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The New Challenge of e-cigarettes

presented to

Myra Wisotzky, MSPH


Technical Advisor, Tobacco Control

Overview
What are e-cigarettes?
What are the challenges?
How is the public health community
responding to the challenges?
What is your role as a journalist?
Selected resources for more information

Quick Google scan:


Your country + e-cigarette

In recent times e cigarettes have become more


common in Kampala where vaping an
electronic cigarette is almost similar to
smoking a traditional cigarette.

What are e-cigarettes?


Designed to generate inhalable nicotine aerosol (vapor)
When user takes puff, the nicotine solution is heated and the
vapor taken into lungs
Invented in early 2000s - first available on global market in
2007

E-cigarettes (ECs) or Electronic


Nicotine Delivery System (ENDS)
ECs/ENDS consist of:

Electronic vaporization system


Rechargeable batteries
Electronic controls
Cartridges of the liquid that is vaporized.

Cartridges typically contain between 6 and 24 mg of


nicotine, but sometimes can contain more than 100 mg.
Nicotine is an addictive chemical that, in excessive
amounts, can be lethal (0.5-1.0 mg per kg of weight of the
person).

Tank

Tank systems
Larger devices
Heated with
batteries voltage
varies
Users fill tank with
liquid nicotine, or eliquid
Powerful
Big nicotine kick

Tank

Mods

Some terminology

E-cigarette (EC)
Electronic Nicotine Delivery System (ENDS)
Vapour
Vape
Vaper
Vaping
E-juice

An explosion of brands
A proliferation of flavours
Internet search of EC websites (2012 and 2013/2014)
466 brands (each with its own website)
7,764 unique flavours
Net increase of 242 new flavours and 10 new
brands per month over the 17 months between 1st
and 2nd search
Zhu, SH Tob Control 2014;23

Many flavors: Appealing to kids

Kids brands work to keep names off


e-cigarettes
By Associated Press

May 26, 2014 | 7:49am

....keep notable names like Thin Mint, Tootsie Roll and


Cinnamon Toast Crunch off the flavored nicotine used in
electronic cigarettes.
General Mills Inc., the Girl Scouts of the USA and Tootsie
Roll Industries Inc. . have sent cease-and-desist letters to
makers of the liquid nicotine demanding they stop using
the brands and may take further legal action if necessary.

They want to make sure their brands arent being used to


sell an addictive drug or make it appealing to to children

Why is flavor important?


Important function in determining who is
attracted to a product
Important function in helping people get
started on a product
Flavored products are disproportionately used
by youth

Marketing and promotion


Being marketed like cigarettes in the
1950s/60s
Marketing on TV and radio, internet,
magazines, billboards
Aggressive placement near candy and/or
medications

Marketing channels and messages


Television, Internet, and print advertisements
Often features celebrities
Promoted as healthier alternative to tobacco
smoking
Promoted as useful for quitting smoking and
reducing cigarette consumption
As a way to circumvent smoke-free laws

Content analysis:
e-cigarette websites
100
90
80
70

95

95

Data "Smoking revolution": a content analysis


of electronic cigarette retail websites. Am J Prev
Med. 2014 Apr;46(4):395-403.

93
88
76

73

71
64

60
50
40
30
20

10
0

44
32

31
22

22

Indian celebrities join the e-cigarette


Vape-olution
Indian bloggers have started to invoke the
names of Indian celebrities as e-cig
ambassadors.
Times of India recently highlighted two Indian
film actors who have both successfully
stopped smoking tobacco cigarettes.

http://www.vapestick.co.uk/e-cigarette-blog/indian-celebrities-join-electroniccigarettes-vapeolution

Advertising themes for e-cigarettes

ENDS: A fast-growing market


Use at least doubled among both adults and
adolescents from 2008 to 2012 [Data mainly from North
America, European Union, Republic of Korea

US$ 3 billion was spent on ENDS globally in 2013


ENDS availability is widespread.

Slightly over half of the worlds population live in the


62 countries reporting availability of ENDS.
Source: Electronic Nicotine Delivery Systems Report by World Health Organization 2014

CHALLENGES

Challenges
Safety not scientifically proven
Efficacy in quitting smoking not scientifically
proven
Potential to interfere with existing tobacco
control efforts
And- there is much we still dont know..

The safety of ECs/ENDS has not


been scientifically demonstrated.

Long term effects?


e-cigarettes deliver lower levels of some of the
toxins found in cigarettes
But the long-term effects of exposure to
e-cigarette vapor and to nicotine in the
cartridge is unkown.

