Tobacco control and the

emerging threat (or

promise?)Presented
of e-cigarettes
to

Myra Wisotzky, MSPH

Technical Advisor, Tobacco Control
The Union

Overview
Tobacco control at The Union:
Resource people/contacts at WLC

Key issues in global tobacco control

An e-volving issue: e-cigarettes
and tobacco control
Summary

Tobacco Control at The Union: Goal

To advance the World Health Organizations

Framework Convention on Tobacco Control
(WHO-FCTC). The FCTC is an international
treaty & coordinated global strategy to
reduce tobacco use.
Our work focuses on WHOs MPOWER a
package of evidence-based measures to help
countries implement the WHO-FCTC.

The FCTC provides an internationally coordinated response

to combating the tobacco epidemic, and sets out specific
steps for governments addressing tobacco use, including to:
Adopt tax and price measures to reduce tobacco
consumption;
Ban tobacco advertising, promotion and sponsorship;
Create smoke-free work and public spaces;
Put prominent health warnings on tobacco packages;
Combat illicit trade in tobacco products.

The Union Department of Tobacco Control (TCD) is

based in Edinburgh.
The TCD has tobacco control hubs & staff based in
India, Singapore, Mexico and China and experts across
the globe with specialised knowledge in the legal,
economic, policy development, management, training
and communications aspects of tobacco control.
We work with governments and civil society to develop
policies, legislation and infrastructure proven to reduce
tobacco use

What we do and where

Training
Technical assistance
Capacity building
Resources (grants)
Collaboration and
partnership
Communication and
strategic use of
media

South-East Asia
Asia Pacific
Africa
Latin America
Middle East
Europe

The Union is a key partner in

the

Bloomberg Initiative to
Reduce Tobacco Use
The Bloomberg Initiative (BI) aims at
reversing the global tobacco epidemic in
low- and middle-income countries

Major objectives of BI

Refine and optimize tobacco control programmes to help

smokers stop using tobacco and prevent children from starting.

To support public sector efforts to pass and enforce key laws and
implement effective policies, including taxing cigarettes, preventing
smuggling, altering the image of tobacco and protecting workers from
exposure to second-hand smoke.

To support advocates efforts to educate communities about the

harms of tobacco and to enhance tobacco control activities that work
towards a tobacco-free world

To develop a rigorous system to monitor the status of global tobacco

use.

BI was established to focus on 15 countries with almost 2/3 of worlds tobacco

users

China
India
Indonesia
Russia
Bangladesh

Brazil
Philippines
Thailand
Vietnam
Ukraine

Mexico
Turkey
Pakistan
Egypt
Poland

Focus from 2009 has also included Africa

(with additional funding from The Bill and
Melinda Gates Foundation)

BI *Grants Programme

Supports projects that lead to sustainable

improvements in tobacco control laws,
regulations, policies and programmes at the
national or sub-national level

Since 2007 the Union has provided grants to

132 governments and civil society organisations
in 43 countries leading to remarkable progress,
such as more than three billion people protected
by smoke-free laws.

Grant-funded project representatives and

regional Union TC staff are here at WLC.

*The Union and Campaign for Tobacco Free Kids manage

the BI Grants

Key issues in global tobacco control:

A quick review
What IS the problem/are the
problems?
What are the solutions?
An e-merging issue: How do ecigarettes fit in to the big picture of
tobacco control?

Global Adult
Tobacco Survey
(GATS)

Tobacco use is the single greatest cause of preventable death

in the world

A risk factor for 6 of the 8 leading

causes of death world-wide
Most of these deaths are in low-and
middle-income countries

Tobacco will kill

520 million people
worldwide in the
next 50 years

and the epidemic is growing fastest

in developing countries

Tobacco devastates health

Every day, tobacco kills 14,000 people
Every day, 100,000 young people begin
using tobacco
Young people are essentially the
replacement smokers - - replacing those
who quit .or who die as a result of using
tobacco.

