E Cigarettes

Question 1

history of Ecigs

Answer 1

Term for a family of non-tobacco nonmedicinal nicotine delivery systems

Invented in 2003, by a Chinese pharmacist Hon Lik
- On sale in 2004

500 brands of ecigs mainly made in China

Ecigs the fastest growing product in British supermarkets in 2014
- See everywhere now

Question 2

evolution of ECigs

Answer 2

1st generation: cigalikes
Rechargeable or disposable

2nd generation: tank (refillable)

3rd generation: big tank (customisable)
- Change constituents

Question 3

what is an ECig?

Answer 3

Ecigs have a mouthpiece, battery, cartridge, atomiser or cartomizer (modern combination of atomiser and cartridge)

Current passes through a resistance coil that is in contact with a fluid.

Heat generates an aerosol, the vapour

Variety of formats, large tank systems most popular
- In 2020, 77% use tank systems

19% use cartridge pod systems (Juul systems etc ) newest addition to ecig range
- More subtle

Question 4

what’s in the liquid in ECig (4)

Answer 4

Propylene glycol (PG)

• Thinner, more flavour, throat hit
• In asthma inhalers

Vegetable glycerine (VG)

• Thicker, big clouds, smoother smoke
• Cough medicine

Natural/ artificial flavourings

Nicotine level, mg/ml / 0.0%
- 0%, 1.5/0.15%, 3, 6, 12, 18 mg/ml

Also quote the % of PG and VG.

• Culture wyld75% VG 25% PG
• Vaporised Coconut PG 65% VG 35%

Question 5

vegetable glycerine (VG)

Answer 5

• Thicker, big clouds, smoother smoke

- Cough medicine

Question 6

propylene glycol (PG)

Answer 6

• Thinner, more flavour, throat hit

- In asthma inhalers

Question 7

what is vaping

Answer 7

Vaping is the act of inhaling and exhaling the water vapour produced by an electronic device

E-liquid in gaseous form

Looks like thick smoke but dissipates more quickly

Smells better

Question 8

nicotine

Answer 8

ADDICTIVE

Nicotine is the addictive element, in both tobacco and ecigs

Liquid nicotine level, max strength 20mg/ml , and many liquids are below that strength

‘90% of non smokers and 75% of smokers in Great Britain believe that nicotine is harmful to health, a fundamental misconception that we have not changed.
- It is the many other toxicants in cigarettes that cause disease & death’

Question 9

who uses ECigs?

Answer 9

Population of GB adult vapers (18+)

In 2020

• Ex smokers are the highest users of ecigs (58.9%)
• Moderate numbers of smokers are use Ecigs and smoke(38.3%)
• Low numbers of non smokers use ecigs (2.9%)

Question 10

smokers using ECigs

Answer 10

Ex smokers are the highest users of ecigs (58.9%)

In 2020, 64.1% of adult smokers have ever tried ecigs.

• Of smokers, 32.4% of smokers have never tried ecigs.
• Of smokers, 17.4% are co users of cigarettes and ecigarettes.

Question 11

why use ECigs?

Answer 11

Main reason for vaping among smokers and ex smokers who vape GB 2020

For exsmokers, ‘stopping smoking’( 42 %) followed by ‘keep off tobacco (24%) main reasons

For co users (smoke+ecigs) cut down smoking (24%) main reason
- Harm reduction

Question 12

maximum tar yields and nicotine relationship

Answer 12

present maximum tar yields are 12mg per cigarette, and there is no limit on nicotine (though this tends to have a roughly fixed 1:10 ratio to tar).

There is no meaningful regulation of tobacco additives - some 600 are approved for use in the UK.
- smokers adjust their smoking by taking more or deeper puffs and blocking filter holes to take in the nicotine they are seeking.

Smoking machines are not seeking nicotine and don’t ‘compensate’ in this way.
- Simply further reducing tar yields will make little difference to the amount of tar taken in by smokers.

Similar problems face any attempt to reduce nicotine - indeed an approach that increased nicotine concentrations in smoke could reduce tar intake for a given nicotine dose.
Patents show that the tobacco companies can remove specific toxic smoke constituents with chemically active filters, catalysts or manufacturing processes.

The warnings on packs are thought to be ineffective
- larger, bolder, high contrast hard hitting warnings have some success in Australia and Canada.

Question 13

how to reduce tar intake by smokers

Answer 13

Smoking machines are not seeking nicotine and don’t ‘compensate’ in this way.
- Simply further reducing tar yields will make little difference to the amount of tar taken in by smokers

Indeed an approach that increased nicotine concentrations in smoke could reduce tar intake for a given nicotine dose.
Patents show that the tobacco companies can remove specific toxic smoke constituents with chemically active filters, catalysts or manufacturing processes..

