E-Cig Summit 2021 Roundup - Part 1

Since 2013, the E-Cigarette Summit has been shaping the vaping debate, bringing key scientists, policymakers and public health professionals together. It’s an incredible opportunity to learn a huge amount about vaping in a very short period of time, and as usual Amanda Strange has done a simply superb job putting it together.

In these posts, we’ll be aiming to summarise key points both for those who don’t have the time/funds to attend the conference or watch every talk. You can find previous Summit write ups (bar last year’s) here. You can also see quick summaries for the E-Cig Summit Day 2.

As always, there will be inevitable mistakes from digesting a huge quantity of material, as well as trying to simplify sometimes complex arguments - if you spot any please let me know!

Contents

Pre-Summit interview with Colin Mendelsohn
Science and Evidence
THR and Tobacco Control
Tobacco Control, Regulation and Enforcement

Pre-Summit Interview: Dr Colin Mendelsohn interviewed by Marc Gunther

The E-Cig Summit kicked off with an interview with Colin Mendelsohn, author of the just released Stop Smoking, Start Vaping (see our review here). Key points included:

Most opposition to vaping is based not on evidence but on underlying ideological issues, moral positions, vested interests, political considerations and financial considerations to name just a few.

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If vaping is successful, it will undermine the relevance and prestige of groups who oppose it.
Political risk - much more kudos is gained from attacking tobacco companies and protecting children than ensuring vaping is available. The debate has been hijacked by the children aspect despite the huge benefit of vaping to public health and the evidence that vaping is diverting children from smoking.
There is a problem with new technology - hostile resistance to new developments are seen even when there are substantial benefits (e.g. vaping).
Opposition in Australia is due to a traditional abstinence only approach. But it’s absurd that in Australia it is a lot easier to buy lethal cigarettes than to buy vapes. We’re leaving a large group of people behind by not making it available, particularly to low income and disadvantaged groups.
A combination of harsh laws on vaping and little enforcement has just served to create a black market.
We can’t ignore the evidence of millions of vapers who have quit smoking. Testimonials aren’t scientific evidence but they do make up part of the evidence base and are consistent with the evidence we see.
It’s hard for people to find accurate information about vaping because of all the negative media and misinformation surrounding it.
To change things in Australia, there needs to be pressure put on politicians and a social movement of vapers raising their heads to demand positive change for vaping.

Politicians need to understand the benefits, rather than being exposed to the risks - which are often theoretical, small and exaggerated.

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The more you argue with people with strong feelings, the more likely they are to consolidate those feelings. People look for evidence that justifies those beliefs.

Science and Evidence

Opening Keynote: What will success look like? (A must watch!)

Professor Emeritus Robert Beaglehole, University of Auckland, Chair of ASH New Zealand 2025

The enemy is the toxic substances in burnt tobacco - it’s not the nicotine. Success will be a smoke-free world, not a nicotine-free world.

After almost 5 decades of working with the WHO, Beaglehole is a WHO supporter. But he believes we need a reinvigorated WHO that has taken back leadership on tobacco control and promotes tobacco control policy which includes Harm Reduction.

Of 8 million deaths caused by tobacco every year, 80% are due to cigarette smoking. That’s 20,000 every single day. The WHO needs to be at the forefront of tackling this huge death toll. After listening to the personal stories of smokers and vapers, he is no longer advocating for a tobacco-free world, but instead for a smoke-free world, where the focus is on the harm from toxic burnt tobacco, not from nicotine.

Bloomberg Philanthropies have funded a tobacco intervention (Mpower) to the tune of at least one billion dollars. Regrettably, this source of funding has been detrimental to the WHO because of Bloomberg’s personal prohibitionist approach. Where Mpower has been implemented, smoking rates have either only slowly declined or have risen.

There are three key reasons the FCTC has failed to deliver its promises:

embrace of nicotine abstinence
failure of WHO to embrace less harmful products
undue focus on youth smoking to the detriment of adult smoking.

The WHO, at least in the field of tobacco control, has lost its way, with the most recent conference of the parties characterised by a lack of transparency and its secrecy.

The WHO’s chronic disease goals will only be reached if their tobacco reduction goals are strengthened.

