What is the e-cig summit?
For the last five years the E-Cig Summit has been bringing together vapers, researchers, industry (both independent and big tobacco and pharma), public health and government.
The summit has been key in cutting through misinformation and contributing towards a huge change in attitudes towards e-cigs. I think it is probably also one of the reasons the UK has the most pro-ecig government and public health communities in the world.
Here you’ll find key themes from the summit, and a summary of the many talks. This post depends on my very messy note-taking, taken at speed at an extremely fast paced event, so apologies in advance for any errors!
E-Cig Summit 5 At a Glance: Key Points and Themes
There’s a lot in this post. For those of you don’t have time to read it, here are some of the key points:
Vaping doesn’t cause harm to lungs: A real world, three and a half year study found no reduction in lung function amongst vapers who had never smoked.
Smoking rates falling rapidly: Down to 15% in the UK. E-cigs have definitely played a role in falling smoking rates.
Short fills controversy: Compliant vendors are worried that competitors are using short fills to get around regulations and sell untested e-liquid, but many vapers are keen to keep them.
At least 95% safer claim backed up by more research: Looking at toxins, there is little difference between toxins in vapers and toxins in non-smokers. Harmful constituents of vapour are between 1% and 0.1% of that of tobacco smoke.
Health care professionals are making up facts about vaping: And killing smokers as a result.
PMI puts a billion dollars into a foundation, mostly for research: Should we use this money, or shun it because it is tainted by big tobacco?
Heat not Burn: Don’t know enough about them yet. However, current evidence (almost all provided by the manufacturers) suggests they are orders of magnitude safer than smoking, but 10 times more harmful than e-cigarettes.
A Tobacco Control Plan for England – Challenges in Creating a Smoke Free Generation
Tim Baxter, Deputy Director for Healthy Behaviours, Department of Health
Smoking rates are falling fast in the UK, and are now down to 15%. E-cigarettes have had a role to play. It’s estimated that 2.4 million people now vape – that’s around 5% of adults, and 46% of them are using e-cigarettes to quit smoking.
Ecigs are by far the most popular quitting method, and the evidence shows that they are not a gateway to smoking. England is the first in the world to have government funded public health messages about the benefits of ecigs.
We now have a proportionate regulatory framework. The tobacco products directive will be continued for now but the UK is committed to reviewing the legislation, and will consider whether Brexit is the right time to change the legislation.
Heat Not Burn is a different matter, as we don’t yet know enough about safety. Tim compared heat not burn to other initiatives that turned out to be a disaster. For example, public health got behind low tar cigarettes too quickly – these then turned out to be worse than regular cigarettes.
Improving the Quality of Research on E-Cigarettes
Professor West: Professor of Health Psychology Department of Epidemiology and Public Health, UCL
The quality of the research on e-cigarettes is extremely low. West argued that we need to bring it up across the board, and apply the highest standards to ourselves.
(He later admitted that he and others in public health had been aware in the pre-ecig days that some research had been of poor quality. However, this research had been accepted because Public Health had generally been happy with the results of the research.)
West called for more complete disclosure of competing interests, before going on to play ‘bad science bingo’ with us.
This identified five causes of bad science:
- Over interpreting
- Over generalising
- Cherry Picking
- Double standards
— John Summers (@jsummers71) November 17, 2017
Very often it’s the press release does the real damage. There were a number of examples but the one that really stuck in mind was this headline by Glantz:
More evidence that e-cigarettes harm smokers more than just smoking cigarettes.
How would you interpret that? Most people would see it as saying vaping is worse than cigarettes.
But what the study actually said is that vaping AND smoking together is worse than just smoking.
West argued that in response, e-cig researchers should not stoop to the anti-vaping community’s poor ethics and tactics. Instead, we should seek to maintain the moral high ground.
That means a respectful attitude and maintaining strict discipline when interpreting and communicating the results of studies. There was also a call for journals to apply more discipline when accepting papers, and for increased monitoring to ensure studies are meeting scientific standards.
