs passed in House of Commons

http://www.ash.org.uk/files/documents/ASH_741.pdf

Prevalence of electronic cigarette use: smokers and recent ex-smokers

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

2014-2

2014-3

2014-4

2015-105

101520253035404550

AnyDaily

Perc

ent o

f sm

oker

s and

rece

nt e

x-sm

oker

s

N=16529 adults who smoke or who stopped in the past year; increase p<0.001

www.smokinginengland.info/latest-statistics

2.1 million users in Great Britain

Prevalence of nicotine products while smoking

12

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

2014-2

2014-3

2014-4

2015-105

101520253035404550

E-cigsNRTAll nicotine

Perc

ent o

f sm

oker

s

N=15433 smokers, increase p<0.001 e-cigs and all nicotine; decrease p<0.001 for NRT

NRT use continues to decline (slowly) even after plateau in e-cigarette use


Prevalence of nicotine products in recent ex-smokers

13

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

2014-2

2014-3

2014-4

2015-10

10

20

30

40

50

60

70

E-cigsNRTAll nicotine

Perc

ent o

f ex-

smok

ers

N=1096 adults who stopped in the past year; increase p<0.001 for e-cigs and all nicotine; decrease p=0.003 for NRT

There continues to be an increase in use of e-cigarettes in recent ex-smokers


Pro Con

Do not help patients quit

‘Gateway’ for children

Unknown health risks

Distract from smoking cessation /tobacco

control

Reduce harms from smoking

Help patients quit smoking

Safe

Being chosen by public

The

deba

te

ARE E-CIGARETTES SAFE?What’s the evidence?

First do no harm

Cigarettes kill ½ of regular usersIt is not difficult to be less harmful than cigarettes

But are e-cigarettes safe? – Contain ultrafine particles and carcinogens– How much is inhaled by usual use?– Paucity of evidence– Variability and unregulated nature of devices– Fires– Poisoning

“the electronic cigarette is not a proven nicotine replacement therapy. WHO has no scientific evidence to confirm the product’s safety and efficacy. However, WHO does not discount the possibility that the electronic cigarette could be useful as a smoking cessation aid. The only way to know is to test.”

Ale Alwen, the Assistant Director General for Non-communicable Diseases and Mental Health, August 2008

Particles/vapours/carcinogens

Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco control. 2014;23(2):133–9.

“…one would expect that if a person switched from conventional cigarettes to e-cigarettes the exposure to toxic chemicals and related adverse health effects would be reduced.”

“How formaldehyde-releasing agents behave in the respiratory tract is unknown, but formaldehyde is an International Agency for Research on Cancer group 1 carcinogen.”

Jensen P, Wentai L, Pankow J, Strongin, R, Peyton D. Hidden Formaldehyde in E-Cigarette Aerosols. New England Journal of Medicine. 2015 Jan 22;372(4):389–92.

Low voltage (3.3 V): did not detect formation of any formaldehyde-releasing agents High voltage (5.0 V): a mean (±SE) of 380±90 μg per sample (10 puffs) of formaldehyde was detected as formaldehyde-releasing agents.

The importance of puff

topograpy

Objections

Fires

http://www.bbc.co.uk/news/uk-england-merseyside-28701515.

http://www.bbc.co.uk/news/uk-england-merseyside-28701515

http://www.bbc.co.uk/news/uk-england-merseyside-28701515

Poisoning

Is this picture true?

Vape sites and blogs make bold claims about safety and harm-free use, which is premature. We will have to wait a decade or two before we really know anything. In the meantime patients

ask our advice…

DO E-CIGARETTES REDUCE TOBACCO HARM AT INDIVIDUAL LEVEL?

What’s the evidence?

Nicotine use by never smokers and long-term ex-smokers

Never smoker Long-term ex-smoker0

0.5

1

1.5

2

2.5

3

3.5

4

E-cig NRT

Perc

ent

25

N=22489 never and long-term ex-smokers from Nov 2013

E-cigarette use by never smokers is negligible


Lancet RCT

vs

Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman Jonathan, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet. 2013;382:1629–37.

Pragmatic randomised-controlled superiority trial in Auckland, New Zealand. 13 wks of e-cigarettes vs placebo vs NRT patches with outcome of 6 month abstinence.

Do e-cigarettes reduce tobacco harm at individual level?

Aids used in most recent quit attempt

29

2009-3

2010-1

2010-3

2011-1

2011-3

2012-1

2012-3

2013-1

2013-3

2014-1

2014-3

2015-105

101520253035404550

E-cigsNRT OTCNRT RxChampixBeh'l supp

Perc

ent o

f sm

oker

s try

ing

to st

op

N=10078 adults who smoke and tried to stop or who stopped in the past year

E-cigarette use for quitting is still increasing


“The goal of tobacco control is to diminish the harm caused by tobacco products. While the ideal remains that people should stop using tobacco completely and permanently, consensus currently supports a properly regulated harm reduction approach for those unable to do so”

ASH statement 2014 ….

Is methadone safe?

Aids used in most recent quit attempt

2009 2010 2011 2012 2013 20140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NHS Med Rx/E-cigsNothing/NRT-OTC

31

N=9783 adults who smoke and tried to stop or who stopped in the past year; 2009 is Jul to Dec

E-cigarettes have grown the use of moderately effective aids to cessation from 24% to 35%; use of most effective methods has decreased from 4% to 3%

At stable quit attempt rate of 37% this contributed 0.05% to the decreased prevalence (~20,000 additional ex-smokers)


DO E-CIGARETTES REDUCE TOBACCO HARM AT POPULATION LEVEL?

What’s the evidence?

