Time drifts away like a cloud of gentle vapour, and after attending the 1st E-Cigarette summit in 2013 (and every one since!) it seems astonishing to find myself at the 7th event.

Events change too, and gone are the huddles of dedicated vapers at the back of the room. Indeed, you can't now vape in the building of the Royal Society, or even in the forecourt. Instead you have to head to the side of the road and join the tobacco guys, the engineers and the occasional remaining advocate for a chilly vape and warmer conversation.

The E-Cigarette Summit is still the best conference I attend through the year, bringing together some of the foremost experts in vaping and tobacco harm reduction and focussing the bright light of science and analysis on wild claims about vaping.

There were 22 talks and four panel discussions crammed into 8 hours, so it’s obviously impossible to cover everything. In this blog post I’ve tried to highlight key points from as many talks as I can but the usual disclaimers remain - I’m relying on memory, was lubricated with whisky while I wrote this in the early hours of the morning and all mistakes are my own.

There's a lot here. Do feel free to skim, but otherwise settle back in your armchair, charge up your vape and join me as we absorb some of the knowledge of the top experts and researchers in the industry.

Intro

Vaping has been dogged almost throughout its history by misinformation and determined attacks, but at no time in my eleven years in the industry can I remember the attacks being so frenetic. This weariness seemed shared by our chair, Professor Ann McNeill, who said that there are facts and opinions, but right now she's sick of opinions and is desperate to hear facts, not fiction.

Professor Tikki Elka Pangestu, National University of Singapore: Harm reduction in Asia - challenges and the way forward

Vaping is generally either banned or being banned in much of Asia. As Clive mentioned later on in the summit, India, with it's 100 million smokers, was recently congratulated by the WHO for banning electronic cigarettes. Yet the region has six of the 10 countries with the highest number of deaths in Asia - 1.8 million a year in China and 743,000 a year in the now vape-free India.

What's more, while smoking rates amongst youths are plunging in Western countries, progress is slower in Asia - in fact, in Indonesia smoking rates are increasing rapidly. But the fear of the gateway effect amongst children is stopping governments from accepting vaping.

Why? Scientists think good research leads to policy, but in fact policy is influenced by many factors that Tikki calls the Policy Pie. These factors include the media, lobbyists, values, habits, traditions and the electoral cycle. It's exacerbated by the fact politicians put more emphasis on local research but there is a dearth of quality research on vaping in these areas. The WHO is heavily relied on, and their anti-vaping stance has further hindered the potential of vaping.

Then there's the economic factor. Half of the countries largest tobacco companies are in Asia, and state owned tobacco monopolies in the region account for 40% of global cigarette production. Cigarette revenue is huge - in Indonesia, for example, it accounts for 6% of total tax revenues.

What to do? Tikki emphasises that scientists must avoid hubris. Instead of preaching from the moral high ground, scientists should strive to reach consensus and avoid taking sides. They need to communicate with fewer stats, and with more warmth, empathy and stories. And they need to work with sympathetic governments to influence and change the WHO's position and stance on harm reduction.

Cliff Douglas, American Cancer Society: Vaping in America: ‘Dead or Alive’? The prognosis for harm reduction in the US

THR (tobacco harm reduction) in the US is losing ground. Some of the factors Cliff identified were:

• Vape marketing (too extreme)
• Increase of vaping in youth
• The higher levels of nicotine in the US compared to the EU
• FDA inaction and delayed reaction
• Recent deaths from THC which have been conflated with vaping

Cliff believes the hands-off-approach to vaping has backfired creating an environment where there is fear over vaping and children, and that this fear has taken priority over the need to help adult smokers.

This has been confounded by fears created by cannabis vaping - despite the fact that the 40 lives lost pale in comparison to the 240,000 smokers who lost their lives in the same period [Note: this sounds like a large number for a short time, and I may have misheard the period.] Now vapers are going back from vaping to smoking, including Cliff's niece and her boyfriend.

Still, Cliff is worried himself about youth vaping. He also seemed to hint that his own charities position on vaping might evolve given the current anti-vaping climate and the pressure on charities to be anti-vaping.

Note: Cliff has put a summary of what he discussed in the comments below.

Professor Jarvis, University College of London: Epidemic of youth nicotine addiction?

