E-Cig Summit Round Up: The Vape Debate Continues

I’ve popped these notes up for anyone interested in the e-cig summit but was unable to attend.

This year saw a hectic pace, with more speakers and more content in the same amount of time. Konstantinos alone had over 50 slides in a (theoretical!) 20 minutes.

So this time round, I’ve chosen just to highlight key points, quotes and data. If you need more, do monitor the E-Cig Summit website – slides and videos should be up soon.

For a downloadable, printable PDF of this post, click here.

Prof Robert West: Trends in E-Cigarette Usage

Professor Robert West runs monthly surveys to track smoking, e-cig and cessation trends. He found that E-Cig usage still growing but has slowed down.

There might be a reason for this – probably because of negative media reports, only a minority of smokers believe e-cigs are safer than cigarettes. However, around one third of smokers are using another nicotine product (most likely e-cigs).

The use of other licensed nicotine products is decreasing. However, this trend started before e-cigs took off. E-cigs are the most popular aid to cessation at the moment, and are significantly more effective than over the counter NRT aids.

Good news for those worried about a gateway effect – only 0.2% of never smokers have used a nicotine products, and even this tiny number could be down to error.

Since 2011 smokers have been more successful at quitting smoking, although there has been a recent dip in quit smoking attempts – this could be a blip.

You can find more data on the Smoking in England website.

Andrea Crossfield: E-Cigarettes: Practitioners Beliefs, Experiences and Concerns

Andrea ran a workshop for stop smoking practitioners. She found that many were confused, took much of their knowledge from the media and were unsure about the safety of e-cigarettes. Her workshop went a long way towards educating practitioners about the benefits.

E-Cig Use in Enclosed Public Spaces: How can research inform regulation?

Prof Marcus Manafo

Manafo looked at patterns in carcinogens following smoking and vaping. Smoking is followed by a spike in formaldehyde. While vapers exhale formaldehyde, there is no spike, suggesting that the formaldehyde present is created by internal metabolism.

(Later in the summit, it was noted that formaldehyde levels in smoking are so low they are not likely to be the cause of smoking diseases.)

Marcus also pointed out that that we are able to detect carcinogens at extremely low levels. Just because we detect them doesn’t mean they have an effect. What we need to think about is the relative exposure compared to cigarette smoke and then work out whether they have a biological effect.

The constituents in e-cigs are completely dwarfed by those in tobacco cigarettes. Marcus argued he probably inhaled more carcinogens walking to the conference from the tube than he would from second-hand vapour, and that’s there’s enough data from various sources to calculate that e-cigarettes are consistently orders of magnitude safer than tobacco cigarettes.

Linda Bauld

Linda pointed out that particulate matter in a vaping environment is similar to that in a non-vaper environment. She’s also yet to see any evidence that e-cigs are leading to a renormalisation of smoking, and argued that if we banned e-cigs on the basis of their emissions, we would also have to ban scented candles and air-fresheners.

Deborah Arnott (Action on Smoking and Health): E-Cigs and Children: What does the evidence show us?

Deborah said we are not seeing a gateway effect in the UK.  Surveys throughout the UK are basically showing some experimentation but almost no regular use (even when regular usage is measured at once monthly). 3 month usage among never smokers is zero.

There are very similar patterns worldwide with exception of Poland. Deborah pointed out that many studies poorly reported – what they say they say and what they actually say is very different. She also highlighted that from 2011 -2014 it is very clear that cigarette use has gone down as e-cigarette use has increased.

E-Cig regulations may lead to unintended consequences –  according to one study, youth smoking rates in US increased after e-cig bans were introduced. This is not conclusive but we do need to be careful.

Jim McManus: E-Cigarettes and the Challenge for Local Public Health Systems

This was the first time I have heard Jim speak. He gave an excellent presentation – funny, compassionate and wise.

Jim said that a lot of bad science is being done. There is a suspicious attitude from researchers who don’t like e-cigs because because of a fear of re-normalisation (of smoking). But if we are not going to do science properly, how are we going to make good decisions on policies? Jim went on to say:

We are supposed to be an evidence based profession, so let’s put aside our misconceptions and start with the evidence . E-cig users are tax payers and have a right to expect a proper and unbiased service

Jim also said he hadn’t seen a single shred of evidence that e-cigs renormalise smoking, that’s a “scientific boogie man”.