The missing ingredient in WHO strategy is harm reduction. Countries that have embraced harm reduction are rapidly reducing smoking rates e.g. Sweden, Japan (30% decrease). But under the influence of Bloomberg, WHO has discouraged THR products. Several countries have banned them - leading to them being rewarded by the WHO even though smoking rates went on to increase.

We can take lessons from the Covid-19 pandemic - we need a coordinated global response with strong, independent evidence, science-based policy and transparent discussion of the risks and monitoring of progress.

What will success look like?

Includes:

WHO and FCTC will lead, not obstruct, harm reduction strategies
more countries will adopt and achieve radical cigarette reduction targets
tobacco companies increasingly transition from most harmful to less harmful nicotine delivery products.

How?

Start with an independent enquiry into the WHO’s leadership in this area.
Progressive countries work together to reform WHO and Conference of the Parties.
Relentless and urgent focus on urgent goal - reduce adult smoking and deaths.
Active promotion of reduced-harm products such as vaping.
Take advantage of the reelection of Dr Tedros and question him about his and the organisation’s leadership in this field.

A question for harm reduction deniers:

“What if you are wrong? If you are wrong, the cost will be huge and will be measured in millions of preventable deaths. This seems to me a totally unnecessary and unacceptable risk to take, and I would ask you to consider the possibility that you are wrong.”

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We can and will be able to achieve a smoke-free world.

Depolarizing E-Cigarette Research: The need for epistemic humility

Professor Marcus Munaffo, University of Bristol

The Scientific Method is the best means of science we have. But the reality is, on the ground, somewhat different.

Scientists are human. They often laugh at what scientists have found in the past, without realising the future will be laughing at them.

What is in the interests of scientists is not always in the interest of science. For example, academic scientists are incentivised to publish research and get grants, but not always to be right.

Scientists are human and subject to biases, most of which are unconscious, and this influences how they conduct research and interpret evidence. Their views are also influenced by incentive structures, even though this bias may sometimes be unconscious. Instead of consensus, this leads to a polarized debate.

In theory, science should be self correcting. But scientists are people, and people don’t like admitting they are wrong. That’s especially the case when they have based their careers on their findings.

Professor Munaffo demonstrates this by using the example of a random trial on antidepressants. A good proportion of trials were negative. However:

Many negative trials were not published.
Of those published, the conclusion was changed.
Neutral studies were spun to make them look more positive.
Positive trials were more likely to be cited (citation bias).

Ultimately, our allegiance and our personal investment in a topic shapes our interpretation of the evidence (allegiance bias).

What do we need to do?

Try to bear in mind that the biases are affecting us, try to avoid bubbles with those who have similar views to us, and hold our beliefs lightly. Respect those who acknowledge uncertainty, and listen in particular to people who acknowledge conflicting evidence even on their most strongly held views.

Do e-cigarettes help people quit smoking? A plea to focus on the evidence

Jamie Hartman Boyce - Cochrane Tobacco Addiction Group

Jamie introduces the Cochrane organisation, a global non-profit organisation that is considered the gold standard of scientific reviews.

Initial signals on vaping have remained quite consistent. Early reviews gave some evidence of benefit of e-cigs for quitting, but with low certainty. This has now moved to moderate certainty. The reason for only moderate certainty is the low number of studies.

There is no clear evidence of harm from e-cigs, albeit with caveats that the longest study period was 2 years and there was a low number of studies. Serious adverse events are very uncommon, although Jamie would like more data on this.

There are 2 different pathways to testing whether e-cigs help smokers quit:

e-cigs compared to NRT
nicotine e-cigs compared to non-nicotine e-cigs

Both are showing a really clear increase in the number of people quitting smoking.

Why does it matter?

Year on year the perception of harm from e-cigs is going up. But the evidence has moved in the opposite direction - there is increasing evidence that e-cigarettes are less harmful than smoking and can help people quit.

That’s a real problem - it means something is going wrong. The results of publicly funded research are not reaching the public that pays for it.

Why? There is a lot of conflicting information, especially in the media. But the elephant in the room is the harm from smoking. Cigarettes kill more people than Covid, but are still being sold. The harm from smoking is not new, and therefore not exciting, whereas the evidence from e-cigarettes is new, and therefore exciting. So every time we talk about e-cigarettes, and especially when we talk about new evidence, we need to talk about the harms from smoking.