(replacement smokers RJ Reynolds, 1984

memo )

Major causes of death from tobacco

Cancer
Cardiovascular disease
Including: ischaemic heart disease,
atherosclerosis, stroke
Respiratory disease
Including: chronic obstructive lung
disease (COPD),
bronchitis,
pneumonia

Tobacco use includes:

Smoked
Manufactured
cigarettes
Kreteks
Roll your own
Bidis
Pipes
Water pipes
Cigars

Smokeless
Chewing tobacco
(e.g. Gutka and
Paan)
Moist Snuff
Dry Snuff
Dissolvable
tobacco products

Other
e-cigarettes
and
electronic
nicotine
delivery
systems

Tobacco damages the economy

Burden on low- and middle-income countries, through
increased healthcare costs, loss of foreign exchange
on imported cigarettes and diversion of land to
tobacco farming.
It decreases economic productivity and increases
employee absenteeism.
Example: Tobacco use costs Chinese society an
estimated
US$ 5 billion each year in medical treatment
expenses(US$ 1.7 billion) and lost productivity (US$
3.3 billion).

Tobacco and poverty

People on low incomes are more
likely to smoke than those on higher
incomes.
Money spent on tobacco reduces the
amount of money available to spend
on food, healthcare, shelter and
education.
Tobacco use affects the health,
nutrition, education, employment
and gender equality of people on low

The tobacco epidemic is shifting from highincome countries to low- and middle- income
countries, largely due to the transnational
tobacco companies expanding their
businesses.
For example, British American Tobacco sells
70% of its cigarettes in Africa, Asia, Eastern
Europe and Latin America.

The global cigarette industry is

one of the most profitable (and
deadly) in the world
It is increasingly dominated by five
companies
China National Tobacco Corporation
(CNTC)
Philip Morris International (PMI)
British American Tobacco (BAT)
Japan Tobacco International (JTI)
Imperial Tobacco Group (ITG)

Cigarette market growth

by global region

Future,
present and
past smokers

Tobacco
industry

Tobacco
product

Policy,
advertising
social norms

Reversing the tobacco epidemic:

We know what works
To support global efforts for tobacco
control The Union focuses on several
key policies proven to reduce tobacco
consumption.
These policies are integral to the FCTC
and MPOWER

MPOWER

Monitor tobacco use and prevention policies

Protect people from tobacco smoke
[Offer help to quit tobacco use]
Warn about the dangers of tobacco
Enforce bans on tobacco advertising,
promotion and sponsorship
Raise taxes on tobacco

Monitor tobacco use and prevention

policies
Resource for status of smoking and
tobacco use, attitudes, policy
implementation
Global Adult Tobacco Survey

Global Adult Tobacco Survey Atlas

(www.gatsatlas.org/#)

Global Adult Tobacco Survey

www.gatsatlas.org/*

Protect People
from Second Hand Smoke
There is no safe level of exposure to
second- hand smoke.
Exposure to second hand smoke causes
death, disease and disability.
Exposure to SHS kills about 600,000 nonsmokers each year
Contributes to about 1% of the total global
disease burden, representing about 10
15% of the disease burden caused by
active smoking.

Smoke free (SF) policies protect

health and influence social norms
Implementation of SF legislation causes a
decline in heart disease deaths and
decreased respiratory symptoms in workers.
SF workplaces reduce cigarette consumption
among continuing smokers and lead to
increased successful cessation among
workers.

SF policies do not cause a decline in

business activity of the restaurant or bar
industry.
Smoke-free policies reduce tobacco use
among youth.

Offer help to quit tobacco

use

Nicotine is an addictive drug

Tobacco control oolicies create an
environment which supports quitting
Treatment also needs to be made available
and should include:

Tobacco cessation advice incorporated into

primary and routine health-care services

Easily accessible and free telephone help lines

(known as quit lines)

Access to free or low-cost cessation medicines

Warn about the dangers of tobacco

Graphic health
warnings on cigarette
packs encourage
users to quit and
discourage others
from starting.
Most effective when
large, graphic, and
change periodically.
Effective in showing
harmful impact of
tobacco use.

Example: Philippines

November 2015

Nepal has just

implemented
the worlds
largest
graphic
health health
warnings on
tobacco packs

Enforce bans on advertising,

promotion and sponsorship (TAPS)

 Tobacco advertising is proven to increase

tobacco consumption.
Tobacco companies spend tens of billions
to
recruit new tobacco users
maintain or increase use among current users
reduce a tobacco users willingness to quit
encourage former users to re-start using
tobacco

Tobacco industry marketing

tactics
Brand stretching
Sponsorship
Sports, music,
cultural events

Technology
Targeting women
and children
Point of sale
Billboards
Magazines

Packaging and
advertising
Games and
competitions
Product giveaways
Corporate social
responsibility

Sponsorships of sports and

culture/music

Advertising, promotion and

sponsorship bans
Comprehensive bans on tobacco
advertising, promotion and
sponsorship are very effective at
reducing tobacco use, especially
among young people.