The Changing Global Picture of Tobacco Harm Reduction
Professor Linda Bauld: Professor of Health Policy, University of Stirling
Linda ran through what’s happening internationally. Unfortunately, there are fewer countries relaxing restrictions than tightening them up. There are some positives – New Zealand plans to legalise the sale and supply of e-cigs from 2018. Some of this is down to New Zealand’s connections with the UK, combined with activism from vapers and researchers and the opinion of a key clinical advisor (McRobbie).
Scotland took two years to reach their conclusions on e-cigs, but is now positive on them. They now have the ability to ban advertising on e-cigs but this may not take place – they certainly don’t seem to be in a rush to do so. Wales has tried and failed to ban e-cigs in public places and there are no more plans to bring the ban back into place.
In summary, bans and restrictions in major countries are restricting the growth of e-cigs. In much of the world, policy is clearly harming Public Health.
Linda Bauld referred to the recent Stoptober campaign told us to “watch this space” for more public health campaigns that will correct the misconceptions around vaping.
Values and The Continuum of Harm Reduction
Prof Amy Fairchild, Associate Dean of Academic Affairs/Professor, Health Policy and Management, Texas A&M School of Public Health
Amy contrasted the different picture in the US and the UK – as you can see, the attitudes are very different:
— ECigaretteDirect (@ECigDirect_UK) November 19, 2017
The problem in the US is that their interpretation of the precautionary principle is very strong. Essentially this means that even the suspicion of harm leads to a call for total prohibition, even if the potential health gains could be huge. It’s a world away from the harm reduction approach adopted by the UK.
[I think there’s more to it than this, including the influence of big business and huge financial considerations over revenue from tax and tobacco settlements, especially in California.]
But things are starting to change. There is now a new FDA commissioner, with a different attitude, and a greater awareness that nicotine is not the cause of smoking harm.
The Good, The Bad and The Ugly about Derek Yach’s Foundation for a Smoke-Free World
Professor Jean Francois Etter, Professor of Public Health, University of Geneva, Switzerland
Philip Morris International (PMI) have invested not millions but billions into alternatives to cigarettes. In a very short time period their product has taken 14% of the tobacco market in Japan.
The tobacco company has now started the Foundation for a Smoke Free World. PMI are funding it to tune of 80 million dollars a year, or a billion dollars over 12 years.
The main aim is to support research into smoke free alternatives. This will aid Philip Morris in its goal of diversifying its product range, and will also help them in future legal battles. They will, in the future, be able to argue that they did everything they could to mitigate the effects of smoking and provide less harmful alternatives.
Should researchers accept funding?
There’s pros and cons.
The biggest problem is the danger that research won’t be independent. Public Health doesn’t trust Big Tobacco and their history of distorting research. And while the foundation is supposed to be independent, PMI appointed the director of the foundation.
On the other hand, there is currently a lack of funds for research – and research is needed. This would be valuable funding and could attract new talent into the field. It could also lead to studies in countries where is currently very little research. And a billion dollars is a lot of money to waste.
Clive Bates and others have written to PMI to demand it do more to ensure independence – you can see some of the key ideas in the slide below.
In the panel discussion that followed, Dr Knapton of the British Heart Foundation flat out stated he could not work with a PMI funded foundation.
Derek Yach of PMI was present at the conference and promised to take more actions to ensure independence, such as ensuring an independent transparency commission. Dr Knapton didn’t seem convinced…
Q&A panel give two fingers to tobacco ? pic.twitter.com/WA16Z0qbts
— ECigaretteDirect (@ECigDirect_UK) November 17, 2017
One huge problem is that researchers who accept funds from a tobacco linked group may struggle to get funds in the future. This concern was reiterated in a chat with a researcher in the break, who felt accepting funding from PMI would devastate his chances of getting funds in the future.
