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October 23rd, 2016:

E-cigarettes: a consumer-led revolution

Oct 23rd, 2016
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E-cigarettes are used by millions in the UK, but information about them is sometimes conflicting. So what is the current evidence on them?

https://www.theguardian.com/science/sifting-the-evidence/2015/oct/23/e-cigarettes-a-consumer-led-revolution

It has been described as a ‘disruptive technology’ potentially capable of breaking our fatal relationship with tobacco. So the setting for a public debate on e-cigarettes – a museum part-funded by the tobacco industry, in a city home to the global headquarters of one of the largest tobacco manufacturers – was perhaps ironic. Yet on Wednesday evening, I found myself at the M-Shed in Bristol, watching just that: a debate about whether e-cigarettes could be part of the solution to the tobacco epidemic.

To mark the launch of a new Integrative Cancer Epidemiology Programme, linked to the Medical Research Centre Integrative Epidemiology Unit at the University of Bristol, Professor Marcus Munafò (Professor of Biological Psychology at the University of Bristol) and Professor Linda Bauld (Professor of Health Policy at the University of Stirling), both collaborators of mine, discussed e-cigarettes. Professor Gabriel Scally (Public Health Doctor and former Regional Director of Public Health for the South West of England) chaired the discussion.

Billed as a debate about whether e-cigarettes might be ‘the key to reducing smoking’, some in the audience may have expected a heated discussion. However, with this line-up of academics, influential in the fields of public health, tobacco and addiction, the discussion was evidence-based and measured. As for the motion of the debate, the panel was unanimous: e-cigarettes may not be the key to reducing smoking, but they are certainly an important part of the solution.

This may be surprising to some, given ongoing discussions surrounding e-cigarettes in the media. So what is the current evidence on e-cigarettes?

Although we don’t know the long-term health effects of e-cigarette use, they’re less harmful than cigarettes

Pretty much everything is safer than cigarettes. There is no other consumer product, which, when used as the manufacturer intends, kills every other user, taking from them an average of 10 years of healthy life.

It’s been said that “people smoke for the nicotine, but die from the tar”. E-cigarettes present a solution to this problem by providing a ‘clean’ (or cleaner) method of nicotine delivery. They deliver nicotine in a similar way to a cigarette (and much faster than other forms of nicotine replacement therapy; NRT), but don’t contain the other chemicals that ultimately kill cigarette users.

A recent Public Health England report stated that e-cigarettes are 95% less harmful than cigarettes, a controversial figure. However, as Linda pointed out, it’s almost irrelevant whether e-cigarettes are 95%, 90% or even 80% less harmful than cigarettes. What’s important, is that they are less harmful.

Yes, there are still some concerns about e-cigarettes and increasing levels of confusion and misinformation among the public around them. Evidence suggests that both adults and teenagers are more likely to report that e-cigarettes are equally harmful as cigarettes today, than they were a few years ago. Both Marcus and Linda speculate that these views may have been shaped by media reports fueled by disagreements between academics.

Horror stories of children drinking the liquid nicotine (a problem which can be alleviated by having stricter controls on safety caps) and fires and accidents caused by exploding devices (the frequency of which is still far lower than the risk of fire posed by cigarettes) have been reported in the media. There are ongoing concerns about the chemicals produced when e-cigarettes are used, some of which are the same as the dangerous chemicals found in burning cigarettes (although the amount of these chemicals is a tiny fraction of the amounts found in cigarettes). Finally, we can’t yet be certain about the long-term health consequences of vaping, simply because people haven’t been using them for long enough to know (just like we didn’t know for decades that cigarettes definitely caused lung cancer).

For these reasons, we should be careful to ensure that children and non-smokers don’t start using e-cigarettes – currently there is very little evidence that these groups are regularly using the devices. However, most academics and public health officials are in agreement that for current smokers, e-cigarettes are a safer alternative to smoking.