Professor Jarvis set out to test claims about youth vaping by the FDA using their own data set.

These claims are that:

• There is an epidemic of youth nicotine addiction from vaping
• E-cigs are a gateway to smoking
• Vaping is reversing the trend of falling cigarette use amongst children

But:

1. E-cig use is strongly related to past tobacco use. The more someone has smoked, the more they are likely to use e-cigs. 1% of children who hadn't smoked before had tried vaping once in the past 20 days in the previous month, compared to 37% who had smoked more than a 100 cigarettes.
2. The gateway theory is not borne out, as most children had tried cigarettes before e-cigarettes.
3. Data shows that youth smoking has continued to fall after the introduction and popularisation of e-cigarettes.
4. While there is some experimentation, only 1% of children who had never smoked had used e-cigs 20+ days in the last 30 days. [Note: this is US data - the rates are lower in the UK.]
5. Symptoms of nicotine addiction were rare in children who had not previously used cigarettes.
6. If anything, e-cigarettes are displacing cigarettes, not slowing the decline in youth smoking.

"We find a gaping chasm between the vision of an epidemic of e-cigarette use threatening to engulf a new generation in nicotine addiction and the reality of the evidence contained in the NYTS."

Much of this mirrors my own analysis of youth smoking in the US and UK here.

Deborah Arnott, Action on Smoking and Health: The UK approach to e-cigarettes and tobacco harm reduction - data, policy and evidence

Deborah ran through the regulatory approach in the UK (we've covered much of that on this blog before, so I won't repeat), and pointed out that youth vaping is extremely low, with 0% of non-smoking children using e-cigarettes more than once a month.

She then went on to attack the industry for its use of social media, packaging and labelling, arguing that if the industry didn't clean its act up plain packaging would be forced on it and all, rather than just some, advertising banned.

Deborah argued that better compliance was needed on sales, and suggested that MHRA notification fees could be used to better fund trading standards.

Thoughts:

• I’m in the middle ground on vape branding and marketing. I’d like to see some industry self regulation to prevent extreme marketing which could be interpreted as attractive to children. Despite the evidence that non-smoking children are not using e-cigarettes, the industry needs to show itself to be responsible. At the same time, companies need to be able to make their products attractive to smokers. After all, there’s a reason companies brand their products - because branding works.
• At the same time, I can’t help wondering what’s going to happen to children who smoke. Are we saying that adults addicted to smoking should have access to a product 95% less harmful, but children who smoke can’t? What about the evidence that around 40% of children who quit smoking did so using electronic cigarettes? Perhaps there should be some way children can access electronic cigarettes, such as through stop smoking services who can hopefully ensure it only goes to children who need it.

Professor Borland: ITC and the four counties summary

Professor Borland summarised findings from a survey of four countries: Australia, the UK, Canada and America.

While 70% of smokers had visited a health professional in the last year, less than 7% had received advice from health professionals on vaping. If I heard correctly, half the time it was brought up was when the health professional was a vaper. Advice was more often positive than negative.

In general, 29% of respondents had never been given any helpful advice. When they had helpful advice, 43% of the time it came from colleagues/friends or family, and 20% of the time from specialist vape retailers. Little helpful advice came from doctors (2.6% of the time).

Why do people use e-cigarettes? One of the biggest reasons includes preventing relapse to cigarettes. That’s super important, because as was mentioned several times at the conference many smokers who quit eventually go back to cigarettes. (Ironically, my post-conference taxi driver told me he had recently gone back to smoking after years of abstinence.) But another key reason is that vapers enjoy vaping.

Professor Robert West: Practical Solutions to the problem of low quality in e-cigarette research

As everyone in the industry knows, there is a lot of bad research around. West highlighted the example of using mice specifically bred to develop cancer being used in studies on the effect of vapour (which we covered in our recent vaping myths post).

Studies are either correlational or causal. But many correlational studies are being taken as causational, if they support the view of the researcher.

Some of this is due to bias, which itself is due to:

• Desire for impact.
• Wishful thinking.
• Desire for confirmation.

After all, releasing a news story that says “we didn’t find anything” doesn’t make a very good story. It’s much more rewarding for the researcher to ‘find’ something in the study and put out those findings as a press release.