The need to unbias the application of competing interest principles in e-cigarette research

Professor Emeritus Robert West, University College London

Starts by outlining his own competing interests. Robert argued that whether or not these interests should disqualify him from talking about this topic is a matter for you. These interests are, however, objectively identifiable characteristics that apply to Robert and may or may not result in a bias.

Why do we do tobacco research? To reduce illness and premature death. If we can’t stop smoking, then we want to reduce the harm from it. If we allow bias, then we are not doing our job properly. So we have to do everything we can to reduce the harm from bias.

What’s the difference between potentially competing interests, competing interests and bias?:

All potentially competing interests should be listed. It’s not for us to judge whether they influence us - it’s for others.

But it’s really important that potential competing interests are not treated as competing interests. If they are, they may or may not lead to biases. Indeed, some researchers identify potentially competing interests in other researchers as bias, while not declaring their own, as they believe they personally are beyond reproach.

What’s the cost?

Serious distortion of the evidence base.
Researchers having to ‘toe the line’.
Distress and reputational damage to honest researchers.
Discouraging good researchers from working in a field.

This has all been found in e-cigarette research. Indeed, even researchers who have no potentially competing interests have been accused of bias, while actual competing interests have been overlooked.

Solution:

Make clear distinctions between potentially competing interests, competing interests and bias.
A more structured approach towards specifying and classifying potentially competing interests.
Clearer rules regarding what to do with specific types of potentially competing interests.
A change in ethos in the following areas:
- collegiality and respect for people with whom we disagree
- self reflection
- fuller and more meaningful disclosure.

Could e-cigarettes contribute to harm reduction for children as well as adults?

Professor Emeritus Martin Jarvis, University College London

The issue of potential benefits from vaping has been bedeviled by the perceived conflict between the needs of children and adult smokers. The uptake of vaping by non-smoking children is seen as an unmitigated bad thing.

However, there is no clear evidence of a gateway effect. In fact, the growth of vaping has occurred at the same time as an unparalleled decline in youth smoking. We need to look at the shared risk model instead of a simplistic gateway model.

Jarvis walks us across a range of risk behaviour. Children who engage in more risky behaviour do it across a spectrum - for example, children who are involved in violence are more likely to smoke, use drugs, have sex, vape, binge drink and so on.

The argument that one risky behaviour, such as vaping, is leading to another risky behaviour, smoking, has no plausibility. Instead, children who engage in one form of risk behaviour are more likely to be involved in others.

So what would happen if youth vaping was eliminated? The ‘implausible utopian future’ of a nicotine-free youth would not occur. The reality is e-cigarettes are replacing cigarettes.

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Jarvis went on to discuss additional evidence.

It’s likely that there is a shared genetic propensity for risk taking that leads some youths towards both smoking and vaping. Source: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003555
Flavour bans in San Francisco were associated with an increase in smoking. Reducing access to vaping may motivate youths who would otherwise vape to smoke. Source: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780248
There is some evidence that e-cigarette taxes and bans cause youths to smoke more cigarettes, which may do more harm than good. Source: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3077468

What’s happened to overall nicotine addiction since the introduction of vaping? This image explains:

The simplistic gateway model that states vaping leads to smoking and nicotine addiction lacks support. The most likely outcome of reducing youth e-cigarette use is not sweetness and light, but a group of youths remaining vulnerable to risky behaviour - which includes cigarette smoking.

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Panel Discussion and Q&A

Speakers: Prof Ann McNeill, Prof Robert Beaglehole, Prof Marcus Munafò, Prof Robert West, Jamie Hartmann-Boyce, Martin Jarvis

Do note that the sheer amount of content here limited what I could include. Here are some key points - if you have the chance, I very much recommend watching the full video when it is available.

Unconscious bias and improving academia

Marcus Munafo: There is currently a big focus on unconscious bias and improving academia. One question is how do we fundamentally change how we do science, e.g. by being more transparent, adopting open access research processes? When we are very invested we can be led astray by our own enthusiasm. There is a need for humility, we need to admit we can be wrong. If we think someone else is wrong, let’s not be battering rams because that will only encourage people to double down.

Robert West: There is a long way to go in relation to transparency and research. One thing is incredibly important - pre-registration of study designs and analysis plans. Epidemiological studies have a lot of scope to cherry pick. If you pre-register it gives a lot more confidence in the findings.