Question 14

nicotine additives in cigarettes

Answer 14

There is no meaningful regulation of tobacco additives - some 600 are approved for use in the UK.

• smokers adjust their smoking by taking more or deeper puffs and blocking filter holes to take in the nicotine they are seeking.
• that is what they are addicted to

Smoking machines are not seeking nicotine and don’t ‘compensate’ in this way.
- Simply further reducing tar yields will make little difference to the amount of tar taken in by smokers.

Additives need to be assessed for the impact they have on smoking behaviour - not just their own toxicity.
- An additive does its damage indirectly by contributing to increased smoking.

Question 15

ECig Shops

Answer 15

Ecigs and liquids freely available

Online suppliers

Specialist suppliers have sprung up everywhere, sell devices and liquids

Liquids now legally sold only in smaller sizes (10ml), though can be purchased in multipacks

Tank size limited to 2ml

Ex-current smokers

Banned for under 18s

Strongly advise against buying to non-smokers

Question 16

why do people use ECigs

Answer 16

Aid to quitting (evidence)

Less toxic alternative (evidence)

Cheaper alternative

Harm reduction/reduce smoking

Alternative to cigs when cigs are banned

Hand to mouth habit maintained

Psychosocial aspect of addiction maintained

Recreation and socialisation

Vaping community

Question 17

public health pros to ECigs (2)

Answer 17

Public health costs of smoking are vast

Consideration must be given to harm reduction argument, because tobacco so lethal

I can think of no other area, in 30 years, where public demand has leapt ahead, leaving the development of the evidence base, policy and regulation, trailing behind

Question 18

public health cons to ECigs (4)

Answer 18

Renormalisation of smoking?

Gateway or pathway?

Evidence Base?

Involvement of Big Tobacco Firms

Question 19

NICE 2013, updated 2018

Answer 19

Encourage those who can’t quit, to cut down ( harm reduction)
Good communication about the relative safety of nicotine
Ecigs ( 2018)
Many people have found them helpful to quit smoking cigarettes
People using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful

Question 20

3 guidances on ECigs

Answer 20

NICE 2013, updated 2018

Royal College of Physicians Report Harm Reduction 2016

NHS Health Scotland 2017

Question 21

Royal College of Physicians Report Harm Reduction 2016

Answer 21

‘…the hazard to health arising from long term vapour inhalation from the e cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco…’
- Not harmless but less harmful

‘…e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely…’

‘….in the interests of public health it is important to promote the use of ecigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK…’

Question 22

NHS Health Scotland 2017

Answer 22

more cautious advice in favour of ecigs

Outlines their use as a route to quitting (rather than harm reduction)

Emphasises that ECIGS NOT RISK FREE, and don’t fully know long term implications.

Question 23

safety of ECigs

Answer 23

Safety of devices

Number of examples of exploding batteries

Case study of the management of such patients JADA 2016

Cluster of lung disease deaths in the US not repeated in UK (linked to THC use – particular brand in US)

Safety of liquids

We know that they are much safer than cigarettes, but are they safe?

Question 24

oral side effect of ECigs

Answer 24

Largely unknown.
- Surprisingly little attention considering the relationship between e-cigarette aerosols will contact oral mucosa when they are at their hottest.

Mouth and throat dryness

Oral cancer?

Periodontal disease?

Benign mucosal lesions?

Lichenoid eruptions associated with use of an ecigarette

Question 25

evidence of use of ECigs and success in quitting

Answer 25

Pathway to Quitting – Evidence

Evidence base still developing (Cochrane updated on 14 Oct 2020)

50 trials with 12,430 adults who smoked
- For 100 people using nicotine ecigs, 10 would stop smoking compared to 6 using NRT/non nicotine ecigs and 4 with behavioural support/no support

Side effects mouth irritation, headache, cough feeling sick

Further high quality work needed

Question 26

patient’s perspective on ECigs may be

Answer 26

Quitting is hard. I tried an EC, not as good as a cig, but I could live with it.

Are they worth the bother?

Are they any better than cigarettes?

What would you say?

Question 27

advice for smokers who want to quit strategies

Answer 27

Ask, advise, refer

Ask advise assist

Question 28

advice for Co-Users

Answer 28

Encouragement that they are reducing their exposure to tobacco by using ecigs

While it is likely they are safer, evidence base is still developing, particularly with regards to oral health.

Question 29

advice for E cig uses (ex smoker)

Answer 29

Strong encouragement that they have quit tobacco

Evidence base still developing, with regards to e cigs.

Question 30

smoke Vs ECig

Answer 30

There are NO circumstances where it is safer to smoke, than to use e cigarettes.

With so many controversies and lack of long-term studies, it is not surprising the we are naturally cautious, with no defining guidelines with regards to existing?