At E-cigarette summit, experts chart ways to reduce smoking related diseases, deaths

Though an estimated 98 million adult smokers have switched to safer nicotine products worldwide, public health experts have not agreed whether this has led to tobacco harm reduction.

Speaking at the 10th anniversary of E-cigarette Summit in London, United Kingdom, tagged: “Science Regulation and Public Health,” experts affirmed smoking remained the biggest single cause of preventable death in the developed world.

They also argued that while tobacco control policies have saved a lot of lives since the first Royal College of Physicians (RCP) report was released, there hasn’t been much progress after the report.

Organisers said the aim was to ensure that disparate views could be explored in context of a common aim, which is to reduce smoking related death and diseases.

Held at the Royal College of Physicians on December 9, the summit was a meeting point for scientists, industry regulators and public health practitioners to discuss the latest research on e-cigarette and chart a part for tobacco discussion.

In her welcome address, the Director/Owner, E-Cigarette Summit Smooth Events, Amanda Strange, said, “the debate over the role that e-cigarettes and other novel nicotine products may play in addressing smoking-related morbidity and mortality continues to be heated, dividing many within the tobacco control and public health communities.”

She added, “the number of people who believe that vaping is as dangerous as smoking is increasing, even though many of tobacco harm reduction’s strongest critics would concede this is not an accurate assessment of the scientific evidence, given the known harms of smoking.”

The Guardian checks revealed that disposable e-cigarettes or vaping, that is, the inhaling of a vapour created by an electronic cigarette (e-cigarette), grew in the United States as an unexpected consequence of the US Food and Drug Administration’s (FDA) restriction on flavoured pod products, but have now entered every market and continue to innovate.

Vaping is the situation where you heat a liquid until it becomes a vapor, which is inhaled. Though common among teens, the health risks of vaping or e-cigarettes (or ‘vape pens’), include: addiction.

E-cigarettes contain nicotine, a drug that’s highly addictive. You don’t have to vape every day to get addicted. It also leads to anxiety and depression.

The liquid (called e-liquid or ‘vape juice’) can contain nicotine or marijuana distillate or oil. E-cigarettes can be refillable or pre-filled with cartridges containing the e-liquid. The pre-filled e-cigarettes (called ‘Puff Bars’) are designed for one-time use. After taking a certain number of ‘puffs’, the user throws the device away.

The Founder and Managing Director of ECigIntelligence, Tim Phillips, provided valuable insights into how consumers and marketS are responding to the changing product and regulatory environments.

According to him, “the total market value of novel nicotine products globally will reach $50 billion, and almost 100m consumers, in 2023: how does this breakdown between geographies and between vape and other novel nicotine products, and which regions are being left behind?”

A PhD student in Epidemiology and Public Health, Tobacco and Alcohol Research Group Department of Behavioural Science & Health, University College London, Harry Tattan-Birch, said: “Until recently, disposable e-cigarettes were considered of historic interest, made obsolete by rechargeable devices with better nicotine delivery. For instance, just one in 20 British vapers chose disposable e-cigarettes as their main device from 2016 to 2020.

“Yet over the past two years, we have witnessed the market become flooded with new disposable e-cigarettes that are cheap, convenient, and good at delivering nicotine. There is mounting concern that these modern disposable devices may be especially appealing to children and younger adults. Recent data from Great Britain shows that the popularity of disposable e-cigarettes grew rapidly between 2021 and 2022, particularly among young people.”

Tattan-Birch concluded: “Now, more than half of 18-year-old vapers mainly use disposable products. The public health impact of this growth will depend on who uses disposable e-cigarettes: people who would otherwise smoke cigarettes, vape, other types of e-cigarettes, or avoid nicotine entirely.”

Professor of Respiratory Science, Institute of Lung Health, University Hospitals of Leicester, Prof Sanjay Agrawal, who spoke on Tobacco as a Public Health Emergency, said RCP’s report laid the foundation of tobacco control and progress that has been made in reducing smoking prevalence.

Agrawal said: “The COVID-19 pandemic illustrated the collaboration and effectiveness with which the global scientific, public health and medical communities can come together to tackle a public health emergency. And it is in this same spirit that the tobacco control community must overcome the devastation that tobacco leaves in its wake.”

A senior lecturer in Tobacco Harm Reduction, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Dr. Debbie Robson, in her presentation, an overview of the report on Nicotine Vaping in England commissioned by the Department of Health and Social Care, said: “The purpose of the reports is to inform government and policy makers about prevalence and characteristics of vaping among adults and young people in England and each year we cover at least one additional topic in depth. This year’s report included systematic reviews on the health risks of vaping compared with smoking, and vaping compared with non-use, as well as harm perceptions about vaping and smoking. It also puts the findings in the context of the series of evidence reviews since 2015.”