Relative Risks of Cancer Posed by Combustible and Vapourising Forms of Nicotine Delivery – Evidence from Chemical Exposures
Dr Ed Stephens: Senior Research Fellow, University of St Andrews
Many harmful constituents in tobacco smoke have been identified but only a few are hugely important. Most data shows that the constituents of vapour are well below that of tobacco smoke, in region of 1-0.1%
Later generation e-cigs do appear to be slightly more dangerous, but this is possibly because the power range is so much greater. Why is that a problem? Because researchers ramp up the the power to maximum.
That doesn’t reflect reality.
A study by Konstantinos Farsalinos has shown that as formaldehyde levels increase vapers stop vaping because the sensation is unbearable.
[Vapers, this is the dry puff phenomenon. We stop vaping if we get a dry puff, but in the lab scientists keep their experiments going.]
But there is a low temperature effect as well as a high temperature effect, shown by changes in composition in cartridges, which needs to be explored.
We also need to look at metals – most metals carry low harm but there is one which is highly carcinogenic (9Cr(VI)). Ed felt it was unlikely this was present in vapour, but this and other areas still needs to be investigated. That’s for two reasons. One is simply for greater reassurance. Secondly, if we do find any problems, we can probably fix them.
Toxicant and Carcinogen Exposure Associated With Long Term E-Cigarette Use
Dr Lion Shebab: Senior Lecturer in Healthy Psychology, University College London
Lion looked at bio-markers of subsequent risk. These were much lower than those found in smokers, but at first glance, these appeared to be higher than hoped for. At least until they were compared with those found in non-smokers. When compared with non-smokers, toxicant levels were almost identical.
Is the claim that e-cigs are in the region of 95% safer than tobacco cigarettes correct? Based on the based characterised toxicants in tobacco – yes!
Liam also paraphrased this by saying:
If we are prepared to say that not smoking is around 95% safer than smoking, that’s likely to be case for e-cig use (based on these biomarkers at least).
Comparing the Cochrane Review of Electronic Cigarettes to Other Meta Analyses
Jamey Hartmann-Boyce – Senior Researcher, Health Behaviours and Managing Editor of Cochrane Tobacco Addiction
Can e-cigs help people quit?
In summary, there is a limited range of data to explore, and the quality of evidence is low. However, the balance of this evidence is showing that e-cigs can help people quit. Other meta-studies found the opposite but this was down to the way they did their research and using even poorer evidence.
There is still no evidence of adverse events, but we need longer term data.
Of 27 studies that are currently planned, they feel 14 will offer value and give us a clearer picture.
[It’s a shame they can’t take into account the millions of people who have successfully stopped smoking with e-cigarettes and have to rely on poor research instead!]
Heat Not Burn
Dr Konstantinos Farsalinos, Researcher, Onassis Cardiac Surgery Center Greece, University of Patras
Farsalinos had decided the night before to ditch his planned presentation and focus on heat not burn.
The research is currently positive – BUT we need to be careful because all the research is coming from the manufacturers. This research needs to be replicated by independent studies.
In the very few [I think Konstantinos mentioned three] independent studies the chemicals being shown are not very impressive and not always what the manufacturers have said. In general, toxins were around 10% of that of a cigarettes but Farsalinos found one toxin (Acenaphthene) which was 295% higher – this should have been reported by PMI.
In summary, at present heat not burn products do look orders of magnitude safer than cigarettes but are still around 10 times more dangerous than e-cigs.
That sounds bad, but in comparison to how bad cigarettes are they are still a very viable alternative which could be considered for people who can’t quit with electronic cigarettes. However, this is based on current evidence, which is almost all from the manufacturers.
As we can’t rely on suppliers’ information, more independent research will be needed before we can be confident about the product.
The Impact of Long Term E-Cigarette Use on Lung Health
Professor Riccardo Polosa MD – Full Professor for Internal Medicine, University of Catania, Italy
Aerosols in e-cigs are far less complex than tobacco cigarettes. And when it comes to carcinogens the difference is huge.
So where are the concerns about e-cigs coming from?
- Studies which lack good methodology are leading to the repetition of mistakes.
- Surveys which have problems with design and definitions.
Polosa said he had very little interest in lab studies – so let’s forget the lab and look at the real world.