Unfortunately, current scientific method is not proving sufficient to overcome the problems with research. What’s more, it’s not sufficient to trust a study simply because it appears in a peer reviewed journal. For example, a recent heart attack study had been peer reviewed despite having poor conclusions.

West suggests two solutions:

1. Research should be pre-registered, with the plan and type of hypothesis confirmed at this pre-registration phase. A lack of pre-registration leads to a bias towards confirming pre-conceptions and ‘impact’ findings.

2. Creating an E-Cigarette Ontology (E-CigO). At the risk of oversimplifying, there will be better communication and less confusion if researchers on both sides of the debate have a shared understanding of how vape specific language is used.

John Britton: Vaping and lung diseases

John Britton started by covering the risks of vaping. Vaping can contain some of the same harmful substances as in tobacco smoke, such as Acrolein and Acetone, but at levels far lower than in cigarettes. There are likely to be modest increases in diseases like lung cancer, but the risks are much lower than that of smoking - probably less than 5%, and this could be improved further via product standards regulation and improved technology.

The sudden outbreak of disease which has been linked to vaping has only taken place in the USA and is linked to typically young people who are using THC with Vitamin-E Acetate. Not every person has admitted using THC, but we need to bear in mind that they might not want to admit they were using THC, and they might not even know they are using THC. A search has been done of the MHRA database and no UK e-liquids have been found to contain Vitamin-E Acetate.

In conclusion, while we might expect rare cases of acute disease from vaping, we know that smoking causes 100,000 deaths a year with an average of 10 years loss of life, 5,300 fetal deaths, 2,200 premature births, 19,000 low weight birth babies, 165,000 new cases of asthma, bronchitis, ear disease and meningitis and billions of dollars in cost to society.

Professor Britton was scathing of the media. Poor reporting is sending vapers back to smoking which will cause premature death.

Professor Konstantinos Farsalinos: Is e-cigarette use associated with cardio-vascular disease?

Konstantinos looked at the concern that nicotine causes cardio-vascular disease. Some researchers have pointed out that nicotine has a short term effect on the body, such as increasing aortic stiffness and blood pressure. But caffeine has exactly the same effect and does not cause any long term harm. What’s more, Nicotine Replacement Therapies (NRT) also create acute aortic stiffness in the short term, but over the long term they decrease aortic stiffness.

Konstantinos then took the Glantz heart attack study mentioned earlier, and demonstrated that if you applied the same method to cholesterol-lowering medicine it would also show an increased risk of heart disease. [Yep, that’s the study where vaping was said to cause heart attacks that happened before the subject started vaping.]

Farsalinos also covered the lung disease outbreak in the USA, highlighting that this was a sudden acute outbreak of disease, in one country and in a specific demographic, and that epidemiological principles tell us that this can not possibly be linked to e-cigarettes which have been used widely for at least 9 years.

Dr Sarah Jackson: Do e-cigarettes and dual use undermine quitting?

E-Cigarettes appear to be a quitting success story.

They are the most popular quitting aid, are nearly twice as effective as NRTs, and have the potential to help 70,000 smokers a year quit smoking. However, some academics have challenged the effectiveness with several questions, which Jackson went on to address.

1. Do e-cigs renormalise smoking?

Fortunately, the data shows quite clearly that smoking has continued to fall as e-cigarette use has grown.

2. If smokers see other people vaping, will this make them less likely to want to quit?

[My proof reader left me with a comment saying: Shouldn't less be more? But this is correct - it's a real concern some in tobacco control have.]

More than a quarter of smokers are regularly exposed to vapers, and those smokers are both more likely to have a high motivation to quit and are 20% more likely to try to quit.

3. Are dual users less likely to quit?

Surveys of smokers and dual users show that dual users are more motivated to quit smoking. They also smoke less cigarettes than smokers, and were 2.8 times more likely to successfully quit than people who only smoked.

Peter Hajek: E-Cigarettes, smoking initiation and smoking cessation

Originally the key question around vaping was whether it would encourage smoking. (It’s now more about whether it encourages nicotine use.)

Hajek pointed out that a good new product doesn’t encourage the use of an old product, it replaces it. He uses cameras an an analogy. Digital cameras killed film camera, and now cameras on mobile phones are replacing digital cameras.