E-cigarettes can be an effective method of stopping smoking

Linda presented evidence on the effectiveness of e-cigarettes for smoking cessation. E-cigarettes seem to be somewhere in the middle of the range when it comes to helping smokers quit. Some studies show that they are more effective than either willpower alone or NRT bought over the counter, but less effective than behavioural support.

The type of e-cigarette used matters too. The early models (‘1st generation’ or ‘cigalike’ models) don’t seem to be very effective methods of smoking cessation – interestingly, these are predominantly the models being bought up by the tobacco industry. The 2nd generation e-cigarettes and tank models (which can be refilled with liquids) seem to lead to higher levels of quitting success.

The sheer reach of e-cigarettes is their most powerful weapon. While behavioural support for cessation, combined with NRT or varenicline, has been underused by smokers wanting to quit, the rise of e-cigarette use over the past five years has been unprecedented. There are now an estimated 2.6 million vapers in the UK. With such a large numbers of users, even modest levels of smoking cessation success from their use will have a large impact on cessation rates.

E-cigarettes are a consumer-led revolution

The speed of the e-cigarette revolution and its ability to galvanize a whole community of individuals who now define themselves as ‘vapers’ is impressive. Never before has a route out of smoking garnered as much support from its users. As far as I know, there are no online forums for nicotine patch users to discuss optimal patch placement, no celebrity endorsements for nicotine lozenges and no users of nicotine nasal sprays challenging European Union Directives.

Many vapers feel passionately that e-cigarettes have enabled them to quit smoking. Indeed, a passionate crowd was in attendance at the debate. When asked at the beginning to raise their hands if they had ever tried an e-cigarette, over half of the audience did so. This is in comparison to population surveys that report 1.5%, 16.5% and 58.5% rates of ever use among non-smokers, ex-smokers and daily smokers respectively.

The last question in the debate came from a member of the public who defined himself as a ‘vaper and ex-smoker’. He expressed his dismay that new the EU Tobacco Products Directive (TPD – due to come into force in May 2016) will impose strict regulations on e-cigarettes, including bottle sizes, tank sizes and nicotine strength. In order to continue selling e-cigarettes not meeting these new regulations, retailers can instead apply for their products to be registered as medicines. But this is an extremely costly route, likely to be impractical for the majority of e-cigarette retailers other than the incredibly wealthy tobacco industry. The TPD is currently being challenged by one e-cigarette retailer. However, if it goes ahead, there are concerns from vapers and those in the public health community, that it may mean the end of vaping as we know it.

Arguably one of the reasons why e-cigarettes are so popular is that they reflect a consumer-led revolution, built from the ground up. Users can personalise their product, and many see vaping as a lifestyle choice rather than a smoking cessation aid or a medicine. If strict regulation means fewer smokers switch to using e-cigarettes, this could be a huge public health opportunity missed.

Olivia Maynard is a tobacco researcher at the University of Bristol. You can find her on twitter @oliviamaynard17.

Vaping on the verge: Prop. 56 would tax it like tobacco

Oct 23rd, 2016
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“Unicorn” opens his mod device and lets a few drops of clear juice fall. His vaporizer replenished, he deeply inhales and slowly exhales — an enormous amount of smoke billowing out of his nose and mouth. But it’s not actually smoke: The smell isn’t foul, it’s sweet.

“The nicotine mellows me out without any of the negative impacts of smoking,” Ryan Freeman, a.k.a. Unicorn, a 28-year-old salesman in jeans and a backward baseball cap, says as he sinks into a couch at a vape shop in Folsom (Sacramento County). “I went from wheezing every day to breathing.”

Vaping nicotine has grown in popularity in the past decade, especially among young adults like Freeman who are current or former cigarette smokers, according to the National Health Interview Survey. The liquid nicotine — or vape juice, e-juice and e-liquid — is touted as a safer alternative than cigarettes that contain harmful carcinogens and chemicals. But because e-cigarettes and vaping are relatively new to the market, they have been largely unregulated.