Reduce tobacco harm at population level?

https://publichealthmatters.blog.gov.uk/2014/05/21/e-cigarettes-and-harm-reduction-where-are-we-now-and-what-next/





Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, et al. Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach. European Addiction Research. 2014;20(5):218–25.

IS THERE A GATEWAY EFFECT?What’s the evidence?

Won’t someone think of the children?

Take-up of smoking

39

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

2014-2

2014-3

2014-4

2015-10

102030405060708090

100

Perc

ent w

ho re

port

hav

ing

ever

sm

oked

regu

larly

N=12931 people aged 16-24

Proportion of people under 25 years who have ever smoked regularly has remained constant


IS POLICY ADDRESSING ANY OF THIS?

Policy

Consumer devices under EU tobacco

Products directive (< 20mg/ml)

Those making health claims under stricter

regime of MHRA (>20mg/ml)

Regulation from 2016

From: Calc M, Gear SUY, Board V, It S, Buys A-CC, Sales MS-C. NEW ASH document. Hot off the press! [cited 2015 May 31]; Available from: http://allaboute-cigarettes.proboards.com/thread/16831

http://allaboute-cigarettes.proboards.com/thread/16831

E-cigarettes re-normalise smoking, de-normalise smoke-free environments?

http://www.telegraph.co.uk/news/health/11216824/Advert-to-show-e-cigarette-vaping-for-first-

time.html

http://www.telegraph.co.uk/news/health/11216824/Advert-to-show-e-cigarette-vaping-for-first-time.html



“Above all we should not let electronic cigarettes divide the tobacco control community, or distract us from the comprehensive approach to delivering a smokefree future.”

Andrew Furber, Dept Public Health, WakefieldThorax Dec 2014

QUESTIONS?

ConclusionsCigarettes kill ½ of regular usersTobacco harm continues to be a major global problem, and huge contributor to inequalityE-cigarettes appear to be significantly less harmful than cigarettesMore research is needed on the safety of ENDS, and regulation will improve safetyLong term effects will not be known for many yearsE-cigarettes are being chosen by the public as harm reduction and as quit devices We have a responsibility to advise individual patients in informed and honest ways, so keep up to date

Dr, I was thinking about trying those e-cigarettes. What

do you think?

Vote

References • http://www.ash.org.uk/files/documents/ASH_741.pdf• www.smokinginengland.info/latest-statistics• http://www.npis.org/NPISAnnualReport2013-14.pdf• https://publichealthmatters.blog.gov.uk/2014/05/21/e-cigarettes-and-harm-reduction-w

here-are-we-now-and-what-next/

• Britton J. Electronic cigarettes. Thorax. 2013;68(10):904–5.• Britton J. Electronic cigarettes: pro. Thorax. 2015;70(4):309–10. • Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman Jonathan, et al. Electronic

cigarettes for smoking cessation: a randomised controlled trial. The Lancet. 2013;382:1629–37.

• Calc M, Gear SUY, Board V, It S, Buys A-CC, Sales MS-C. NEW ASH document. Hot off the press! [cited 2015 May 31]; Available from: http://allaboute-cigarettes.proboards.com/thread/16831

• Dawkins L, Turner J, Hasna S, Soar K. The electronic-cigarette: Effects on desire to smoke, withdrawal symptoms and cognition. Addictive Behaviors. 2012 Aug;37(8):970–3.

• Fidler, et al., 2011. 'The smoking toolkit study': a national study of smoking and smoking cessation in England. BMC Public Health 11:479

• Furber A. Electronic cigarettes: reasons to be cautious. Thorax. 2015 Apr 1;70(4):307–8.



http://www.smokinginengland.info/latest-statistics

http://www.smokinginengland.info/latest-statistics

http://www.npis.org/NPISAnnualReport2013-14.pdf

http://www.npis.org/NPISAnnualReport2013-14.pdf





• Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco control. 2014;23(2):133–9.

• Hajek P. Electronic cigarettes for smoking cessation. The Lancet. 2013;382(9905):1614–6.

• Jensen P, Wentai L, Pankow J, Strongin, R, Peyton D. Hidden Formaldehyde in E-Cigarette Aerosols. New England Journal of Medicine. 2015 Jan 22;372(4):389–92.

• Kotz D, Brown J, West R. “Real-world” effectiveness of smoking cessation treatments: a population study: Smoking cessation treatment in the real world. Addiction. 2014 Mar;109(3):491–9.

• McCauley L. An Unexpected Consequence of Electronic Cigarette Use. CHEST Journal. 2012 Apr 1;141(4):1110.

• McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub2

• Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, et al. Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach. European Addiction Research. 2014;20(5):218–25.

• Rahman MA, Hann N, Wilson A, Mnatzaganian G, Worrall-Carter L. E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis. Le Foll B, editor. PLOS ONE. 2015 Mar 30;10(3):e0122544.

• Siegel MB, Tanwar KL, Wood KS. Electronic Cigarettes As a Smoking-Cessation Tool. American Journal of Preventive Medicine. 2011 Apr;40(4):472–5.

http://www.slideshare.net/_elljay_

@drlaurajane

Thanks

• First RCP debate on smoking.

• Cigarette advertising banned on TV

• Children’s Act bans sale of tobacco to under-16s

• Doll &Bradford-Hill epidemiological study of smoking and lung cancer. Of 1357 men with lung cancer 99.5% were smokers

• First government health warning on cigarette packs

• Sales of tobacco products in hospital shops ceases

• First smoking cessation clinic established in Salford

• First e-cigarette sold commercially

SpR Training Day June 2015 Quiz

LJ challenges you to test your knowledge of smoking history

Health & Medicine

E-cigarettes: pros, cons and controversy