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
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 1/10th 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.”
28
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