E-Cigarette Summit 2014

Return of the Titans: Ecig Summit 2

Yesterday saw some of the key players in e-cigarettes in the UK (and quite a few from the US too) gather in London for the second electronic cigarette summit.

For your information, we’ve put together a summary of the event. Given that people may have different levels of interest, I’ve structured it so we have key quotes first, followed by a summary of the event and then finally detailed notes for those who have more interest.

Also, huge thanks to ECigaretteForum and Smooth Events for once again putting together a fantastic summit – it has obviously taken a huge amount of effort and funding. I am very impressed with ECigaretteForum, who have chosen to use their numbers and clout for the good of the industry.

Please note all errors are my own, if you were at the summit and notice any big ones please let me know in the comments!

Key Quotes EcigsummitLouise Ross, NHS Stop Smoking Service

Stop smoking success rates increased 20% when e-cigarettes were introduced into the process. Tweet this quote!

Clive Bates

Too much regulation will take perfectly good products off the market. Tweet this quote!

The tobacco products directive is a wretched piece of legislation, full of rubbish. Tweet this quote!

Public Health England

We can’t ban e-cigs on the basis they look like cigarettes. Tweet this quote!

Sending people outside to vape could actually increase children’s exposure to vaping. Tweet this quote!

Scale of harm with e-cigs is much, much smaller, including 2nd hand exposure. Tweet this quote!

Dr Farsalinos Konstantinos 

The most important toxins in cigarette smoke are missing – those that remain are orders of magnitude lower.

Risk reduction of ecigs is at least 95%, and probably 99%. Tweet this quote!

Professor Hajek

No serious adverse effects with e-cigs have been found in any study. Tweet this quote!

Saying e-cigs are 95% safer is not a medical claim, it is a truth. Tweet this quote!

Professor Bauld

E-cig gateway theories are just that – theories. Tweet this quote!

Professor West

At a very conservative estimate, ecigs have saved at least 10,000 lives. Tweet this quote!

E-cigarette Summit SummaryOne of the most important things to come out of the e-cigarette summit is that there now a consensus that ecigarettes are at least 95% safer than tobacco cigarettes. That’s a conservative estimate – Professor West said his was a pessimistic forecast, and Konstantinos indicated that he felt the actual figure could be closer to 99%. This is a figure backed up by the UK government representatives, some of whom are actually travelling the country and educating local councils on e-cigarettes.

Huge threats remain. The biggest come from the EU – as the UK gov pointed out, they don’t have a choice in whether to implement this, but are offering some support to Totally Wicked in their legal challenge. An additional problem is that some public health organisations are being manipulated by large corporations who are threatened by e-cigarettes in order to maintain the status quote (e-cigs remain just 1% of the global tobacco market.)

E-cig summit detailed notesProfessor West: Latest trends in e-cigarette use and associations with smoking and smoking cessation

E-cigs now exceed NRT as the main quitting tool. However, about a year ago a cap was seen on the growth of ecigarettes. Later discussion focussed on whether this was because of health fears generated by public health organisations manipulated by large corporations, poor media reporting and the WHO report.

West discussed the concern that e-cigs might undermine quitting, but pointed out that actually cessation was increasing and is at its highest point since the late 70’s, and that the total use of nicotine is falling. We can’t definitively say that this is because of e-cigs, but at the very least it is highly unlikely that e-cigs are negatively affecting the quit rate.

At a very, very conservative estimate (with e-cigs adding just 0.5% to the cessation rate) West estimates that at least 10,000 lives have been saved by e-cigs.

Professor Linda Bauld: Are children using e-cigarettes?

Use of ecigs amongst children is confined to those who already smoked. The highest identified rate in all studies of children who don’t smoke but use ecigs is 2%. Bauld’s team have identified very little interest in ecigs or intention to try ecigs. Children primarily see ecigs as a way for adults to stop smoking. There is some awareness of marketing but a lack of engagement or brand awareness.

Professor David Sweanor: Evidence and harm reduction – what are the legal and ethical responsibilities of Public Health

David argued that we have an ethical duty to tell the truth, with the implication that many public health bodies are not doing that now. He disagreed with the notion that one could ethically mislead the public or manipulate the truth for public health goals.

