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August 18th, 2015:

Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence

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The Global Health Implications of e-Cigarettes

Andrew Y. Chang, MD; Michele Barry, MD

This Viewpoint discusses the threats to public health from e-cigarettes specific to developing countries and urges governments and nongovernmental organizations to control their spread.

Few topics in tobacco control have been more hotly debated in the past several years than electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems (ENDS). Advocates claim that the devices, which use battery power to aerosolize nicotine into a chemical propellant, offer significant harm reduction because they do not create the carcinogenic combustion products found in conventional paper cigarettes.1,2 Critics, meanwhile, point to a host of concerns regarding the unproven health claims and questionable advertising tactics by e-cigarette companies as reasons for greater regulation of these products. While health departments and researchers try to collect data on these issues, the use of ENDS has increased substantially globally, with a 2014 World Health Organization (WHO) survey suggesting that more than half the world’s population resides in countries where ENDS are available for purchase.3 The growing market was valued at an estimated US $3 billion in 2013, with projections estimated to reach $10 billion by 2017.3,4 The availability of ENDS extends not just to wealthy nations but also to low- and middle-income countries (LMICs) because the devices can now be made more inexpensively.

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e-Cigarette Use and Subsequent Tobacco Use by Adolescents: New Evidence About a Potential Risk of e-Cigarettes

Nancy A. Rigotti, MD

1Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
JAMA. 2015;314(7):673-674. doi:10.1001/jama.2015.8382.

Few topics in public health and medicine are as contentious as electronic cigarettes (e-cigarettes), novel handheld battery-operated nicotine-delivery devices that resemble conventional tobacco cigarettes and simulate the experience of smoking a cigarette.1- 3 Unlike cigarettes that burn tobacco to generate smoke, e-cigarettes heat a liquid consisting of nicotine, propylene glycol or glycerin, flavorings, and other chemicals to create a vapor that is inhaled. Both conventional cigarettes and e-cigarettes deliver nicotine, the addictive agent in tobacco, but e-cigarettes do not expose the user to the many other tobacco smoke constituents responsible for causing tobacco-related diseases. e-Cigarettes therefore offer the tantalizing prospect that they could reduce the harms of conventional tobacco use, the leading cause of preventable death and disability in the United States and worldwide.


Keck School of Medicine of USC research demonstrates teenagers who use e-cigarettes may be transitioning to tobacco products

Scientists say more study is needed on the link between e-cigarettes and tobacco use

Contact: Leslie Ridgeway at (323) 442-2823 or

To watch a video on the research, go to (Link live on Aug. 18)

For a copy of the study, please email the JAMA press office at

LOS ANGELES — A multi-university team led by Keck Medicine of the University of Southern California (USC) researchers has found, for the first time, that using or “vaping” of electronic cigarettes is associated with a propensity to start smoking cigarettes or other, harmful tobacco products.

Based on a survey of 2,530 14-year-olds at 10 public high schools in Los Angeles, the team found that teens who use e-cigarettes were more likely to transition to smokeable tobacco products.

However, researchers cautioned that additional studies are needed to determine whether the association is causal.

The findings were published on Aug. 18 in the peer-reviewed Journal of the American Medical Association.

“E-cigarettes may be drawing a new generation of teens into recreational nicotine use because they are high-tech, can be purchased somewhat easily, come in enticing flavors and have a perception that they’re not harmful,” said Adam Leventhal, Ph.D., associate professor and director of the USC Health, Emotion, & Addiction Laboratory (USC-HEAL) at the Keck School of Medicine. “Some e-cigarette devices appear to be very efficient at delivering nicotine to the lungs and brain. If you enjoy the experience of inhaling nicotine in e-cigarettes, it makes sense that you would be open to trying other nicotine products, like cigarettes, hookah, and cigars.”

The research is among the first to be released by a Tobacco Center of Regulatory Science (TCORS), funded by the federal Food and Drug Administration through the National Institutes of Health (NIH). One of 14 TCORS was established in 2013 at the Department of Preventive Medicine at the Keck School of Medicine.