Some more key quotes:

“We seem to want evidence that e-cigs are zero risk before we work with them, but how many of us fly on holiday. Life is not zero risk. We don’t have randomised controls for bridges but on the whole they stay up.”

“The tobacco lobby debating ecigs feels like the Church of England debating homesexuality.”

“The careful position taken by Public Health England convinces me more than increasingly shrill comments from some of those opposed to e-cigs.”

Charlotta Psinger: An Up-dated Systematic Review of the Health Effects of E-Cigarettes

Charlotta Psinger is interesting as her research has been used by many of those opposed to e-cigs.

As she commented AE Smokes at one point: “I’m one of the bad guys here.”

However, she deserves credit for turning up and debating the issues – I wish more people opposed to e-cigs would do the same. She also said that she would be very happy to change her views on e-cigs if she was persuaded by the evidence.

Charlotta highlighted that e-cig studies are problematic because:

• there is a conflict of interest, more than a third of studies have been conducted by tobacco industry
• a difference in brands used
• over heating has place in some studies
• animal studies have seen very high dosages given to animals
• methodology is often suspect

Charlotta raced through a huge number of studies (nicotine on puffer fish sticks in my mind for some reason!) Some points from her presentation included

• harmful substances have been identified
• included carcinogenic compounds, sometimes traces, sometimes low concentrations, sometimes high concentrations
• particle counts and size also varied
• results very conflicting and makes it difficult to draw strong conclusions

She is worried about e-cigs being a gateway to smoking, and that e-cigs are adding to overall nicotine usage rather than reducing it. She cited an example from Denmark which contradicts the UK experience, saying that Danish vapers had not decreased the amount they smoke, and that meant overall use of nicotine products had increased.

Liam from Totally Wicked pointed out later that this could well be because nicotine liquids are banned in Denmark, so vapers need to smoke to get their nicotine fix.

Here conclusion was that e-cigs are probably safer than tobacco cigarettes but definitely not a safe product. She was criticised by Clive Bates for not providing a framework and context for the studies.

John Britton: The Theoretical Health Risks Associated with E-Cigarettes

John Britton’s presentation covered the theoretical risks of e-cigs.

The crux of his talk was that that e-cigs are a safer product – not a safe product. There are some carcinogens, albeit at a much lower level than in cigarettes.

E-Cigs are being used by smokers who have often been smoking for decades, and these smokers have a high residual risk of cancer from smoking. As e-cigs are not 100% safe, some ex-smokers will blame e-cigs for the disease they occur. This will lead to lawsuits in the future. He emphasised that e-cig companies must be able to show they have done everything they can to ensure their products are as safe as possible.

Peter Hajek: E-Cigarettes Provide Smokers with Nicotine – Is This A Problem?

Peter believes the “renormalisation of smoking is clearly a bogus concept.”

He believes the anti-tobacco lobby have three aims.

1. To eliminate use of nicotine.
2. To destroy the tobacco industry.
3. To reduce harm and disease.

The third goal is important but not as important as the first too, and this explains their attitude towards e-cigarettes.

Professor Hajek also discussed addiction. Cigarettes are highly addictive, but nicotine on its own does not seem to be very addictive. That’s why experimentation with e-cigarettes by never smokers is not leading to regular use.

Professor Polosa: Electronic Cigarettes and Harm Reversal

With long term evidence on e-cigs still at least a decade away, how can we evaluate the benefits of e-cigs now.

One way is to look at the effects of e-cigs on smokers affordable vape online who have switched to e-cigs. And studies are already showing enourmous benefits, especially in people with pre-existing diseases. One example included blood pressure. Smokers with high blood pressure who switched to e-cigs went on to experience major improvements in blood pressure levels.

(For more info, see our post on e-cig side effects.)

Addison & Morrison: Advertising Rules & Marketing After the TPD

Almost every form of advertising is banned. That includes social media, email marketing, radio and tv. Non-paid for blogs and tweets will be allowed, as will outside posters and trade advertising.

While the government is trying to be as liberal as possible, there is little room for movement on this as it is clearly defined by the TPD.

This could potentially have a devastating impact on blogs and forums.

TPD Updates (Various Speakers)

The worst thing here is confirmation that there will be a maximum limit of 2ml in tanks. Previously, the consultation from the government seemed to imply that refillable tanks would be allowed at more than 2ml. This was due to poor drafting.