His findings include:
- Healthy smokers who switch to vaping: No negative effect on lung function.
- Smokers with disease: Experience no difference whether they quit with e-cigs or without.
- Asthma smokers who switch to e-cigs: See constant improvement over time.
- COPD sufferers: Experienced to no detrimental effect over 36 months of vaping.
Much of this has already been reported on this blog, but there’s a new study with huge implications.
Farsalinos managed to find a group of vapers who had never smoked before. This wasn’t easy, as there aren’t many of them! After three and a half years of vaping, they had experienced no reduction in lung function at all.
— Amelia Howard (@Amelia_RH) November 17, 2017
Industry Post Regulation – Has the TPD Worked?
Tim Phillips: Managing Director, E-Cig Intelligence
There have been a huge number of submissions of e-cig products to the MHRA. Companies are continuing to submit, and growth has not been particularly affected.
But there are regulatory gaps, for example shake and vape aka short fills. This is essentially DIY e-liquid mixing.
- A failure of regulations caused by a regulatory gap.
- There are cost savings in not notifying, and not doing the testing required with other e-liquids.
- There is an average 30% difference in price saving.
Heat not burn is now being rolled out very fast but this is very much a Japanese phenomenon (and they don’t have e-cigs in Japan!)
Deborah Arnott, Chief Executive, Action on Smoking and Health (ASH)
[Deborah Arnott’s talk was mostly about smoke not burn but I have mostly focussed on the vape side of her discussion here.]
There is a troubling trend – while we increasingly realise vaping is far safer than smoking, the public’s perception is going the wrong way. More people now thinking vaping is worse than or as bad as smoking, and this is leading to a flatlining in the growth of electronic cigarettes.
— ECigaretteDirect (@ECigDirect_UK) November 17, 2017
The real issue is with how media is representing e-cigs. Positive stories are often reported in very small stories, other studies are mis-represented and splashed on the front page.
The aim is now to counter this with public health campaigns around the facts of vaping.
An Update on the CAP and BCAP Consultation on E-Cigarette Advertisers and Health Claims
Robert Morrison: Senior Regulatory Policy Executive, Committee of Advertising Practice (BCAP)
If you were hoping for an update on the relaxing of advertising rules you’ll be disappointed, I’m afraid. The advertising regulatory bodies have been consulting on some relaxing of the rules and allowing health claims, but we’re unlikely to see an update this side of Christmas.
There hasn’t been much happening, other than a few complaints enforced. Two websites have been forced to amend their wording to be less promotional. Both of these have come after complaints from other vaping companies [sounds a bit like shooting yourself in the foot!]
The Independent Vape Sector – A Unique Relationship with Smokers and Vapers
Mathew Moden, Chair IBVTA Manufacturer’s and Importer’s Committee and MD of Liberty Flights
Moden discussed the incredible connection many in the independent sector have with their customers.
Vaping was a phenomenon that caught everybody out, and it was a phenomenon that was principally driven by customers, many of whom were went on to start their own businesses.
Independent vape stores were and are essential, comprising of thousand of experts offering advice to smokers thousands of times a day.
This closeness of the independent sector to their customers shaped the devices and products that were provided to vapers, allowing vendors to be incredibly sensitive to their customers.
At least until the TPD came along. This has slowed innovation and penalised long term vapers (who can no longer get the devices and e-liquid strengths they were used to).
The lack of enforcement has also penalised responsible businesses. They are now put at a competitive disadvantage by having to compete against businesses who break the law.
[Side note: We have seen business who:
- Sell to children
- Sell un-notified products
- Sell untested products – some which almost certainly contain diacetyl.
Despite the mooted high penalties, trading standards are understaffed and I have yet to see any shop get more than a warning – in some cases these shops carry on regardless.]
Many competitors are now also selling short fills which are untested.
Later on in the panel discussion Moden made another key point (in my opinion) that we are going from a market driven by consumers to one being driven by regulators.