Of course, attempts have been made to show that electronic cigarettes don’t help quitting. One study, for example, argued that electronic cigarette use reduce quitting. But this was down to selection bias; the study only looked at smokers who had failed to quit, and ignored the vapers who had successfully quit.

Other studies have claimed that vaping leads to an increase in the initiation of smoking, but if this was true smoking rates would be increasing, not falling.

Vaping is not a gateway to smoking for young people, either. In fact, vaping is not even a gateway to vaping. In 2018, for example, only 0.1% of non-smoking youngsters in the UK vaped on at least 15 days a month. And half of those were vaping marijuana, not nicotine.

E-Cigarettes are more often a gateway away from rather than into smoking. Daily smoking amongst young people has virtually disappeared, falling to just 0.4% amongst 12-17 year olds, and not a single young person who hasn’t previously smoked vaped on a daily basis.

Tim Phillips: Scandal in the US and global implications

Tim Phillips looked at the impact of the vape crisis and its implications for the vape industry. I interviewed Tim recently for an in-depth post on the same subject, so I won’t go into this one in detail. However, it is interesting that the vaping cannabis sector has been the least impacted by the illness caused by vaping illicit cannabis, and faces the least regulation.

Louise Ross: I had given up giving up - how smokers have reacted to a new gateway out of smoking

Louise gave a fascinating insight into the lives of the people being helped by smoking services.

For example, many smokers live in families where most people smoke, and sometimes quitting smoking can seem like a betrayal to these people. Regulators see tax hikes as a way to control smoking, but in fact these people don’t always buy at shop prices [i.e. they buy black market tobacco]. Culturally, many see getting help as a weakness, making it difficult for them to access stop smoking services. Frequently, these people have other issues, such as mental health problems.

But e-cigarettes are helping.

For a start, when smokers switch to vaping, they don’t feel they are betraying their family. They still get to have ‘me time’ and enjoyment. Vaping also gives lie to the adage: “To be successful, you have to want to quit smoking,” as there are many accidental quitters. These include the partners of services users who tried vaping and never smoked again.

The effect has proven remarkable. In addition to health, these people are experiencing improved finances, well being and an ambition to improve their lifestyle.

But there are problems. Pressure is put on people to stop vaping before they are ready, which increases the risk of relapse.

Vapers are also faced with 'fire hosing'. From Louise’s slide:

“Fire hosing inundates us with so many wild opinions that it becomes exhausting to continually disprove them.”

That includes misinformation from medics, and Louise talks about how stop smoking services can work hard to convince a smoker to switch to vaping, only for their doctor to tell them they are better off smoking.

Liam Humberstone - Regulations and Product Standards - current controversies for the vape industry

Liam highlighted the value of vape shops. Well trained teams provide a welcome to ordinary adult smokers, and are essentially well trained stop smoking advisors, often with huge experience. They are able to provide a choice of devices and flavours to help smokers - and those flavours are important.

For example, when Totally Wicked simplified a product range for new customers, they provided a range of just 4 flavours - two tobacco flavours, one menthol and one fruit flavour. New vapers chose the fruit flavour 40% of the time.

Liam also examined sales of a larger range. In that range, only 8% of vapers chose tobacco flavour, and while unflavoured e-liquid was available, sales were so low they came in at 0% of the total.

Liam believes that companies want to supply the best products, and that regulation does not set a high enough bar in terms of product. That’s why the IBVTA and companies like his are not only complying with existing regulations, they are also contributing to the development of new ones.

Linda Bauld, University of Edinburgh: The UK Approach to tobacco harm reduction; The pillars that guide policy

Linda discussed how the UK approach to tobacco control is based on three pillars: Communication, Regulation and Research.

Key to tobacco control in the UK is harm reduction. This has lead to accusations that the UK has been influenced by tobacco companies, but in fact the UK has been ranked number one in the world for resisting influence from the tobacco industry by the Global Tobacco Industry Interference index.

There is a strong link in the UK between policy makers, charities and researchers. This helps ensure policy is based on research, while both ongoing surveillance and research both provide evidence to maintain policy when it’s working as well as to change it when it’s not. One of the biggest funders of research is Cancer Research UK (CRUK), which has funded 57 vaping studies since 2014 - they also provide a monthly evidence briefing of the latest studies which researchers can request from CRUK.