The longitudinal study included 2,530 students who had never smoked tobacco when they were first surveyed at the start of ninth grade. Of these students, at the first survey, 222 had used e-cigarettes (also known as “vaping”) and 2,308 had never vaped. The students were surveyed again in six months and 12 months. By the six-month mark, 30.7 percent of the e-cigarette users had started smoking one or more combustible tobacco products including cigarettes, cigars and hookahs, as compared with 8.1 percent who had never used e-cigarettes. At the 12-month mark, as the students were heading into 10th grade, differences in rates of tobacco smoking persisted between students who had used e-cigarettes versus those who had not.

Leventhal’s research team conducted the e-cigarette study as part of a larger substance abuse and mental health study funded by the National Institute on Drug Abuse (NIDA).

The research team includes Matthew Kirkpatrick, Ph.D., Jennifer Unger, Ph.D., Steve Sussman, Ph.D., Matthew Stone, B.A., Rubin Khoddam, M.A. and Jonathan Samet, M.D., M.S. (USC); Janet Audrain-McGovern, Ph.D. (University of Pennsylvania), David Strong, Ph.D. (University of California, San Diego), and Nathaniel Riggs, Ph.D. (Colorado State University).

The research, “Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence,” was published online ahead of print in JAMA on Aug. 18, 2015.

The study was funded by the NIH, through NIDA under R01-DA033296 and the National Cancer Institute under P50-CA180905.


Leventhal, A.M., Strong, D.R., Kirkpatrick, M.G., Unger, J.B., Sussman, S., Riggs, N.R., Stone, M.D., Khoddam, R., Samet, J.M., Audrain-McGovern, J. (2015). Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. Journal of the American Medical Association, 314(7): 700-707. Published online Aug. 18, 2015; doi:10.1001/jama.2015.8950



Keck Medicine of USC is the University of Southern California’s medical enterprise, one of only two university-based medical systems in the Los Angeles area. Encompassing academic, research and clinical excellence, the medical system attracts internationally renowned experts who teach and practice at the Keck School of Medicine of USC, the region’s first medical school; includes the renowned USC Norris Comprehensive Cancer Center, one of the first comprehensive cancer centers established by the National Institutes of Health (NIH) in the United States; has a medical faculty practice, the USC Care Medical Group; operates the Keck Medical Center of USC, which includes two acute care hospitals: 401-licensed bed Keck Hospital of USC and 60-licensed bed USC Norris Cancer Hospital; and owns USC Verdugo Hills Hospital, a 158-licensed bed community hospital. It also includes more than 40 outpatient facilities, some at affiliated hospitals, in Los Angeles, Orange, Kern, Tulare and Ventura counties.

In 2015, U.S. News & World Report ranked Keck Medical Center of USC among the Top 10 in ophthalmology and among the Top 50 hospitals in the United States for urology and cancer care.
For more information, go to

Young people and e-cigarettes – what do the latest data tell us?

Linda Bauld

In an article co-commissioned with The Conversation, Professor Linda Bauld – Director of the Institute for Social Marketing at the University of Stirling, and Cancer Research UK’s cancer prevention champion – looks at the latest evidence on e-cigarette use in young people.

Thanks to decades of action against tobacco, smoking rates among children and young people are in decline: far fewer teenagers are now taking up smoking than in the past.

In England, for example, just 3 percent of 11-15 year olds are regular smokers, with similar figures in Scotland and elsewhere in the UK. This is welcome news, and will play a significant role in protecting the adults of the future from the fourteen types of cancer linked to smoking, as well as other diseases such as heart disease and stroke.

Over the same period, we’ve also witnessed the advent of nicotine replacement as a means to help adult smokers quit. Reviewing these products back in 1991, Professor Michael Russell remarked that smokers ‘smoke for the nicotine, but they die from the tar’. In other words, it’s the many other toxic chemicals in combustible tobacco that cause disease and death – not nicotine.