According to the Emeritus Professor of Toxicology & Chair of the UK Committee on Toxicity, Imperial College London, Prof. Alan R Boobis: “Cigarette smoking is a significant public health concern, despite stringent regulation. Switching smokers to a less harmful product would therefore mitigate some of this harm.”

Prof. Peter Hajek said e-cigarettes have emerged as a more popular quitting aid among pregnant smokers. Though e-cigarettes have been condoned in the UK, it is advised against in the United States.

However, the Director of the Health and Lifestyle Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, in his paper titled: Smoking vs nicotine use in late pregnancy: Can e-cigarettes be recommended to pregnant smokers?”

Professor Emeritus of Health Psychology, University College London, Robert West, who spoke on Hopes and fears for the public health impact of e-cigarettes, said, “credible evidence has emerged that e-cigarettes are not harmless but the degree of harm appears likely to be an order of magnitude less than from cigarette smoking. At a population level, evidence has not supported the hypothesis that e-cigarettes would be a gateway to tobacco use among young people. There is evidence that some young people who would never have smoked have used e-cigarettes, but to date this use appears to be primarily occasional.

“E-cigarette technology continues to advance in terms of creating devices that deliver nicotine efficiently in a palatable form, but there are challenges regarding their impact on the environment. The topic of e-cigarettes has become, if anything, more divisive among public health experts, with evidence often being distorted or misrepresented and personal attacks being launched both ways across the divide. It remains possible that with the right kind of regulation, e-cigarettes could contribute further to a reduction in tobacco-related harm as part of a comprehensive tobacco control policy. This will be more likely if protagonists sign up to a set of ethical standards regarding the conduct and interpretation of science and work collaboratively to the development of evidence-based policies.”

Taking a look at the impact of policy changes designed to protect young people on smokers and vapers, Senior Research Associate, Smoking Studies, University of Bristol, Dr. Jasmine Khouja, said, “it is well-established that vaping helps some people quit smoking, but concerns over the unknown long-term health effects and rise in youth disposable vaping, has seen greater demand for tighter restrictions.”

Khouja said, “it is well-established that vaping helps some people quit smoking, but concerns over the unknown long-term health effects and rise in youth disposable vaping, has seen greater demand for tighter restrictions. But policy decisions have consequences and not all of them are intended.”

Speaking on Listening to Young Smokers and Vapers Talking About Disposable, the Research Fellow in the Department of Sociology, University of York (UK), Dr. Frances Thirlway, said: “Public health professionals in England recognise that vape products can play a useful role in helping smokers cut down or quit, but a recent rise in young people’s use of disposable devices has led to calls for increased regulation.”

Another speaker, the Principal Research Fellow in Behavioural Science, Tobacco and Alcohol Research Group, UCL, Dr. Sharon Cox, said: “Tobacco smoking is a leading cause of poor health outcomes and inequalities amongst people experiencing extensive health and social needs (example, homelessness, substance dependencies). An erroneous perception exists that individuals living with such needs do not engage in health services and as such, are described as ‘hard to reach’, ‘disengaged’ or ‘uninterested’.”

Director, Counterfactual Consulting Limited, Clive Bates, who rounded off the second session, revealed, “many professionally engaged in tobacco control leadership roles had their formative experience in the heat of the tobacco wars. But is that experience help or a hindrance now? How should we understand the drug nicotine, nicotine addiction, the motivation of consumers, youth risk behaviours, the tobacco industry, and the intense opposition to tobacco harm reduction?”

The third session, which began with the topic: Achievability of a United Kingdom Medicinal License, saw the Chief Impact Officer, David Graham (NJOY), an independent American company that manufactures and distributes electronic cigarettes and vaping products, said, “medicinally-authorised e-cigarette has been a topic of discussion since the first Summit in 2013. There were those who argued that only medicinally-licensed e-cigarettes should be on the market, while others believed that a medicinal-only marketplace would be accessible only for the big tobacco companies – who arguably had the least incentive to lead a revolution against combustible cigarettes.”

On Tobacco Harm Reduction, Nicotine and End Game: A conceptual model for measuring and understanding the possible role of alternative nicotine products and policies for reducing smoking, the Founder and Chief Principal Investigator of the International Tobacco Control Policy Evaluation Project, Prof. Geoffrey T. Fong, said: “Research over the past decade has provided evidence for the potential of harm reduction from e-cigarettes, but there are considerable challenges along the path from potential to reality, of which a key component is the extent to which e-cigarettes can help smokers quit.”