Linda felt one area where success had been limited was in the area of communication, as the UK approach, research and regulation in the field of tobacco control and harm reduction had been poorly understood.

One area where they had been helped, though, was by the Science Media Centre, where a small team of people are working to provide expert reaction to studies. [This an excellent site for those interested in vaping, and it’s well worth checking out.]

Professor Jean-Francois Etter, University of Geneva: The Foundation for a Smoke-Free World

Etter was taking a look at a charity set up by Philip Morris, The Foundation for a Smoke Free World (FSFW), to provide grants for both harm reduction projects and charities.

There has been plenty of scepticism around a tobacco company setting up a foundation, from both tobacco control and media. This had been anticipated, and Derek Yach, the Director of the Foundation, insisted on complete independence from PMI. However, as Etter pointed out, if they do have complete independence, this has its own problems. With complete independence, where is the accountability?

Could the real goal be to create divisions in THR? Etter pointed out there have been divisions, although this might have been unintended. Researchers who have accepted grants have been harassed, bullied and defamed, and cut off from other sources of funding. The fault for this, though, lies with bias on both sides of the debate.

What about transparency? Etter thought more information should be available on a number of areas from the names of the grantees to the minutes of the board meeting. However, this may have been limited to protect people involved from harassment.

Etter also looked at how the money has been spent. So far in 2019 32 million dollars has been spent on grants, 4 million on communication and 20 million on expenses. Etter felt the proportion spent on grants was low, although the foundation argues this is usual in the early days of setting up a large foundation.

Throughout its history 156 million dollars has been approved for 90 grants and 15 researchers, although because of that previously mentioned harassment FSFW has struggled to recruit mainstream THR researchers. Still, that might bring new people into the field.

Clive Bates, Counterfactual: What could possibly go wrong?

Clive covered the unintended consequences of regulations. Summarising a report from the Royal College of Physicians, he pointed out that if a precautionary approach makes e-cigarettes less accessible, less palatable or acceptable, more expensive, less effective or inhibited innovation then it causes harm by perpetuating smoking.

1. Bans (including effective bans from over-taxation or over-regulation)

A great example of a ban doing harm is the example of Snus in Sweden and Finland. Until 1995, both Sweden and Finland had rapidly falling smoking cessation rates. Then the EU Snus ban put an end to Snus sales in Finland. Sweden, where Snus is legal, continued to see falling smoking rates while Finland flattened out. That lead to a situation in 2014 where Finland had a smoking rate of over 25% while Sweden had a smoking rate of 15%.

2. Protect the kids

Clive redefined this as “being clueless about kids”. As with other presenters, he broke down the claims that over 20% of children are vaping to what they really represent - less than 1% of non-smoking children use vaping more than 20 days a month. As most vaping children were/are smokers, vaping may actually be helping them.

And vaping is a massive distraction from more serious problems. One survey found that in 12 months 17% of children had contemplated suicide, 7.4% of children had tried to kill themselves and 2.4% of children suffered serious harm from suicide attempts. Focussing purely on nicotine distracted from what we really needed - a person-centric approach to children’s problems.

3. Warnings

What about those warnings on e-liquid? The single largest reason smokers are not switching to electronic cigarettes is because they do not want to substitute one addiction for another. But because of regulation, we have a massive addiction warning on e-liquid bottles and hardware. Research suggests fewer people are switching, and more people are smoking, because of this. Instead, Clive recommends a more positive message which says that products are 95% safer than smoking.

4. Advertising bans

Quite simply, e-cig adverts on tv encourages adult smokers to quit. If we’d had a more relaxed environment around advertising, the quit rate would have increased by 10%.

5. Limits on nicotine strength

TPD limits on nicotine strength make it more difficult for heavy smokers to switch. Clive Bates suggested 36mg is equivalent to unfiltered/extra-strong cigarettes, and 24mg is equivalent to full strength cigarettes. Both of these are now banned, making it harder for some smokers to switch.

In conclusion, Clive argued that few regulatory interventions so far have been better than doing nothing.