Yet considerable public confusion exists about nicotine, with up to 90 percent of non-smokers, and 75 percent of smokers, believing it is harmful.

More recently, we’ve witnessed a rapid rise in the use of e-cigarettes, which has caused considerable debate and controversy – particularly surrounding their use and uptake among young people. This concern is probably partly caused by the confusion over the relative harmfulness of nicotine.

E-cigarettes commonly contain nicotine, as well as other substances including propylene glycol and flavourings. But unlike tobacco, they don’t expose people to many of the harmful chemicals found in tobacco. They’re widely available: the World Health Organisation recently estimated that half of the world’s population live in countries where e-cigarettes can be bought. And there’s a growing body of evidence that they can help adult smokers to stop using tobacco.

However, health professionals, policy makers and others are worried that e-cigarettes’ widespread availability might create a new generation of young nicotine addicts. If they were to take up tobacco smoking, this could undermine the great strides made against teenage smoking.

Is this a valid concern? What do the latest data tell us?

Emerging evidence

When my team at the University of Stirling first reviewed the studies on e-cigarette use in young people, early in 2014, we could only find nine published peer reviewed studies reporting prevalence of use in any country. Since then, more than 30 new studies have been published, from countries as diverse as Korea, France, Poland, Canada and Iceland. Most of these studies, particularly from larger countries like the USA, focus on a single region or school district.

The UK is an exception, and nationally representative cross-sectional data are available. What do they show?

Four representative surveys of UK teenagers were conducted in 2014, and while they focused on slightly different age groups, their findings were very consistent – a significant proportion of young people had tried electronic cigarettes at least once (8 percent in one survey in Great Britain, and 12 percent in a representative UK-wide survey, and in national surveys in Scotland and Wales).

The same survey for Great Britain had also been conducted previously in 2013, and in an analysis published just yesterday in Public Health, the proportion of young people who had tried e-cigarettes rose between the two surveys. But the proportion who regularly used e-cigarettes (i.e. more than once a month), was still very low in 2014 (from 0.4 per cent in Scotland to 2 percent in the UK survey), and concentrated in youth who also smoked.

Three of these surveys failed to find any young non-smokers who regularly used e-cigarettes
But what about among non-smokers?

Three of these surveys failed to find any young non-smokers who regularly used e-cigarettes, with the fourth – a survey of about 9,000 11-16 year olds in Wales – identifying just 54 participants who had never tried tobacco but who regularly used an e-cigarette.

What this all tells us is that, while young people are experimenting with e-cigarettes, and that the proportion who say they’ve tried them is rising, only very small numbers of young non-smokers are attracted to these products on any regular basis.

This, it’s worth remembering, is during a period when smoking rates among young people are continuing to fall, suggesting that – in the UK at least – there is no evidence yet that more young people are starting to smoke because of e-cigarettes.

But there’s an important caveat. The UK studies – like those in other countries – are cross-sectional surveys that merely provide a snapshot. They say nothing about longer-term trends, nor about changes in behaviour. For that, we need longitudinal studies, which follow the same group of people over time.

The US picture

New research – published today in the Journal of the American Medical Association – conducted in 10 high schools in Los Angeles, USA, provides the first example of a longitudinal study looking at e-cigarette and tobacco use.

It involved approximately 3,300 participants, who were 14 years old on average when they joined the study. They were followed up twice, after 6 and 12 months.

Among all participants, 7 percent had used an e-cigarette at least once in the past 30 days.

But once the researchers looked at the 2,530 who had never used tobacco at the start of the study, just 222 of them – 8.7 percent – said they’d ever tried an e-cigarette.

But were these young people more likely to then try smoking (either cigarettes, cigars or hookah pipes)?

The researchers found that those who said they’d tried an e-cigarette at the start of the study were also more likely to have tried smoking six months later (30.7 percent vs 8.1 per cent) and 12 months later (25.2 percent vs 9.3 percent).

