E-cigarettes: Evidence,

perceptions and

misconceptions

Martin Dockrell, Tobacco Control Programme Lead

Smoking causes the greatest

number of preventable deaths

2

• 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?

First some good news!

3 Smoking Toolkit Study

24.2

22.0 21.5 21.4 20.7 20.0 19.3 18.5 18.7 18.0

15.8

0

5

10

15

20

25

30

2007(N=22079)

2008(N=18990)

2009(N=21137)

2010(N=24794)

2011(N=21879)

2012(N=21330)

2013(N=22167)

2014(N=20170)

2015(N=20026)

2016(N=20437)

2017 Feb(N=3360)

Perc

ent

Smoking prevalence in England

First some good news!

4 Smoking Toolkit Study

15.714.1 13.6 13.4 13.7

17.615.8

19.117.9 18.5

26.6

0

5

10

15

20

25

30

35

2007(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)

2016(N=1226)

2017 Feb(N=192)

Pe

rce

nt

Success in stopping among those who tried

5 The Tobacco and Related Products Regulations 2016

Are EC less tightly regulated in

the UK than elsewhere?

WHO recommendation Action in England

Prevent the initiation among non-smokers

and youth

Age of sale of 18.

Packs must state the products not for use by non-

smokers or children

Minimise health risks to EC users and

protect non-users from exposure

Prior notification of all new e-cigarette products;

limits nicotine concentration and size of tamper

proof/child resistant refill containers

requires information on safe use, contra-

indications/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.

6 The Tobacco and Related Products Regulations 2016

Are EC less tightly regulated in

the UK than elsewhere?

WHO recommendation Action in England

Protect tobacco control activities from

vested interests related to EC

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

Consider prohibiting or regulating EC,

including as tobacco products, medicinal

products, consumer products

The UK provides both medicinal and consumer

product regulatory frameworks for e-cigarettes.

Consider banning or restricting

advertising, promotion and sponsorship

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.

Comprehensively monitor the use of EC,

including the relevant questions in all

appropriate surveys

EC use among adults and children is

comprehensively monitored by several national

Government surveys

Additional national and local surveys are

undertaken by other organisations

Did PHE’s 2015 report

mark a new policy direction?

7

2007 – RCP Tobacco Harm Reduction

2008 – Beyond Smoking Kills

2013 – NICE Harm Reduction Guidelines

2015 – Smoking Still Kills

2016 – RCP Nicotine without smoke

Evidence reviews: PHE 2014 & 2015

8

• 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

• 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

2017: Updated evidence review on EC and novel tobacco products

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.

• Seeks to identify research priorities, discuss funding opportunities, generate ideas

for new projects and promote collaboration.

10 ASH Smokefree Youth

95.291.4

86.1 87.7

3.76.5

10.6 9.3

0.9 1.7 3.3 2.60.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2013 2014 2015 2016

Youth using e-cigarettes

Never-used EC

Experimenter

Monthly or more user

Use among youth increasing rapidly?

11

Do non smoking youth vape?

ASH Smokefree Youth

0.4

1.23.9

7.65.3

7.8

13.5

20.2

27.2

2.60

10

20

30

40

50

60

70

80

90

100

2013 2014 2015 2016

E Cigarette use (by smoking status)

Never smoker

Former smoker

Current smoker

All youth

Use

s E

C a

t le

ast m

onth

ly

12Goniewicz, Maciej Lukasz, et al. "Levels of selected carcinogens and toxicants in vapour from electronic cigarettes."

Tobacco control (2013): tobaccocontrol-2012.

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.”

13Polosa, 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.

How toxic are EC?

14Nutt, David J., et al. "Estimating the harms of nicotine-containing products using the MCDA approach." European

addiction research 20.5 (2014): 218-225.

How toxic are EC?

15Nicotine carcinogen and toxin exposure in long term e-cigarette

and NRT users. Shahab et al 2017

How toxic are EC?

Nicotine equivalence Toxins and carcinogens

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

What risk of passive

exposure?

17Fernández, Esteve, et al. "Particulate Matter from Electronic Cigarettes and Conventional

Cigarettes: a Systematic Review " Current Environmental Health Reports (2015): 1-7.

What risk of passive

exposure?

18Protano, C., et al. "Second-hand smoke exposure generated by new electronic devices (IQOS® and e-cigs)

and traditional cigarettes ." Ann Ig 28.2 (2016): 109-112.

.

RCP 2016 report

19

“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.”

How effective are EC in helping

smokers to quit?

20 Smoking Toolkit Study www.smokinginengland.info/latest-statistics

N=12244 adults who smoke and tried to stop or who stopped in the past year

0

5

10

15

20

25

30

35

40

45

50

Perc

ent

of sm

okers

try

ing t

o s

top

E-cigs

NRT OTC

NRT Rx

Champix

Beh'l supp

21

How successful are EC in local

services?

LSSS Quarterly Monitoring 2016-17

26

46

50

50

51

53

54

57

58

61

67

Not Known

Combination of L NCPs concurrently

Single L NCP

L NCP / Bupropion / Vareniciline concecutively

All types

Bupropion only

No medication or NCP

Licensed meds and U NCP concurrently

U NCP

Varenicline only

Licensed meds and U NCP consecutively

Four week quit rates in English stop smoking services by therapy type (2016-17)

4 week quit rate

Note: Unlicensed Nicotine Containing Product (UNCP) are usually e-cigarettes

22

How widely EC used in local

services?

LSSS Quarterly Monitoring 2016-17

Note: Unlicensed Nicotine Containing Product (UNCP) are usually e-cigarettes

Single NCP only24%

Comb. licensed NCPs concurrently

31%

Bupropion only0%

Varenicline only30%

Licensed NCP +/-Bupropion +/-Vareniciline

consecutively2%

Comb licensed med + UNCP concurrently

3%

Licensed med + UNCP consecutively

1%

UNCP1%

None6%

Not Known2%

Percentage of succcessful quits by therapy

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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 1/10th to

1/100th the level of cigarette smoke 2

• BO is rare and smoking has not been found to be a risk1

• There are 2 case reports of BO in long term smokers who

use EC3

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): 420-435.

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): 168-174.

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, 2016. 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 1/10th to

1/100th the level of cigarette smoke 2

• BO is rare and smoking has not been found to be a risk1

• There are 2 case reports of BO in long term smokers who

use EC3

Today the top suggestion for “Popcorn” on google is

“Popcorn lung”

The second is “Popcorn lung and vaping”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): 420-435.

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): 168-174.

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, 2016. A6513-A6513.

25

Addressing misperceptions

ASH Smokefree GB

26

Harmful misperceptions

ASH Smokefree GB

• 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.

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

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.”

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