We also need to be reflective on our biases, and that we see each other in different camps. We all think we’re right, and the other idiots have the wrong position. So we need to hold each other accountable, we need to ensure accountability and transparency. And when someone has been found to be wrong, it’s just not okay to say ‘oh well, moving on.”

Youth vaping

Martin Jarvis emphasised that he didn’t want to promote vaping to under-18’s. However, a total ban on nicotine use is not viable. The risk is that by bearing down on e-cigarettes we simply advantage incumbent cigarettes. The issue is will, in the future, society continue to use nicotine? If yes, it’s better to do so in the form of products that will not kill you. It’s not that e-cig use is a good thing, but it is the least worst option available.

The WHO

Robert Beaglehole said there is plenty of scope for change in the WHO. The WHO responds to member states. If we want to reform it, we must work through member states. Much work also comes from specific grants from groups like the Bloomberg foundation. A simple solution would be to take all donating grants and put them in a common pool.

Harm reduction

Robert West argued that harm reduction is a behaviour, the continued use of a substance that results in reduced harm, e.g. Switching to a different form of tobacco. But switching to an e-cigarette is not tobacco harm reduction because you’re not still using tobacco. You could call it nicotine harm reduction. You also need to distinguish between harm reduction as behaviour (may/not succeed) and harm reduction policy, which can have unintended consequences.

New Zealand

Robert Beaglehole said that the adult daily smoking rate has declined dramatically, coming down to 9.4%. Adult daily vaping rate has gone up, so association suggests this is the reason. The young adult smoking rate has collapsed, with 1.1% of people aged 15-18 smoking. Youth vaping has gone up, but there are regulations to discourage it. New Zealand is on track to reach the 2025 Smoke Free goal.

THR and Tobacco Control

Is there a place for low-risk nicotine ‘alternatives’ when smoking is about to disappear?

Dr Karl E. Lund, Norwegian Institute of Public Health

Thanks to Snus, smoking is about to be eradicated amongst Norwegian youth. So Snus cannot really be seen as an alternative to youth smoking. Is there a place for Snus for recreational use in the future?

Tobacco controls original objectives were:

Because the market was dominated by cigarettes, there was no conflict between these objectives. Now things have changed.

In the future cigarettes could become a niche product. Low-risk products would become redundant. Why would we use them? They are addictive - but the difference is that they do not kill the consumer. People will use them for enjoyment, passion, interest and inspiration.

Lund then summarised the arguments on either side:

Then there’s the conditional approach:

We can calculate this using risk. We need 20 non-smokers to take up Snus to balance the gain of one smoker switching to Snus.

Despite the benefit from Snus, politicians have not trumpeted their success, but have in fact regulated Snus and banned other reduced-harm products such as electronic cigarettes. The industry is in a catch-22 situation - their success in eradicating smoking is leading to regulators arguing that low risk products are redundant. However, free choice arguments, rather than tobacco harm reduction arguments, may eventually lead to a legitimisation of reduced harm products.

The tobacco control climate in Germany?

Professor Daniel Kotz, Heinrich-Heine University

Germany scores low on the tobacco control scale, scoring the lowest rank of all countries in Europe, with insufficient implementation of the FCTC (the WHO Framework Convention on Tobacco Control).

The results are:

high level of tobacco use - around 30%
England’s tobacco use half that of Germany - around 15%.
However, low youth usage is low.

Germany also has relatively low usage of electronic cigarettes, despite evidence that it can help quit smoking. They are still the most popular way of quitting smoking. Health organisations are mostly very critical, and official guidelines are not encouraging, stating: E-Cigarettes should not be used for tobacco reduction.

They also state there is inconsistent evidence for smoking cessation, and have long term risks, although there is evidence that there is some disagreement over this statement. However, the DEBRA study seems to show that e-cigarettes are associated with higher rates of cessation.

Reconsidering the meaning of tobacco harm reduction

Dr Debbie Robson, RMN, PHD. King’s College London

There are several different definitions of Tobacco Harm Reduction (THR) but not one that is universally agreed upon. Conversations around THR have focussed on the product rather than the person. Smokers are often caught in the crossfire of the debate.

In the last year 37% of smokers in England have tried to quit (the highest since 2014) - with a quarter of them managing to do so. This means around 91% of existing smokers either couldn’t quit or didn’t want to. What do we do about them?