Dr Graham Moore, Cardiff University: Children and adolescents’ perceptions and use of e-cigarettes

Drawing upon research by Rachel Brown et al, Graham pointed out that experimentation with vaping was considered acceptable by youth in a social setting. However, regular use was not, unless vaping was being used as a tool to quit smoking. He also looked at post-TPD use of e-cigarettes, and found that there had been a slight decline in youth vaping after the introduction of the TPD, although he was unsure whether it was the TPD that lead to this. Vaping does appear to provide a challenge for schools and parents - they give out a strong consistent message that smoking is bad, but are often confused about what to say about vaping.

Graham concluded that vaping does not appear to be renormalising smoking, and part of this is down to a perception that vaping is something adults do to quit smoking.

Dr Caitlin Notley, University of East Anglia: Long term smoking relapse prevention - understanding trajectories of e-cigarette use

In general, most smoking interventions focus on getting people to quit. However, quitting is the easy part - staying quit is far more difficult. And currently, we’re not very good at getting ex-smokers to stay ex-smokers.

One of the problems with quitting is that people lose their identity as a smoker. But vaping can help here, as people gain a new self-identity as a vaper. A qualitative interview study backed this up, and also found that vaping could help prevent relapse by fulfilling the physical, psychological and social needs of ex-smokers.

Vape shops also help. They’re easy to access, and often provide expert access. What’s more, different vape shops appeal to different smokers. [This is something that my experience backs up. For example, young hip vapers often go to a very different vape shop to older, more reserved vapers.]

However, while e-cigarettes can help support sustained abstinence from smoking, vapers also need social support and acceptance. Public perceptions that nicotine is bad for you, media mis-reporting and bans on flavours all threaten the ability of vaping to help ex-smokers stay smoke free.

Jacques Le Houzec: Vape Shops and their role in public health

Jacques has been running a program to train staff in vape shops, and came up with some interesting points.

Although nicotine is not the cause of smoking diseases, smokers fear nicotine. Vapers, who are ex-smokers, also fear nicotine. Most staff in vape shops are vapers, which mean they need educating about nicotine and its relative safety compared to smoking.

Smokers know how to smoke and self-titrate, but they don’t know how to vape - they need to be taught. Smokers usually take shorter, sharper drags on cigarettes, and properties in tobacco help prevent coughing. Combined with nervousness when they first vape, they take a short drag with plenty of air which causes them to cough. This can be easily solved by teaching new vapers to take a longer drag with no air. They also need to learn that e-cigarettes deliver nicotine more slowly than cigarettes, and that they will need to vape more regularly throughout the day.

What device do new vapers need? A device with a tight airflow (what we call a mouth-to-lung device in the industry) and e-liquid with high nicotine levels. The current EU nicotine strength cap of 2% is too low for 25-30% of smokers. However, remember that while vaping is better than smoking for pregnant women, women who are pregnant metabolise nicotine twice as fast as non-pregnant woman.

Houzec recommended that given the cap on nicotine, people who smoke more than a pack of 20 cigarettes a day should also use a nicotine patch at the highest strength available. He also pointed out that some ‘light’ smokers may need more nicotine than you thought - if vaping is not working for them, you should increase the nicotine level.

Also see our interview with Jacques Houzeq on nicotine and e-liquid.

Ethan Nadelmann, Drug Policy Alliance; Science, compassion and human rights - a 21st century drug war in the making?

The evening wrapped up with a passionate, breakneck speech by Ethan Nadelmann.

The speed killed my ability to take notes, but Ethan did predict that this century would see the war on vaping replicate the war on drugs. He reminded us of 'reefer madness', the idea that a toke on a (relatively harmless) joint would lead to madness and crime to show how ridiculous US approaches could be, and feared that the US was once again exporting its craziness to the rest of the world.

A lot of this is down to Bloomberg - the former Mayor of New York is spending hundreds of millions on a campaign against vaping and bankrolled the WHO’s report on vaping, leading to vaping bans across the world. Ethan advised building alliances to combat misinformation, and highlighted the value of writing joint letters that go beyond just experts in the fields and bring in other names that raise eyebrows. This approach helped change attitudes towards drugs in the UN, and could help with vaping.

That’s all for this year. Once again huge thanks to Amanda Strange for putting together this whirlwind of talks, and apologies for the errors I am sure have crept into this post!