The Current State of the E-Cigarette Consumer Notification Process
Beryl Keely – E-Cigarette Notification Scheme Lead, Medicines and Health Care Products Regulatory Agency
The MHRA has received 32,000 notifications from 500 companies, and are still getting between 100 and 200 submissions a week.
The yellow card reporting system is in place, although there is still a low level of awareness. [The yellow card reporting system is a scheme for reporting adverse reactions.] Most of the reports that have been received talk about how wonderful e-cigs are. While this is nice, it is not what the system was designed for.
There have been a very low number of adverse reports – while this has to be taken into account with the low level of awareness, this is still a positive sign. There are still no sign of licensed products, but Beryl has offered to meet with anyone interested in taking a medical device forward.
There didn’t seem a whole lot of enthusiasm in response…
How Might Medicinal Regulations Evolve in their Expectation for Ends
David Graham: Chief Impact Officer, NJOY
David compared medicinal regulation to a walled garden. It looks attractive to people from outside but the walls are very high and even if you get in there are surveillance cameras to monitor you.
The barriers, David felt, are too high which is why there are no medicinal e-cigs on the market. He put the argument forward for a much lighter licensing procedure for e-cigs.
The comparison he made was a nicotine inhaler that was allowed a licence for harm reduction. The reasoning behind this was that there was no doubt it was much safer than smoking. The same reasoning should be applied to e-cigs, which are now accepted as safer.
Discussion, both in the panel and at break, was sceptical. The feeling is that the barriers to medicinal regulation are so that high that even if a few devices got through, choice would be limited.
Many people feel the reason vaping is successful is because there is so much choice, different people need different devices and there is no one choice fits all solution. David did argue that we could have a range of devices but there seems very little appetite from the commercial sector.
[It seems to me to be another example of regulators trying to take control of and steer a consumer-led revolution.]
Time to Act: Reaching The Last 35%
Martin Dockrell, Tobacco Control Programme Lead, Public Health England
Martin highlighted the success of the Stoptober campaign. This was the first ever government run campaign to persuade smokers to switch to vaping, and was run in conjunction with our trade organisation, the IBVTA. This lead to a clear increase in sales of e-cigs.
Public Health England is now working to develop skills of health care professionals, including creating online courses and guidelines. They are also working with NCSCT (the National Centre for Smoking Cessation and Training) and the NNA (The New Nicotine Alliance) to produce videos of vapers explaining how e-cigs have helped them.
The number of dual users (people who both smoke and vape) is often cited as a concern, but Martin highlighted that dual users are far more likely to be intending to quit in the next 3 months than smokers who don’t vape. (The exact figures are 19% and 8%, so vapers are more than twice as likely to be aiming to quit smoking.)
Martin did highlight that smokers who used to vape but have stopped seem more addicted (as measured by time to first smoke.)
I loved one quote from Martin:
The task of harm reduction (policy makers) is to help people be as safe as they choose to be.
So many in public health seem to feel their role is to force people take the route they want. Instead, Martin argues we should provide the information that allows smokers and vapers to make their own, informed decisions. This is a refreshing attitude!
Finally, Martin asked us all to tweet this video:
— ECigaretteDirect (@ECigDirect_UK) November 18, 2017
The Challenges and Achievements of Advocating for E-Cigarettes – A Service Provider’s Journey from Sceptic to Advocate
Louise Ross: Stop Smoking Service Manager, Leicester City Council
Louise highlighted the success of e-cigs in quitting, and showed that she is getting consistently high rates of success with e-cigs (above 60%).
The number of people in her area successfully quitting is increasing year on year, from 180 quits in 2014-15 to 512 quits in 2016-17.
Louise Ross showing the quit success using e-cigs in Leicester, through Stop Smoking Services. Behavioural support + e-cigs looks to be the way forward for many (but not all) #ecigsummit pic.twitter.com/V0fz7FhH1h
— Carl Alexander (@CarlDAlexander) November 17, 2017
It’s clear that using e-cigarettes would help stop smoking services becomes a success in all areas, including those with mental health problems and pregnant women.