These people have the highest smoking and mortality rates. Many of those who can’t/won't quit include those in mental health, prison or substance use services, the homeless and the unemployed. To ensure these groups are not left behind in England’s Smoke Free goals, we have to address the challenges of THR & maximise opportunities.

Debbie focuses on measuring THR outcomes and reaching the most disadvantaged groups.

Traditionally THR outcomes are based on the amount of cigarettes smoked daily, improvements in health and reductions in mortality. There are opportunities to expand this by focusing on what vapers, smokers and clinicians believe are the most important outcomes.

During the March 2020 lockdown, 5000 homeless people in London were given hotel rooms and a Drug & Alcohol service, which included THR, was set up for them. The hotels were stocked with e-cig starter kits and other quit aids to try and minimise smoking, risky smoking behaviours (e.g leaving the hotel to smoke, congregating in smoking areas etc), nicotine withdrawal symptoms and fire risks.

People in this group said the THR outcomes that mattered most to them was the reduced embarrassment/indignity of having to smoke discarded cigarettes, reduced guilt, shame and stigma, improved respiratory health and saving money. Many of them (5 in 10) continued to vape afterwards.

Clinicians have voiced concern that Smoke-Free policies, while protecting non-smokers, could actually increase harm to smokers - e.g. surreptitious smoking causing fires. An 81-month study in a mental health facility gradually increased the permittance of vaping from disposables only in certain areas to all types of e-cigarettes in all areas. This showed that the number of fires in the facility decreased by almost ⅔. The trade off to this was the number of false fire alarms increasing by ⅔ - this was attributed to the introduction of higher-powered tanks/mods setting off alarms.

Debbie concludes that we need to support ALL smokers - those who want to/ are able to quit as well as those who try, those who can’t and those who don’t want to quit nicotine. Let’s put people back at the centre of what we do.

Australia doubles down on its e-cigarette sales ban

Professor Emeritus Wayne Hall, University of Queensland

Australia has been successful in reducing smoking rates but this rate of decline has slowed in recent years, and a 10% targeted smoking rate has not been reached. The lung disease EVALI is also still attributed to nicotine vaping (in fact, it is caused by vitamin E acetate in illegal cannabis products.)

Why? Regulators are worried it will discourage quitting and encourage youth smoking. The country has a ban on e-cigarettes (unless prescribed). This means e-cigarettes are used infrequently, while most people who want to vape simply break the law, despite draconian penalties including fines and imprisonment.

What will happen? Doctors are discouraged from prescribing, pharmacies are reluctant to stock e-cigs, misinformation is rife and e-cigarette use is likely to fall. However, there are some parallels with medical cannabis which did eventually take off despite initial medical resistance (but with government support).

The new tobacco wars

Clive Bates, Counterfactual Consulting Ltd

Science

There is a desperate search for harm by the tobacco control industry, because without harm there is no reason for control. This has led to a terrible abuse of studies, for example in the areas of toxicology, animal studies e.t.c. The biggest abuse is correlation and causation.

For example, someone found an association between vaping and bone fracture, then spun it as a press release to show there was causation. When you look at the limitations of the study this is ridiculous - limitations included not knowing when the fracture occurred (e.g. they didn’t know if people started vaping before or after the fractures.)

Bates went on to show a series of advertisements purported to be fact - but not. Here’s one:

Policymaking

Prohibition: has been encouraged, sponsored by Bloomberg Philanthropies - but it doesn’t work. Awards are made for countries that prohibit vaping, but no evaluation of success is made. In fact, Bhutan’s example (with tobacco) shows prohibition also leads to young people getting involved with the criminal supply change. If you study prohibition, you’ll find it never works.

Flavour bans: The intended outcome is nicotine abstinence, but there are a thousand different other options (illicit market, home mixing e.t.c.). San Francisco shows flavour bans lead to increased smoking rates. [See our own analysis of bans here]. But prohibition is all about the policy and has nothing to do with health outcomes.

Taxing vapes: Scientist Michael Pesko has pointed out that a federal vaping tax would lead to an increase of half a million young smokers, and that for every e-cig pod eliminated, more than 5.5 cigarette packs will be sold. Who could think that was a win?

‘Kids’: There was a moral panic over children. Rates fell:

But no one has cancelled the youth vaping smoking epidemic. What’s more, these are children who might otherwise have smoked - but no one seems to care about that.