He also emphasised that people are fundamentally intuitive, not rational, are blinded by ideology and tend to take a position based on emotion, and then selectively choose the evidence which backs up their position. Vested interests are everywhere. The anti-tobacco industry is simplistic, non-strategic and counter productive (later discussion focussed on the fact they were also manipulated by large corporations).

David pointed out that many things we now accept (eg. vaccinations, manufactured foods and even bikes) were originally vigorously opposed – fear of change protects the status quo. Misrepresentation of science should be vigorously opposed and held to account, and we should use social media to voice opposition.

(See our original interview with David here.)

Deborah Arnott (Action on Smoking and Health): Putting the UK in a global context: Feedback from the WHO FCTC meeting in October

Deborah pointed out that unlike unelected, self appointed public health organisations, our elected government has no say in WHO policy. (The unelected, self appointed comments are my own addition, not Deborah’s!).

There were two reports from the WHO, one official and one unofficial. The unofficial one was more negative, and unfortunately got the most attention. The official one was more balanced, arguing e-cigs are both a threat and a promise. However, the WHO FTC came out with a purely negative conclusion, arguing e-cigs should be banned or regulated.

Panel Discussion: Some Key Points

Professor West: Pointed out many dual users go on to quit. (See Are ecigs leading to a drop in smoking rates? for details).

Professor Hajek: Never in history has sales of a safer product lead to an increase in sales of a less safe product.

West: Possible that an increase in belief that e-cigs are as bad as cigarettes has lead to a cap in the growth. So we must make people aware that they are a safer alternative. Other speakers reiterated this. (However, new advertising guidelines, which forbid us from sayings e-cigs are safer than smoking OR quoting health experts will make this more difficult.)

Professor Sweanor: People must have enough information to make an informed decision. Nonsense needs to be blown away on social media, if that happens you will get less nonsense.

Doctor Farsalinos (comment from the audience): If 10 adolescents take up vaping but 50 adults give up smoking that is a public health gain.

Professor Hayek: Cochrane review of efficacy of e-cigarettes for smoking cessation and harm reduction

Hayek discussed his Cochrane review, but can not yet release full results.

Discussed dual users, and said that saying reducing smoking doesn’t help health is pure nonsense. (Deborah Arnott made this claim last year, strongly refuted by Konstantinos Farsalinos, but did not repeat it this year.)

No serious adverse event has been related to ecigs in any [non biased] study.

Studies are of varying results and of varying quality. The big problem with some studies is that they used obsolete and ineffective models. Some studies used nicotine free ecigs as a placebo but that is ridiculous because even nicotine free ecigs can help.

Both here and later on in the summit he discussed schizophrenic patients. He argued that these people can’t stop nicotine use – but that ecigs CAN help.

Professor Riccardo Polosa

Polosa pointed out that e-cigarettes are not the same across the spectrum. 1st generation e-cigarettes are just not very good, but 2nd generation appear to be much more effective, and are much more effective at suppressing cigarette cravings.

He pointed out that lots of scientists and journalists use nicotine to help their brain to work to a certain level. Nicotine can also help working memory and can prevent memory decrement.

52% of smokers with hypertension experienced lower blood pressure after switching to electronic cigarettes. (Also see: Could vaping lead to a decrease in blood pressure? on this blog).

Gordon McFiggans/Professor Roy Harris: A chamber study of second-hand e-cigarette “smoke” – preliminary results

Update: Both Clive Bates and Carl Phillips have blogged about this. Clive’s version is here, while Carl’s simplified version is here.

This was a complex and controversial presentation, and McFiggans was challenged over some key figures (a colleague later heard someone say to Gordon that he got some of the figures wrong). A key part of it is that while there is a big reduction in larger particles in vapour there are higher amounts of smaller particles. There was disagreement over whether this is an issue – Gordon doesn’t seem to think it is a major issue but Roy Harris is more concerned.