Only a few studies have studied the health effects


of exposure to e-cigarette vapor
Some of the studies show that EC vapor can have
negative health effects
Long-term health effects are unknown at this time
because e-cigarettes have not been in widespread
use long enough for assessment

Contents vary and are not listed


Products vary widely in the amount of
nicotine and other chemicals they deliver
There is no way for consumers to find out
what is actually delivered by the product they
have purchased

Propylene glycol
ECs/ENDS vapor contains volatile organic
substances, including propylene glycol, flavours,
nicotine

Exposure to propylene glycol can cause eye and


respiratory irritation
When heated and vaporized, propylene glycol can
form propylene oxide a class 2B carcinogen

Nicotine
Nicotine is the addictive component of tobacco
Can have adverse effects during pregnancy
May contribute to heart disease.

Although nicotine itself is not a carcinogen, it


may function as a tumour promoter

Other chemicals and particulates


EC vapour usually contains some carcinogenic
compounds
Much lower than tobacco smoke but higher than in a
nicotine inhaler

In some brands, levels of some cancer causing agents,


(e.g. formaldehyde, acrolein) are as high as in the
smoke produced by some cigarettes
EC vapor particles ultrafine (smaller) compared to the
bigger size in cigarette smoke.
ENDS generate lower level of particles than cigarettes.

Physical safety
Major injuries and illness have resulted from
e-cigarette use including explosions and fires
Poisoning from exposure to nicotine in
cartridges has occurred and is a risk for
children in particular

Efficacy for smoking cessation


(quitting)

Marketed as a way to quit smoking

May promote dual use - maintain smoking


and use e-cigarettes
May serve as a gateway

May encourage quitters to relapse

The efficacy of ENDS for helping


people to quit smoking has not been
scientifically demonstrated
Population based studies
Clinical trials
Some conflicting findings

Population-based studies on
EC/ENDS use and smoking cessation
Analysis of 4 longitudinal and 1 cross-sectional
studies
e-cigarette use in the real world is associated with
significantly lower odds of quitting smoking

Clinical Trials on
EC/ENDS use and smoking cessation
Analysis of 4 clinical trials suggests that
e-cigarettes are not associated with successful quitting
Are not any more effective than approved
pharmaceutical aids (e.g. nicotine patch)

Smoking Toolkit Study, England


Recent study in England
People using e-cigarettes to quit were significantly
more likely to succeed than those people using overthe-counter nicotine replacement

Placement with approved cessation


products in mainstream stores

Promoted by Vape stores

Electronic cigarettes at Boots Chemist


(UK)

As a healthcare provider and retailer,


Boots strives to meet your health
needs by providing products,
information and support you can
trust.

We already help people who smoke to


cut down, or stop, using medicines,
like Nicotine Replacement Therapy,
and support services. But, we also
know many smokers would like access
to an alternative to smoking
traditional cigarettes, such as
electronic cigarettes.

Therefore, you can buy the Puritane


brand of e-cigarettes from Boots

Harm reduction

Are e-cigarettes an opportunity or threat to


public health?
How can we ensure benefits are maximized
and harms minimized?

Gilmore A, Hartwell, G European Journal of Public Health, Vol. 24, No. 4, 532533

The e-cigarette debate rages on over at


the BMJ (British Medical Journal)
ECs. a weapon of mass distraction distracting
advocates, researchers, and decisions makers from
time and resources that could otherwise be devoted
to measures we know to be effective, and the
community from messages about quitting.
Quoting Mike Daube in Tobacco Control news and views on-line
http://blogs.bmj.com/tc/2013/10/02/e-cigarettes-and-the-marketing-push-that-surprisedeveryone/

advertising of e-cigarettes is not something to worry


about or ban, rather it should be embraced. It is how
smokers will find their way to these new products and it
is how new brands will push the cigarette brands aside.
The normal controls on truth and fairness in advertising,
supplemented by restrictions of the type applied to
alcohol, should be sufficient to balance public health
opportunities and fears that something might go wrong.
Quoting Clive Bates in Tobacco Control news and views on-line
http://blogs.bmj.com/tc/2013/10/02/e-cigarettes-and-the-marketing-push-that-surprisedeveryone/

We certainly dont yet have all the answers as


to their long-term health impact, but what we do
know is that they are much safer than
cigarettes,

Professor Ann McNeill, lead author from the National Addiction Centre, Kings College London, UK