Reasons for opposition

There are 2 main reasons. One is cultural interia. Tobacco control have a playbook, one that is coercive and punitive - it is about punishment, restrictions and stigma. The second is institutional inertia. A massive machine was constructed to fight smoking. Put those together, and you have a formidable complex that has swivelled its gun turrets on to the new thing and is now blasting away.

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Reasons for optimism

Nicotine is popular. We have had major innovation in the way it is used. As with other new technologies, it is bringing a major benefit to consumers. New technology is often met with vilification and opposition. But in the end, the underlying benefit of these technologies will prevail, and all the underlying noise and vitriol will fade.

Session 2: Panel Discussion and Q&A

Speakers: Prof Thomas J. Glynn, PhD, Dr Karl E Lund, Prof Daniel Kotz, Deborah Robson, Prof Wayne Hall, Clive Bates

Harm reduction

Thomas Glynn and Clive Bates agreed that support for harm reduction is seen as synonymous with supporting the tobacco industry, as the industry’s interests can be aligned with it. Clive thinks that’s a good thing as it makes harm reduction more likely to happen. We need to accept nicotine is a legal recreational drug like coffee, and just focus on how it can be used without the gigantic toll of smoking.

Are reduced-harm products addictive?

Karl is not sure. Most definitions of addiction include harm. Yes, Snus can cause some harm, but is it high enough to be labelled addictive? Clive argues that this is a fundamental question. After all, we might be addicted to coffee, but how bad is that? We don’t have a coffee control movement. Maybe the problem is that we are not adjusting our perceptions of relative risks fast enough. We should be relatively indifferent to nicotine use, but we should be very concerned about harmful nicotine use.

Why has Australia ignored the UK’s experience with vaping?

Wayne Hall explained that Australia is much more focussed on stories from the US (EVALI, JUUL etc) than what is happening in the UK. The degree to which they have completely ignored evidence such as the Royal College of Physicians report on vaping amazes him. They did acknowledge the Public Health England report - but then attempted to discredit it.

Tobacco wars

Clive argues that tobacco control is split into different groups with multiple objectives e.g. reduce harm, destroy the tobacco industry, oppose nicotine for moral reasons and so on. When these groups were only confronted with smoking, their objectives appeared to be aligned. But when safer alternatives came along, the underlying objectives became clear and the tobacco control group fragmented into groups, leading to an internal war.

Kotz argued that the term ‘war’ is not helpful for a rational, evidence-based debate. The hard core tobacco control people are intelligent and have a viewpoint, and we must be careful to listen to them and the arguments they put forward. Debbie pointed out the situation in the UK is different - thanks to a history of harm reduction, and some excellent people in tobacco control, a consensus has been built that has led to civil discussion.

Tobacco control, regulation and enforcement

MHRA regulatory update

Craig Copland, MHRA

Craig first covered how the UK MHRA notification processes work post-Brexit. This has some niche interest, but evades useful summary, so do check the video out if it is relevant to you. [If you think it’s painful, you should see some of the other notification processes in the EU.]

The Yellow Card scheme is a way to report adverse reactions - not just for e-cigs. Over a decade, there have been just 150 yellow card reports for vaping. To put that in perspective, the MHRA receives 40,000 yellow card reports per year.

The MHRA evaluated the EVALI (US lung disease) crisis carefully. I found this section difficult to understand. 275 Adverse Drug Reactions (ADR) reports were received, but I wasn’t sure if these were EVALI. Crucially Craig said that UK consumers are very unlikely to experience EVALI with the products sold in the UK.

How can consumers protect themselves?

Be wary when buying from non-traditional sources.
Buy from UK trusted retailers.
Check security labelling to ensure you have bought a legitimate product.

Craig also covered non-compliant products, which may be of interest to the many legitimate vape companies currently frustrated with competing with black market sellers.

The challenge of e-cigarette enforcement

Kate Pike, Trading Standards North West

Kate pointed out that Trading Standards have a budget that equates to about £1.80/person, and just 2000 officers for the whole of the UK, which perhaps explains some of the problems we have seen with compliance. That dovetails with a huge amount of enquiries across the board and competing resources, as well as other challenges.

In 2019/20, there was reduced need for tobacco control activity except for amongst under-age sales. But in the first 6 months of 2021/22 there has been a 240% increase in reports, mostly due to non-compliant disposable vapes. However, reports on vaping products are still less than 5% those of illicit tobacco.

