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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.
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
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
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
www.smokinginengland.info/latest-statistics
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
www.smokinginengland.info/latest-statistics
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
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.
Fires
http://www.bbc.co.uk/news/uk-england-merseyside-28701515.
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…
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
www.smokinginengland.info/latest-statistics
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.
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
www.smokinginengland.info/latest-statistics
“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)
www.smokinginengland.info/latest-statistics
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.
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
www.smokinginengland.info/latest-statistics
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://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
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
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.
• 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.
• 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