The authors collected information on other factors that might put young people at risk of smoking (such as their socio-economic background) and adjusted for these – but still found the link.

So what to make of this finding? There are several caveats, as the authors make clear. This association doesn’t prove that e-cigarettes cause young people to take up smoking – it merely demonstrates a statistical link between the two. On top of this, the way e-cigarette and tobacco use were measured was very basic, only determining whether people had ‘ever’ or ‘recently’ used them – not whether this was regular or sustained use.

And importantly, the age group in the study had just moved to secondary school – a time of transition and trying new things.

The numbers that were the main focus of the analysis were also very small – just 222 non-smoking e-cigarette users.

So to find out more, future longitudinal studies are needed, that follow people up for longer, provide more information on how regularly they use e-cigarettes and tobacco, and also the types of products are used. And we need studies that provide evidence on the safety of e-cigarettes, and their role in smoking cessation.

And research is also needed to assess the impact of policy changes being introduced in a number of countries to regulate e-cigarettes, including measures to limit youth uptake.

For this reason research organisations such as Cancer Research UK are looking closely at the issue of e-cigarettes and funding a number of studies. Ongoing monitoring and research, including studies that involve the public and e-cigarette users, are important if we are to inform policy and practice.

Previous research has played a hugely valuable role in helping to protect young people from the disease and death that smoking causes. The place of e-cigarettes within this remains to be seen – but it may be important, and we need to study it.

Minister continues to mislead on TPPA and tobacco

“Trade Minister Groser continues to mislead on the way that the TransPacific Partnership Agreement (TPPA) would affect health” said Dr Gay Keating of Doctors for Healthy Trade. “Saying that the TPPA won’t stop government making health regulation is like saying that there is nothing to stop anyone buying a house in Auckland. The TPPA will make it much harder and much more expensive for Government to get to its goal of Smokefree Aotearoa by 2025.“

“Recent statements from the Minister have repeated carefully contrived half-truths. He keeps saying that the government will not be prevented from regulating in the public interest. That is simply misleading” said Dr Keating, a public health specialist and researcher.

“Of course the TPPA won’t have a clause that New Zealand can’t make smokefree regulations. But the TPPA would let companies sue us if we followed World Health Organization advice and brought in stricter controls on tobacco. The TPPA would make it too expensive and too risky to bring in those law changes. The Minister is being misleading. Under the TPPA there will be nothing to stop us passing smokefree laws except the potentially exorbitant price tag” she said.

The TPPA includes provisions for Investor State Dispute Settlement (ISDS) that are currently in very few New Zealand treaties. Australia is fighting an ISDS case where it is being sued by tobacco giant Philip Morris over the law for plain packaging of cigarettes. Even if Australia eventually wins, the cost of defending their law will be high. It has already cost the Australian government $50 million for the first stage of the defence of regulating in the public interest. If Australia should lose the tobacco company could be awarded hundreds of millions dollars.

“Minister Groser needs to release the text and openly discuss the issues rather than indulging in name-calling. Instead of offering incomplete, misleading statements and saying doctors and nurses are ‘breathless children’, he needs to answer our well founded concerns about the cost of medicines and tobacco control.” Dr Keating said.

PH gains in bid to stop tobacco industry from marring public health protection

By: Tricia Aquino,

“Protect your lungs, protect your life,” say World Health Organization Prevention of Non-communicable Diseases director Dr. Douglas Bettcher and Southeast Asia Tobacco Control Alliance senior policy advisor Mary Assunta. (Tricia Aquino/

“Protect your lungs, protect your life,” say World Health Organization Prevention of Non-communicable Diseases director Dr. Douglas Bettcher and Southeast Asia Tobacco Control Alliance senior policy advisor Mary Assunta. (Tricia Aquino/

MANILA – The Philippines has slightly improved in its efforts to ensure the tobacco industry does not crimp government efforts to protect public health from what the World Health Organization (WHO) calls a “global killing machine which is almost unparalleled in human history.”