What can we learn from illicit tobacco?

Get the message right.
Counter myths.
Tackle the whole supply chain.

A stitch in time: Safeguarding the UK market from youth uptake

Hazel Cheesman: Deputy Chief Executive and & Policy Director, Action on Smoking and Health UK (ASH)

How can we maximise the public health opportunity of e-cigarettes?

There is huge alarm over youth vaping, especially in countries like the US, which are worried about questions such as whether vaping could lead to smoking or harm adolescent brains. There’s no conclusive evidence on these concerns, but they remain a risk.

There are also counter-arguments - vaping could, for example, help young smokers quit and divert young people who would otherwise have taken up smoking. Still, even the perception that vaping harms youth is leading to regulations around the world, even at the cost of harm to adults.

UK youth vaping is low, but can we lower youth vaping further without harming adult smokers? The percentage of children who vape, especially never smokers, is low. Regular use is very, very low. However, low percentages still translate into numbers, with 122,800 under-18’s in the UK vaping at least monthly.

Why are young people using e-cigarettes?

Among 11-18 years olds, the biggest reason is just to give it a try. Flavours are not that big a reason, especially with children who haven’t smoked before. In fact, just 4.8% of never-smokers try vaping because of flavours.

What’s happening with youth vaping and smoking rates?

Youth smoking rates have been declining, especially since 2017, while vaping rates have plateaued. This is a regulated market, and regulations aren’t doing a bad job of keeping vaping rates low.

But is there more we could be doing? Hazel suggests we:

Close a loophole that allows free e-cigarettes to be given to under-18’s.
Set standards on packaging to limit youth appeal.
Require notifications of nicotine-free e-liquids including shortfills.
Add further restrictions on social media marketing.
Include all novel nicotine products in regulations, not just shortfills.

Hazel then focussed on packaging. ASH showed adult smokers and young people in Canada different packaging. Young people responded more to branding, while adults’ preferences were unchanged.

This is an extreme example, and we need more research on how this could be done. But Hazel also asked whether plainer packaging could increase adult uptake of e-cigarettes. After all, why do people vape? Mostly to cut down on smoking - people are effectively using them medicinally. How can we further increase adult uptake of vaping through regulations?

Hazel also noted that further regulations on tobacco (e.g. raising age of sale for tobacco to 21) would further reduce youth smoking rates, and might in turn lead to fewer young vapers.

E-Cigarette Regulation: Finding the Sweet Spot

Marcus Saxton, Chairman, Independent British Vape Trade Association (IBVTA)

When we look at regulations and prohibition, we need to think of unintended consequences. For example, in the USA the EVALI crisis may very well be down to the way cannabis is regulated in different states. Marcus went on to discuss a number of areas.

Flavours: Flavours are not purely about youth attraction. 82% of Totally Wicked customers use non-tobacco/menthol flavours. It’s a similar story with other independent brands. Yes, this tails off after the most popular flavours, but we need to serve every single customer so that each customer gets the flavour that enables them to get off cigarettes.

What would happen if flavours were banned? 1 in 4 vapers would still try and get flavours. 1 in 10 say they would make their own.

Youth vaping: Less than 1% of children who wouldn’t have smoked vape. Let’s not try to fix something that isn’t broken. The debate isn’t just about children - it’s about making vaping attractive to adults too. We need responsible packaging, but brands also need to distinguish themselves from each other. We also need relative harm messaging if we want further penetration in the future.

Marketing: Relaxing marketing restrictions will simply mean tobacco brands will dominate. However, we should relax restrictions in some areas. One of the biggest areas is prices - we need to allow both discounting and communication of relative prices.

Shortfills and tank size: It’s often argued EVALI couldn’t happen in the UK. But that’s just not the case. Shortfills do not fit under UK regs, and are readily available on EBAY. It’s really important these are brought into line. The limits on tank size is also a problem. Vapers will go to Ebay and seek out larger tanks. These also need to be allowed and regulated, so we can keep them away from unregulated retailers.

Marcus concluded that areas of the high street have been decimated over the last few years. Vaping is very well controlled. We mustn’t knee jerk into reactions if we are to allow vape retailers to continue helping smokers.