I discussed this with Tom Pruen, Farsalinos and Polosa in the break. Farsalinos felt it was a load of rubbish, as there was a lot of data for exposure to small particulates but that there was no evidence that it has ever been a cause for concern. Polosa felt that there might be an increase in small particulates (I think he mentioned in the region of 11%) but didn’t feel this was a cause for concern. I’d personally like to know more about this.

At one point Professor Harris referred to the WHO report – at which point the audience burst out laughing. It was clear much of the audience didn’t take the WHO report seriously.

Update: Rolygate has left his own analysis on the Facebook comments below, which I have pasted here: 

G McFiggans presented what looked like a competent analysis of ecig aerosol particles. Unfortunately it was ruined and rendered completely irrelevant due to lack of understanding that protocols are everything in refill and vapour analysis. The figures he gave were applicable to nothing at all in the real world, and the scientists present made sure he understood this.

In his defence, it could be pointed out that he was only looking for a way to calibrate his equipment when he ‘measured’ ecig aerosol particulates. However, subsequently presenting data is if it applied to something, or anything, is not really acceptable in a scientist. Again in his defence, he only made the mistake that most others have made when approaching ecig product measurements and analysis: he thought that he could do it without any advice from someone who actually knew something about it.

An analysis that makes no mention of the water vapour injected into the aerosol and that subsequently comprises between 66% and 99% of it (according to various analyses); and taking non-exhaled vapour as the basis for environmental measurements; are in neither case indications of a reliable researcher. Let’s hope he learns from the experience: protocol, protocol, protocol.

That’s particularly interesting to me as Tom Pruen, in the break, was questioning why we needed to be concerned about this when similar particles are created by showers (David Dorn also made this point in the comments).

When we were discussing this later my colleague, Jon Nelsey, was of the opinion that particles from water vapour might be different from particles created by vapour but if Rolygate’s analysis is correct then most of the particles would actually be from water vapour.

I’m not an expert here by any means, so if you are do leave your thoughts in the comments!

Konstantinos Farsalinos: Safety evaluation of E-cigarettes

I took few notes during this presentation as I know from experience Konstantinos goes far too fast for note takers!

However, a few key points are:

  • metals in e-cigarettes (well) below max pharmacological intake
  • no one is going to die from second hand vapour experience
  • most carcinogens existent in smoke are either not present in vapour or are order of magnitudes lower than in vapour

Farsalinos estimates there is a risk reduction of at least 95% but probably more in the region of 99%.

He estimated that if there was an additional quit rate of 2% we would save 324,000 over 20 years in the USA. If we have quit rate of 5% we would save 2,000,000 lives over 20 years. He is hoping for additional quit rate of 10-15%.

Professor Etter

In the break I took the chance to catch up with Etter (we have exchanged a lot of correspondence but have never actually met in person). He emphasised to me that large tobacco companies are deliberately trying to set the bar for legal e-cigs so high that they will wipe out all smaller companies.

Allette Edison, Department of Health: Implementing the Tobacco Products Directive (TPD)

Government are lukewarm on ecigs. Certainly don’t want to stifle them (but will be very limited by EU TPD). They would also like to have some use for ecigs in NRT.

EU TPD will ban cross border sales, which has huge implications for advertising (i.e. no social media advertising).

UK gov is not allowed to modify the TPD but there is a lot missing from TPD. There are some choices allowed which they will consult on. The believes TPD is legal but agrees with Totally Wicked that there are a number of questions to be answered, and are supporting Totally Wicked in this aspect of their challenge.

Paul Marshall, MHRA: Medical licensing for e-cigarettes

Paul discussed the MHRA medical application process. In certain aspects, it seems to be more lenient than the EU TPD.

Paul was asked two questions:

Is it true that nicotine gum and other NRT aids are not as safe as ecigs (apparently in a UK ministers written answer!)
Was it correct that the majority of the MHRA’s funding came from pharmaceutical companies which are known to be campaigning against ecigs?

Paul was unable to answer either question (although we already know the answer to the second question is yes).

Dr Scot Steadman, British Standards Institute: Developing standards to ensure consumer and public confidence in product safety

Dr Scott Steadman gave a very impressive presentation on the BSI. Essentially, we have to make the standards for ecigs or someone else will do it for us. British Standards are voluntary but can be used to deliver legislation. The BSI and ECITA have created a draft British Standards and these are now open for comment. The deadline is 28th November.