This is according to the Southeast Asia Tobacco Control Alliance (SEATCA), a regional network of tobacco control advocates, which released Tobacco Industry Interference Index: 2015 ASEAN Report on Implementation of WHO Framework Convention on Tobacco Control (FCTC) Article 5.3 Tuesday in a forum at the WHO Western Pacific Regional Office in Manila.

The Philippines is a party to the WHO FCTC, introduced in 2005. Article 5.3 states that countries must protect public health policies on tobacco control from commercial and other vested interests of the tobacco industry.

Compared to SEATCA’s first report last year, the Philippines continued to languish in the middle of seven Southeast Asian countries ranked according to how well they implemented these protective measures, SEATCA senior policy advisor Mary Assunta said.

Brunei still delivered the best performance, while Thailand showed the biggest improvement from last year. The two were followed by Lao PDR, Cambodia, the Philippines, Malaysia, and Indonesia, whose performance worsened.

Interference in policy development

Assunta attributed the Philippines’ low ranking to the level of the tobacco industry’s participation in policy development. She said the tobacco industry even had a representative in the Inter-Agency Committee on Tobacco, which was formed through the implementing rules and regulations of Republic Act 9211 or the Tobacco Regulation Act.

SEATCA accused the Philippine Tobacco Institute of using its position here “to actively dilute tobacco control.”

The country was doing better when it came to government agencies refraining from participating in Corporate Social Responsibility activities held by the tobacco industry. According to the report, the Civil Service Commission-Department of Health Memorandum Circular No. 2010-01 enabled government departments to create Codes of Conduct which banned government officials from receiving or supporting such CSR activities, leading to a reduction in these activities.

Assunta lamented, however, that such CSR activities were not banned among most ASEAN countries, although the likes of Cambodia, Singapore, Thailand, and Vietnam had banned their publicity. She commended Thailand as well for banning such activities, making it the first in the ASEAN to do so.

Such CSR activities should be banned, she explained, because they helped foster public goodwill to an industry which killed half of its customers prematurely.

In fact, she noted, Philip Morris International (PMI) had increased its CSR spending in six countries from USD8.2 million in 2009 to USD12.5 million in 2013. Some had even gone to relief for Yolanda-stricken communities, Assunta said.

Longer implementation time

Another finding was that most countries accommodated requests from the tobacco industry for a longer implementation time or a longer review time for tobacco control laws. Only Brunei and Thailand refused to budge on these, Assunta said.

She wondered why PMI was manufacturing cigarette packs with graphic health warnings that made up 85 percent of the front and back of the packs in Batangas to export to Thailand, but would not immediately comply with the Philippines’ Graphic Health Warnings law. The government even had to grant tobacco manufacturers “a 12-month compliance deadline for printing the new graphic health warnings and an additional eight months for depleting old stocks after the initial 12 months,” according to the report.

“You have to ask them, ‘How valuable is life in the Philippines?’” Assunta said.

The Philippines had also made some headway in terms of reducing opportunities for unnecessary interaction between the government and the tobacco industry. These included attendance at social functions, ribbon-cutting ceremonies, and company dinners, Assunta said.

SEATCA also praised the country for its efforts in making government more transparent about its interaction with the tobacco industry. The Joint Memorandum Circular No. 2010-01 required government agencies to report such interactions, it said. The order also regulated such meetings, allowing the government to meet with the tobacco industry only to control, regulate, and supervise it.

However, SEATCA scored agencies such as the Department of Agriculture and the Department of Trade and Industry for not publicly disclosing these meetings, nor submitting reports on these to the CSC.

Countries should look to Australia for a simple practice in this regard, Assunta said. Every time the government has to interact with the tobacco industry, this is posted on a website, along with the schedule and purpose of the meeting.

Conflict of interest

Most of the countries did not improve in preventing conflict of interest, with only Brunei prohibiting political contributions from the tobacco industry, Assunta said.

In Indonesia and Malaysia, retired, senior government officials are even being hired to work for the tobacco industry or its associates, the report said.