Raise Taxes on Tobacco

Increasing the price of tobacco via
taxation
is the single most effective way to
reduce tobacco consumption
Increased tobacco taxes can help to
cover the cost of tobacco use to society
The extra revenue from the tax can be
dedicated for health promotion/tobacco
control.

Tobacco tax impact on tobacco

consumption in South Africa

Tax/price: Most powerful impact is in

low and middle income countries
Increasing tobacco taxes has a
greater impact on consumption in
low- and middle-income countries.
A price rise of 10% decreases
consumption by up to 8% in low- and
middle- income countries and by 4%
in high-income countries

Summary so far

E-merging issue in tobacco

control
E-cigarettes (ECs) and
Electronic Nicotine Delivery Systems
(ENDS)

Overview

What are e-cigarettes (ECs)?

EC promotion and the growth of ECs
global market
What are the EC issues relevant to
tobacco control goals?

Quick Google scan

Country name + e-cigarettes
Consider the following in light of the discussion of tobacco
control and tobacco industry tactics

Bangladesh

China

Democratic Republic of Congo (DRC)

India

Kenya

Nigeria

Pakistan

Russia

South Africa

Uganda

Zambia

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).

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

Why is flavour important?

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

EC marketing and
promotion
Ecs 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, social media 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

Data "Smoking revolution": a content

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

100

95

95

93
88

90
80
70

76

73

71
64

60
50
40
30
20
10
0

44
32

31
22

22

Advertising themes for ecigarettes: A very quick visual scan

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

Global sales of e-cigarettes reached US$ 3 billion 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 to public health

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 in ECs
Nicotine is addictive
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

WHO FCTC, Article 5.2 (b)

Towards this end, each Party shall, in
accordance with its capabilities: .
(b) adopt and implement effective
legislative, executive, administrative
and/or other measures and cooperate as
appropriate, with other Parties in
developing appropriate policies for
prevention and reducing tobacco
consumption, nicotine addiction and
exposure to tobacco smoke.

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?
Conflicting
evidence

Marketed as a way to quit smoking

But...
May promote dual use - maintain
smoking and use e-cigarettes
May serve as a gateway to nicotine
addiction smoking
May encourage quitters to relapse
Research on efficacy in quitting
continues to have conflicting findings

This
public
service
ad
addresse
s the
issue of
dual use
of
cigarettes
and ecigarettes

The efficacy of ENDS for helping people to quit smoking has not been
scientifically demonstrated

Population based studies

Clinical trials
Conflicting findings

The jury is still out

on efficacy for cessation
Cochrane review 2014: ECs may help smokers
quit and little sign they are harmful
600 studies analyzed
Of these, only 13 were up to scientific standard
Of these, only 2 were randomized controlled trials

Authors caution that quality of evidence is low

due to small number of studies

 2015 analysis in American Journal of Public Health:

Smokers who used e-cigarettes were 59 percent
less likely to quit smoking than smokers who never
used e-cigarettes.
2014 study in Journal of American Medical
Association showed that smokers who used ecigarettes were not more likely to have cut their
cigarette consumption one year later.
2014: Smoking Toolkit Study, England: People using
e-cigarettes to quit were significantly more likely to
succeed than those people using over-the-counter
nicotine replacement

Promoted by vape stores and

offered by chemists
Street-side sign for vape
store promoting ECs as a
way to quit smoking

Ad for reputable UK chemist,

Boots for proprietary EC

Interferes with tobacco control

Normalizes and reinforces smoking

Possible gateway for youth nonsmokers

Social media and youth-oriented

marketing
Hyperlink

Description

https://www.youtube.com/
watch?v=d_luws1CHto

Juul (Shades
of blurred
lines music
video )

https://www.youtube.com/watc
h?v=RvB2kKar_no

Sampling PM
Mark Ten

https://www.youtube.com/watch?
v=i6SQiu08DxQ

A sexy view of
the ECC Expo

Harm reduction
policies, programmes and
practices that aim to reduce the
harms associated with the use of
psychoactive drugs in people
unable or unwilling to stop.

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

Electronic nicotine delivery

systems Report by WHO
FCTC/COP/6/10
Whereas 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.