Until now. Increasingly, public health officials are targeting the industry, condemning the products as addictive, alluring to youth and a gateway to cigarettes. And one of the greatest threats facing the industry looms on the Nov. 8 ballot in California.

Proposition 56 is best known as the measure to dramatically boost the state’s cigarette tax. But it also would start to tax e-cigarettes and liquid nicotine like tobacco — which both sides say could trigger a similar push nationwide.

“Electronic cigarettes are extending and expanding the tobacco epidemic,” says Stanton Glantz, professor of medicine at UCSF and director of the Center for Tobacco Control Research and Education. “They are bringing a whole new group of kids into the tobacco market who would never start cigarettes.”

In June, the journal Pediatrics published a study that found adolescents who had smoked e-cigarettes were more than six times as likely to smoke cigarettes than their peers who had never used an e-cigarette.

In May, the U.S. Food and Drug Administration issued regulations classifying the products as tobacco, banning the sale to anyone under 18, after surveys showed e-cigarette use among high school students had skyrocketed from 1.5 percent to 16 percent in the past four years. Over the summer, Gov. Jerry Brown signed a law raising the legal smoking age in California to 21 — and applying it to vaping.

A growing number of cities have banned flavored nicotine, which comes in more than 1,000 combinations of concentrations and flavors: blackberry, watermelon and apple crisp, just to name a few. Five states have imposed additional taxes on e-cigarettes or vapor products.

“We have been under attack,” says Tony Doan, who owns two liquid nicotine manufacturing centers in the San Jose area. “They are making it impossible to stay in business and provide this alternative product. Passively, what they are doing is banning us.”

Prop. 56 would increase taxes on cigarettes by $2 a pack, moving it from one of the lowest tobacco taxes in the country to one of the highest, and impose new taxes on liquid nicotine products.

While the $2 tax increase would certainly hit smokers in the wallet, it would be even greater for vapers. That’s because the proposition would levy a 68 percent tax on liquid nicotine — turning a $15 to $20 bottle of juice into a $40 to $50 bottle.

“Everybody is going to go back to cigarettes,” Doan says. “A lot of people don’t realize that.”

Most experts agree vaping is less hazardous than smoking because the liquids don’t contain carcinogens. But recent studies have linked nicotine itself to adverse health conditions, including increased risk of heart attack and stroke. Most researchers agree little is known about the their long-term effects.

Industry giants Philip Morris and R.J. Reynolds have poured US$66 million so far into the campaign to oppose Prop. 56. The message from the opposition, however, has been largely focused on criticizing how the tax revenue would be spent. Meanwhile, the argument that e-cigarettes and vaping are a safer alternative to tobacco is being voiced at the grassroots level, as wholesalers talk to vape store owners, who then encourage their customers to vote against the measure.

The stakes for this nascent industry are high.

“California is the mother of everything,” Doan says. “Once California passes it, every other state is going to follow suit, and that’s what is alarming.”

Although public polls show support for Proposition 56, voters have twice opposed recent ballot initiatives that would have boosted tobacco taxes. In both cases, in 2006 and 2012, the tobacco industry spent heavily to defeat them.

This year is no different. Tobacco companies have mounted an aggressive TV campaign underscoring that only 13 percent of the money raised would be spent on smoking prevention and cessation programs. Much of the additional tax revenue would pay for medical services for poor people through Medi-Cal.

Health advocates argue that roughly 17,000 minors get hooked on tobacco every year. They say the additional tax money raised by Prop. 56 would fully restore funding to effective antismoking programs that help keep cigarettes, e-cigarettes and vaping devices out of the hands of children.

“If voters pass 56, I think we will wipe out tobacco as a health issue in the next few years,” Glantz says. “If that happens, we’ll set a precedent for the rest of the country and the world that would be devastating for the tobacco industry.”