Nor had there generally been improvement in terms of strengthening measures to prevent the governments’ interaction with the tobacco industry.

“Outside the Departments/Ministries of Health, most government departments have no knowledge of FCTC Article 5.3 Guidelines and treat the industry like any other industry or investor,” SEATCA said.

Assunta said the Philippines and Thailand were doing better than their neighbors in terms of restricting interaction, citing the Joint Memorandum Circular No. 2010-01 as enabling the Philippines to do so.

According to Atty. Krunimar Escudero III of the CSC, the following agencies were already implementing the order: CSC, DOH, Department of Education, Commission on Higher Education, Bureau of Internal Revenue, Department of Labor and Employment, Department of Foreign Affairs, and Metropolitan Manila Development Authority.

Push for guidelines not enough – WHO exec

The tobacco industry continued to interfere with, deter, and thwart government efforts to protect public health, SEATCA said.

This was why Assunta called for a stronger implementation of the FCTC 5.3 guidelines.

For his part, WHO Prevention of Non-communicable Diseases director Dr. Douglas Bettcher said that while countries were doing something to implement the guidelines, these were not enough.

He saw the tobacco industry as “the main vector of the tobacco epidemic,” likening its representatives to disease-carrying mosquitoes.

“If we don’t stand together, we all stand to lose,” he added.

Taxing question of curbs on tobacco smuggling

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New prescription smoking-cessation drug not helping smokers quit

The introduction of a new prescription smoking-cessation aid, varenicline, in 2006 has had no significant impact on the rate at which Americans age 18 and older successfully quit smoking, according to a study led by researchers at University of California, San Diego School of Medicine.

The findings, published online August 17 in Tobacco Control, suggest that the primary effect of varenicline (marketed as Chantix) has been to displace the use of older tobacco addiction therapies, such as nicotine patches and the antidepressant, bupropion (Zyban).

Moreover, in this population analysis, researchers said varenicline’s enhanced effectiveness in helping smokers quit, compared with other cessation aides, appeared to be short-lived, lasting for three months, after which time varenicline users no longer had higher rates of success.

“We had hoped the new pharmacotherapy would help more people quit, but this is not what is happening,” said lead author Shu-Hong Zhu, PhD, a professor in the Department of Family Medicine and Public Health and director of Center for Research and Intervention in Tobacco Control at UC San Diego. “Instead, varenicline is replacing other options like the patch, without having any significant population-level impact on quitting success.”

According to the Centers for Disease Control, almost 20 percent of U.S. adults 18 years or older are cigarette smokers. If smoking continues at the current rate among U.S. youth, one in every 13 person younger than 18 is projected to die prematurely of a smoking-related illness. Globally, tobacco use is estimated to cause nearly 6 million deaths annually.

For the study, UC San Diego School of Medicine researchers analyzed two U.S. Census Bureau surveys of smokers age 18 and older, conducted in 2003 and 2010-11, before and after varenicline became commercially available.

The surveys probed smokers’ efforts to quit in the last 12 months; their use of nicotine replacement therapies (including the nicotine patch, gum, lozenge and inhaler) and prescription medications such as bupropion and varenicline. Varenicline helps reduce nicotine cravings by binding to nicotine receptors in the brain, stimulating the release of dopamine, a neurotransmitter that helps regulate the brain’s reward and pleasure centers.

Based on responses from more than 39,000 smokers, overall use of pharmacotherapy increased from 28.7 percent of smokers trying to quit in 2003 to 31.1 percent in 2010-11, representing a 2.4 percent increase.

This slight increase in the use of cessation aides, however, did not translate into more smokers breaking the habit. In 2003, approximately 4.5 percent of smokers reported successfully quitting for at least a year, compared with 4.7 percent in 2010-11.

“We are not saying Chantix does not help smokers quit. It does, but it won’t solve America’s tobacco epidemic unless it inspires more smokers to try to quit,” Zhu said.

Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence

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