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- thatsurprised-everyone/

2013

2015

Interactive graphic
displaying
relationships of
some scientists with
EC commercial
interests to illustrate
the potential for
bias.

http
://www.bmj.com/content/351/b
mj.h5826/infographic?
utm_source=Tobacco+Control+
Legal+Consortium+Bulletin++November+2015&utm_campa
ign=tclc-bulletinnov2015&utm_medium=email

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,
policy-makers, practitioners, scientists,
and advocates.
Source: Electronic Nicotine Delivery Systems Report by World Health
Organization 2014

Regulation of ECs
and ENDS

ECs/ENDS are largely unregulated:

More needs to be done

Concerns about the impact of ECs on existing

tobacco-control efforts

Gateway effects: ENDS encouraging initiation

of nicotine use, and switching to cigarette
smoking
Renormalization: ENDS use enhancing the
attractiveness of tobacco consumption.
Role of the tobacco industry
Interference with smoke-free policies
Electronic nicotine delivery
ENDS marketing
systems Report by WHO
FCTC/COP/6/10

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.

Strategies for EC regulation

Regulate sale
Regulate
advertising
promotion and
sponsorship
Tax
Use
Product
Institute for Global Tobacco Control
classification
Country Laws Regulating Ecigarettes: A Policy Scan. JH
Bloomberg SPH, February 2015

Sale
17 countries have minimum age for
purchase
21 countries restrict the sale of ECs
with nicotine
Institute for
Global
Tobacco
Control
26 countries ban the sale
of
all
types
Country Laws Regulating Ecigarettes: A Policy Scan. JH
of ECs
Bloomberg SPH, February 2015

Use
3 countries ban the use of ECs
14 countries ban the use of ECs in
enclosed public spaces
8 countries restrict the use of ECs in
certain enclosed public spaces
18 countries prohibit use on public
transportation
Institute for Global Tobacco Control
Country Laws Regulating Ecigarettes: A Policy Scan. JH
Bloomberg SPH, February 2015

Advertising, promotion and

sponsorship
Of the 47 countries that ban or restrict sale

33 prohibit or restrict advertising,

promotion or sponsorship of ECs in their
policies
Some countries contend that TAPS bans
are inherent within their bans on sale
12 countries have explicit bans or
restrictions on EC advertising, promotion or
sponsorship
Institute for Global Tobacco Control
Country Laws Regulating Ecigarettes: A Policy Scan. JH
Bloomberg SPH, February 2015

Product classification
Classification of the product
relates to the regulatory approach

Tobacco products imitation,

derivative, and substitute
Medicinal, pharmaceutical product
Consumer products
E-cigarettes/Electronic nicotine
delivery systems (ENDS)
Institute for Global Tobacco Control
Poisons
Country Laws Regulating Ecigarettes: A Policy Scan. JH
Bloomberg SPH, February 2015

Regulatory mechanisms
61 countries with regulations
Interpretation of existing legislation
Amendment to existing legislation
New law, decree, resolution, circular, notification
Multiple approaches

Most countries use existing laws to regulate

ECs
Many countries have outright banned ECs
for Global Tobacco
through decrees or decisionsInstitute
Control Country Laws
Regulating E-cigarettes: A
Policy Scan. JH Bloomberg
SPH, February 2015

E-cigarette regulation currently varies

across countries that have it in place.
What about those who do not?
Does a one size fits all approach work?
Or do we consider factors unique to each
country?

Union policy statement on ECs/ENDS

Prevent ENDS marketing and promotion to, and ENDS uptake by, nonsmokers, 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 regulation of manufacture, marketing and sales of
EC/ENDS, preferable as medicines.

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

Providing advice to governments

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.

Transnational tobacco companies

Lets not forget

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

 We must not allow e-cigarettes to detract

attention from what should be our key
focussmoked 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

Reflection and Discussion

What is your
role/responsibility as
a journalist as it
relates to tobacco
control and/or ECs?

What issues
SHOULD the
public see/ hear/
read about?

What are the

questions that your
public would like to
see addressed?

What are some

potential themes
or storylines?

In summary
Quickly evolving/expanding market and use
Still learning 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

For more information:

Some useful websites and organizational links follow

www.tobaccofreeunion.org

www.worldlungfoundation.org

www.who.int/tobacco

www.fctc.org

www.tobaccofreekids.org

www.globaltobaccocontrol.org

Johns Hopkins Bloomberg School of

Public Health

www.cdc.gov/tobacco/global/

Tobacco Control and e-cigarette

sessions at 46th WLC

Tobacco Control
region/country staff at WLC

Thank you
mwisotzky@theunion.org
www.tobaccofreeunion.org