Controversy in public health


some experts welcome ENDS as a pathway to the
reduction of tobacco smoking
others characterize them as products that could
undermine efforts to denormalize tobacco use
ENDS, therefore, represent an evolving frontier, filled
with promise and threat for tobacco control.
Source: Electronic Nicotine Delivery Systems Report by World Health Organization 2014

Whether ENDS fulfil the promise or the threat


depends on a complex and dynamic interplay
among the industries marketing ENDS
(independent makers and tobacco
companies), consumers, regulators, policymakers, practitioners, scientists, and
advocates.
Source: Electronic Nicotine Delivery Systems Report by World Health Organization 2014

PUBLIC HEALTH RESPONSE

Regulation of ECs and


ENDS

World Health Organization


Decision adopted October 17, 2014 at Conference of Parties
Framework Convention on Tobaco Control (FCTC)

Prevent initiation of ENDS by non-smokers and youth;


Minimize potential health risks to ENDS users and protect
non-users from exposure to their emissions;
Prevent unproven health claims from being made about
ENDS;
Protect tobacco-control activities from all commercial and
other vested interests related to ENDS;
Invites parties to consider prohibiting or regulating ENDS;
Urges parties to consider banning or restricting advertising,
promotion and sponsorship of ENDS;
Invites parties and WHO to comprehensively monitor the use
of ENDS.

ECs/ENDS are largely unregulated:


More needs to be done

Union policy statement on ECs/ENDS


Prevent ENDS marketing and promotion to and ENDS uptake by
non-smokers, pregnant women and youth
Prevent ENDS marketing and promotion that discourages smokers
from quitting
Minimize potential health risks to ENDS users and non-users through
prohibiting unproven health claims from being made about ENDS
and protecting existing tobacco-control policies from interference
Ensure that there is control over the amount of nicotine and other
substances delivered by e-cigarettes to minimize the health risk to
consumers

The Union strongly supports EC/ENDS


regulation, preferably as medicinesif not then
Ban advertising, promotion
and sponsorship;
Prohibit ENDS for tobacco
cessation;
Prohibit ENDS in retail
stores;
Prohibit sale to minors
Prohibit flavors appealing
to children
Prohibit use in public
places, workplaces or public
transportation;

Set consumer safety


standards for EC cartridges;
Packaging and labelling
consistent with those for
medicines;
Clear information and
warnings on the products
proven health risks,
ingredients and usage.
Protect ENDS regulation
from commercial or vested
interests (Article 5.3)

The Union Position on ECs/ENDS

Margaret Chan, Director General


World Health Organization (WHO)
What is the next challenge? The next challenge is
that the tobacco industry is increasing its
dominance over the market for electronic
cigarettes. This should not come as a surprise.

One company used this years World No Tobacco


Day to call on WHO, and call on all of your
governments, to promote electronic cigarettes as
a way of protecting some of the lives that they
themselves are killing with the other products
they sell.

Transnational tobacco companies

Lets not forget


Smoking tobacco is the single largest
preventable cause of death in the
world responsible to 6 million deaths
each year.

We must not allow e-cigarettes to detract


attention from what should be our key focus
smoked tobacco.
Policies on e-cigarettes must therefore be
combined with those making tobacco even
less desirable and available
Gilmore, A; Hartwell G. European Journal of Public Health, Vol. 24, No. 4, 532533

In summary
Quickly evolving/expanding market and use
Much not known about their safety or utility in
reducing harm or quitting smoking
Potential for public health benefit AND
Potential for public health harm
Transnational tobacco companies: The fox in the
chicken coop
Governments need to regulate ECs/ENDS to
protect public health

Reflection and Discussion


What is your
role/responsibility as
a journalist as it
relates lung health
and e-cigarettes?
What are the
questions that your
public would like to
see addressed?

What issues SHOULD


the public see/
hear/ read about?

What are some


potential themes or
storylines for ecigarettes?

For more information:


Some useful websites and
organizational links

www.tobaccofreeunion.org

www.worldlungfoundation.org

www.who.int/tobacco

www.fctc.org

www.tobaccofreekids.org

www.globaltobaccocontrol.org

www.cdc.gov/tobacco/global/index.htm

the media are not the holders of


power, but they constitute by and
large the space where power is
decided.
Manuel Castells, Spanish sociologist associated
with research on the information society,
communication and globalization

e-cigarette sessions at
45th World Lung Conference
Poster session # 43
31 October 10:15 11:15

Meet the expert


1 November 8:00 9:00
Room 122/123

Thank you!
mwisotzky@theunion.org

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