Fong said clinical trials have demonstrated the efficacy of e-cigarettes as a cessation aid, but ultimately, studies of the effectiveness of e-cigarettes for quitting smoking in the real world will tell us whether the potential of harm reduction is being realised.

The Director, Youdan Consulting (Advisor ASH NZ), Ben Youdan, speaking on New Zealand’s tobacco endgame polices, said government in that country has tabled some of the world’s most aggressive tobacco control policies with an explicit focus on smoked tobacco.

Endgame legislation proposes to remove nicotine from all smoked tobacco, drastically reduce supply by 95 per cent, and ban the sale of smoked tobacco to anyone born after January 2009. The aim being to reduce smoking rates to below five per cent by 2025.

“The proposed smoking endgame legislation builds on recent laws regulating the sale and use of vaping products. A harm reduction approach ensures vaping is accessible to adult smokers, whilst protecting never-smokers from taking up vaping.”

New Zealand’s liberal approach to vaping is seen as prerequisite to highly aggressive policies that will restrict and devalue smoked tobacco. For many, the smoking endgame policy represents the peak of New Zealand’s history of tobacco control leadership. For others, it creates deep concerns about coercive approaches to people who smoke.

Sharing Norway’s experience too, Senior Researcher, Norwegian Institute of Public Health, Dr. Karl E. Lund, said the prevalence of daily smoking in the age-group 16 to 24 years has dropped below the two per cent mark.

“Within few decades, Norway will probably be almost smoke-free, thanks to previous decades of robust infrastructure for tobacco control – and to the long-time availability of a popular alternative to cigarettes,” said Lund.

Lund said Snus is being seen as an alternative to smoking, vaping, chewing, dipping, and dissolvable and snuff tobacco products. Snus is cheaper, comes in a variety of flavours, can be used indoors and correctly perceived as less risky. The majority of Snus users are made up of ever-smokers and youth susceptible for smoking uptake. It usually contains nicotine, which can lead to nicotine addiction.

“But as smoking declines, the reservoir of its most potential users (smokers) will shrink and subsequently the relative share of never-smokers among Snus users will increase. Faced with this prospect, the authorities have signalled that they will make Snus the next target. This is the backdrop for the emerging debate on the future for low-risk nicotine products for non-therapeutic recreational use,” Strange said.

The Associate Professor in Psychiatry, Head of the Clinical School, Johor Bahru, Monash University Malaysia, Dr. Sivakumar Thurairajasingam, speaking on Nicotine and tobacco control in Low to Middle Income Countries (LMIC), said: “The level of adolescent tobacco use ranges from around 2 per cent to over 30 per cent worldwide, depending on region and on the form of tobacco.”

Bahru revealed that as the leading cause of preventable death globally, most of the global mortality burden of tobacco use lies predominantly to LMICs.

He added that about a fifth of young teenagers (13 to 15 years) around the world are smokers. For him, high income countries may have lower levels of adolescent tobacco use, while low and middle income countries have contrastingly high rates of adolescent smoking, where rates in some countries can reach as high as 46% and reflect high rates of all-age smoking.

Adult smoking rates generally appear to reflect adolescent smoking rates. “With this fear in mind, policymakers in LMICs have made “tobacco control” a priority to mitigate effects of tobacco related morbidity and mortality, by harnessing cessation interventions techniques from high-income countries. In reality, we are only seeing an increasing number of smokers in LMIC, questioning the effectiveness of the ‘total cessation’ policy. This session reviews reasons for this failed attempt of ‘total cessation’ in LMICs, and the possible risks it possesses. One evident phenomenon is the creation of ‘hidden populations’ of smokers, who continue their smoking habit against regulations and isolate from health providers, in fear of litigation.

“Is there a role for ‘tobacco harm reduction’ in the form of e-cigarettes or alternate non-combustible products over ‘total cessation’ policies? Despite evidences of its less harmful effects compared to conventional cigarettes, there have been lots of restrictions and hesitations towards ‘tobacco harm reduction’. In driving their agenda, international policies have also neglected special populations, individuals living with mental health problems, where even nicotine replacement has shown modest results.

“This talk stands firm on the fundamental understanding that ‘harm reduction’ initiatives respect the rights, health and safety of smokers, without compromising on ‘the right of all people to the highest standard of health’, as per WHO’s Framework Convention on Tobacco Control.

Chief Executive, Action on Smoking & Health UK (ASH UK), Deborah Arnott, who spoke on how the UK government’s approach to E-cigarettes is misunderstood and overstated both by those who support and oppose the role of these products in helping to bring about the end of smoking, stated that she would make a plea for both sides to recognise that “the UK government positions harm reduction in tobacco control as just one tool in the toolbox, relevant to the UK because of the phase it has reached in the tobacco epidemic.”