Otherwise, there was nothing really new for people who have been following the TPD closely.

The e-cig summit went on to look at what was wrong with the TPD. (Answer: almost everything, but at least it’s not the FDA!) I would have preferred to focus on how we can comply (or get round the TPD.) Unless the Totally Wicked lawsuit succeeds, the TPD is law, we are stuck with it and there’s no point in looking back wishing things had been done differently.

Beryl Keely: What is MHRA’s remit?

Regulating e-cigs is a strange job for the MHRA, as it falls outside their mission and their regular remit. However, Beryl says the MHRA is aiming for light touch regulation. They do not expect to read all data submitted, all they will be looking at some of it.

E-cig retailers will be charged for the work the MHRA does. How much? Beryl couldn’t answer, but it will be nothing like as expensive as medicinal regulation.

There will also be a yellow card portal where consumers can report issues with e-cigs. This is more likely to be exploding batteries, and this could lead to devices being withdrawn.

Roseanna O’Conner (PHE): Building Evidence Based Consensus on E-Cigs

Roseanna spoke on behalf of the PHE, which recently announced that e-cigs are 95% safer than tobacco cigarettes. PHE have been recently attacked for having (very tenuous) connections with big tobacco.

For me, the most interesting part of the presentation was the point that those most opposed to e-cigs had been invited to join in the consultation – and had refused. So they had the chance to contribute, but instead chose not to get involved, and then attack not on the evidence base but on alleged conflicting interests.

Also see:  The Vape Debate: Who Pays Who?

Konstantinos Farsalinos: Common Research Misconceptions

Excellent presentation as usual, and despite the time constraints Konstantinos actually spoke slowly enough that I could follow what he was saying. (That’s still pretty fast!)

One key theme of his presentation was that most researchers don’t understand what they are researching. There’s even a failure to understand the difference between simple concepts such as voltage and wattage.

Animal studies are useless, and use ridiculous levels of nicotine to make a point. For example, to study the effect of vaping on mice, researchers used 50% of the lethal dose for mice. This bears no relation to vaping.

A number of the studies mentioned by Psinger were, well, destroyed.

Shirley Cramer: Can E-Cigarettes Be Part of the End Game For Cigarettes

As I mentioned in our pre-summit post, Shirley Cramer is all about the ‘end game’ in cigarettes.

She carried out an experiment where smokers given de-nicotinised e-cigs. This lead to a fall of 80% in cigarettes smoked and increase in number of e-cigs vaped. So denicotonising cigarettes and forcing every shop to carry e-cigs would hasten the end of smoking.

She got a lot of stick for this but I wasn’t sure whether she was serious about this or whether it was a bit of a thought experiment.

There were a couple of good criticisms of this. One person said this was the opposite of harm reduction, removing the pleasurable part (nicotine) and keep what is harmful (combustion). In the panel discussion, Lorien argued that e-cigs have been successful because they offer choice and empowerment. Trying to force smokers to use e-cigs would be a massive disadvantage.

Professor David Abrams: What the science says about minimising harm and developing a consensus on methodology? 

David gave an excellent presentation and it would be well worth viewing his presentation when it’s up.

His main driving point was that the debate has been clouded by ideology. Remove the ideology and use models to calculate the benefits. By calculating risk and efficacy using 3D models it becomes obvious that e-cigs represent a major benefit.

Some Final Thoughts

I feel very uneasy about the role tobacco control is trying to take in e-cigs.

E-cigs are a consumer led phenomenon that has been successful despite the lack of support in e-cigs. Now that they are clearly a huge success in the UK, elements of the tobacco control lobby are trying to jump on the bandwagon and control the direction e-cigs are going in. Personally, I don’t think that’s necessary.

If consumers and companies are left to get on with the job (with some light touch regulation to ensure harmful compounds are minimised) vaping will continue to be successful. Unfortunately, tobacco control can’t resist its urge to interfere and control.

(However, I love the work the scientists and Public Health England have done!)

A Big Thank You…

At the end of the presentation Ann Mc Neil reminded us that many of the professionals speaking on behalf of e-cigs have put their careers and livelihoods on the line, and we owe them a big thank you. (Note: It is often difficult to get funding if you have supported e-cigs.)

Reference: http://www.ecigarettedirect.co.uk/ashtray-blog/2015/11/e-cig-summit-round-up-the-vape-debate-continues.html