Alan Depauw, Aiduce: A European user’s perspective

Alan pointed out that vapers were heavily influenced by word of mouth information.  He suggested that there was an influence between the devices used and success in quitting? It seemed the more advanced the device the more successful the quit attempt .

91% feared severe regulations. It is clear that there are several tens of thousands of vapers who are ready to form a black market in ecigs and eliquid if the EU TPD comes into force. Alan strongly encouraged other trade organisation in the UK to challenge TPD. He pointed out that in the UK we are in the unique position of  being able to challenge the TPD BEFORE it comes into force.

Martin Dockrell: Public Health England Use of e-cigarettes in enclosed public places – building an evidence based consensus

I had no idea how positive Public Health England had become on e-cigs. Some key points from his presentation are:

  • Scale of harm likely to much much smaller including 2nd hand exposure. He quotes Burstyn – harm from ecigs is likely to be orders of magnitude less than harm from tobacco cigarettes.
  • Sending vapers outside could increase exposure of children to vaping. He gave the example of his office where vapers are sent outside to smoke – just outside the bus stop where school children are getting on buses.
  • He also emphasised that we need to take into account growing body of e-cig evidence.

Gray/Cheeseman: Permitting or prohibiting vaping – ingredients for developing a policy

These two are doing a fantastic job of going round the country educating councils on e-cigarettes. Some examples of the questions they face and the answers they give are:

Are ecigs safe? They’re safer than smoking.
Are they leading children to smoke? There’s no evidence this is the case.

They are also sceptical of forcing vapers outside. Cheeseman gave the example of a vaper who had nearly quit smoking, but couldn’t stop totally because she was forced outside with other smokers.

Gray emphasised that NICE guidance is clear – councils and governments are to reduce harm from tobacco. They also argued that policy development needs to include vapers and smokers.

Professor Etter: Product diversity and user behaviour – patterns of use, diversity of products and the different players that make up the e-cigarette market

Etter covered the development of products. Big tobacco are pouring huge amounts of money into this, one company alone has spent 2 billion dollars on development. He emphasised that second generation products are better than first generation products and again pointed out that tobacco companies are deliberately seeking tough regulations in order to wipe out smaller companies.

Clive Bates: Unholy Trinity: Public Health, Big Tobacco and regulation – a rational way forward

As usual, Clive gave a fantastic presentation, and these notes won’t do justice!

A few key points are:

The current success has been due to continued intervention. Full regulation will put a stop to this. Big tobacco companies need competition (which means light regulation) to keep them honest and innovating, but the TPD will put an end to this.

Both banning advertising and onerous regulations will favour the incumbents i.e. cigarettes. The results will be:

  • lower appeal
  • less innovation
  • fewer new vapers

Clive said the WHO report was very, very shoddy, and the TPD was a terrible piece of legislation. Regulations like this will lead to perfectly good products being taken off the market. Presently we have a good market – not much is going wrong, and a lot is going right.

He calls the public health organisations “useful idiots”. They are useful to the large corporations trying to preseve the status quo. They cry, “we just don’t know” but if they don’t know what is the point of them – they’ve had eight years to do research.

(Clive Bates was later taken to task on his use of the words ‘useful idiots’, on the basis that we need to engage the public health community, not estrange them. I agree (although not without sympathy for Clive) but Clive argued this was the nicest thing he could think of.)

Louise Ross: NHS Stop Smoking Service Listening to Service Users – a perspective from a Stop Smoking Service

Louise originally wrote an article criticising e-cigs. Criticism of this article lead to further research, and a complete turnaround in position. She now integrates e-cigs into her approach, and this has lead to a 20% increase in stop smoking effectiveness.

Finally, thanks for reading. Obviously, there’s a huge amount of information from a fast paced conference and while I hope to have got some of the key points, I won’t have covered everything. Let me know of any other good write ups in the comments and I will link to them from this post!

If you would like to read about last years E-Cigarette Summit, click here.

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