However, there are still stop smoking services blocking the use of e-cigs, and, even worse, professionals making up lies about e-cigs (or repeating lies from media such as the Daily Mail) which is putting people off e-cigs. In some cases, people are even being refused operations unless they stop vaping.
She feels the need to remind other stop smoking services that:
We are a stop smoking service, not a stop nicotine service.
But professionals can’t seem to get their head round the fact that it’s the smoke that kills, not the nicotine.
In her own words, professionals are stopping people doing something which can save lives.
She also highlighted the problem of popcorn lung. This is the question she gets most, both from smokers and professionals. People are getting lung cancer because they are frightened by the spectre of popcorn lung – she doesn’t know why. [As far as I know, nobody has ever got popcorn lung from vaping.]
Louise is retiring this year, but will continue to work with the New Nicotine Alliance. She ended her talk to a standing ovation.
How an E-Cigarette Strategy Could Help Us Move Towards The Goal That We All Have, To Reduce Cigarette Use
Professor David Levy: Professor of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University
Professor Levy ran us through models of how vaping can impact public health, looking at early deaths prevented and life years saved. In order to counter the anti-vaping community, he took a worst case scenario, putting in the most pessimistic facts he could.
He found that even if vaping initiated smoking, wasn’t nearly as safe as the UK government says it is and lead to a decrease in quit attempts, there would still be a net public health gain: over 1,6 million million lives saved and over 20 million life years gained.
In the most optimistic scenario there would be major gains: over 6,5 million lives saved and over 86 million life years gained.
— ECigaretteDirect (@ECigDirect_UK) November 19, 2017
The Ethics of the E-Cig Australian Ban on Electronic Nicotine Devices
Professor Wayne Hall: Director and Inaugural Chair Centre for Youth Substance Abuse, University of Queensland & National Addiction Centre, King’s College London
Wayne covered the ‘incredibly restrictive’ e-cig policies in Australia. This was down to a incredibly precautionary view, a fear that e-cigs could undermine stop smoking policies and the belief that big tobacco companies would take advantage of harm reduction policies. As a result, e-cigs are only available on the black market (i.e. smokers have to break the law in order to save their lives).
But the decline in stop smoking rates has stopped over the last few years, despite huge taxes and plain packaging. [Note: this is a stark contrast to the UK where it has accelerated rapidly as vaping becomes more popular] Until recently, this was done with:
- No public debate
- The harassment of vapers (via fines and labelling as criminals)
- Ostracising anyone who dissents
Wayne felt that for many in public health the aim was not to reduce smoking, but to attack the tobacco industry’s in the mess. He remained pessimistic about the opportunity for vaping.
Five E-Cigarette Summits On – What Are We Still Fighting About?
Sarah Jakes, New Nicotine Alliance
Sarah’s talk was fantastic. I can’t do it justice here, because every sentence and phrase had impact. Here’s a few points I did manage to scribble down:
- The independent vape industry was sensitive to our [vapers] needs because they are us.
- Fighting their [Big Tobacco] lies with your lies just leaves smokers as collateral damage.
- Vapers, advocates and public health goals are the same, the disagreement is over how to get there.
- Freedom of choice is being eroded. Vapers want to make their own choices based on correct and accurate information. They also want public health to stop sucking the enjoyment out of everything.
- On the Philip Morris foundation: If it fails it will be consumers who lose out – smokers and vapers need good quality science and don’t care who pays for it.
- Favourite quote: “When you see our rowdy revolution, all we’re trying to do is stop you from f%$£ing it up.”
Sarah’s talk ended with huge applause – but as the NNA pointed out, donations are even more appreciated. If you’d like to support their work, please consider donating here.
(Just seen that Sarah’s speech is now on the NNA blog – you can read the full text here.)
A Big Thank You 🙂
A huge thank you to Amanda Strange and the E-Cigarette Forum for putting this together – again. This is my fifth visit – and I wouldn’t have gone in the first place if Oliver of ECF hadn’t persuaded me of the importance, so a personal thanks to Oliver for getting me to go to the first event.