Unintended market consequences from the regulation of vape products in the US, and the prospects for future regulation in Europe

Tim Phillips, E-Cig Intelligence/Tobacco Intelligence

Unintended consequences

The PMTA (Premarket Tobacco Product Applications) has caused huge problems. There were around 6 million applications, with 99% for e-liquid - indeed there were only 1200 for other products. There’s a high number of applications for disposables, but less than a hundred for open systems, which means there will be a clear restriction on consumer choice.

An unintended consequence is likely to be a huge growth in disposable products, many with a high nicotine strength. These are also becoming very large in terms of capacity. There is a huge reduction in flavour choice, leading to a choice of just menthol and tobacco - although this is an intended consequence.

Synthetic Nicotine

There’s a huge increase in interest in synthetic nicotine among vape stores as a way around the PMTA requirements. 2/3rds of stores are carrying synthetic nicotine, generating 20% of their revenue. This creates a problem for the FDA, which hadn’t foreseen the issue.

Most consumers and retailers have moved away from 10ml e-liquids to shortfills, which are not included in regulations because they do not contain nicotine (this is purchased separately). This means the majority of e-liquid is outside the Tobacco Products Directive regulations, another unintended consequence.

A number of countries have harsh restrictions on online retail, but enforcement is not working, with around a third to a half of purchasing taking place online.

EU MEP Survey

E-Cig Intelligence surveyed MEPs this and last year - with an increased number of respondents (54) this year. A big (albeit shrinking) majority (70%) believe that vaping is less harmful than smoking. 74% felt Heat Not Burn (HnB) was safer, while 94% believe nicotine pouches are safer. However, there are still many MEPs who don’t know much about them and haven’t made up their minds about them.

A majority (52%) feel vaping is an ‘off-ramp’ for smokers, compared to 31% who believe it leads to smoking and 17% who are unsure. That’s in contrast to HnB, with more MEPs believing it was likely to lead to more smoking. In terms of policy, there is a lot more positivity around allowing online sales, and a lot less around flavours.

Session 3: Panel Discussion and Q&A

Speakers: Martin Dockrell, Craig Copland, Kate Pike, Hazel Cheeseman, Marcus Saxton, Tim Phillips

Note: I couldn’t hear Martin to start with, unfortunately, so I’ve done my best to pick up the first theme from the answers.

On shortfills and regulations:

Kate pointed out that we have strong regulations around nicotine products - but the product next to it with zero percent nicotine can be sold to five year olds. Craig pointed out that shortfills are the unintended consequences of legislation [or, perhaps, of EU legislators not listening to the experts?] When we have more regulations, we will see more attempts to get around it.

Hazel said that we are trying to tread a tightrope of regulation - appealing to smokers but at the same time avoiding large numbers of young people taking up the products. Unintended consequences need to be right at the heart of our thinking. That might mean we don’t take steps which we could be taking now, but which we could take longer term (e.g. in the case of an increase in youth smoking). [This probably refers to potential regulations on branding.]

Marcus Saxton said the independent industry also has to walk a tightrope. That means making the right moral decisions while competing against tobacco behemoths with much bigger resources. Martin and Saxton went on to discuss the unintended consequences and moral dilemmas. For example, sometimes not selling a vape to someone under-18 means they will carry on smoking.

Disposables and youth smoking

Marcus said we have to recognise that disposables mean a large number of adult smokers have tried vaping for the first time. While we work to move them towards more sustainable alternatives, we have to be really careful about what the next steps are. The same goes for licensed products - the endorsement it gives vaping is positive, but we have to be careful about the route we pursue.

Kate said that over the last few months there had been an explosion in people contacting trading standards about youth access to disposable vapes. However, she also accepted that this was not reflected in the data, and that disposables could help adult smokers too. Marcus argued that, as with alcohol, we need to focus on the route to market, not the product.

Enforcement

There isn’t enough funding, and the problem is with (grey market) unnotified products coming in. Marcus shared his frustration that reputable independent companies spend tens of thousands on age verification which is ignored by competitors and delivery companies. Kate suggested that we might want to look at a licensing regime for selling vape products. Hazel said that vape shops enforce the regulations, because they are highly invested in the industry - but we need to ensure non-specialised shops and websites enforce it too.

In the closing moments, the panel agreed that while they have various wishes for regulations around alternative nicotine products, ultimately the number one goal is to remove tobacco from shelves.

Want to find out what happened on Day 2? See E-Cig Summit Part 2 ...