Thursday 3rd December Seminars

On request from the Department of Health and Social Care (DHSC) and Public Health England (PHE), the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) reviewed the potential toxicological risks from electronic nicotine delivery systems (ENDS). The Committee assessed the absolute risks from use of ENDS to former cigarette smokers, naïve users, and bystander, as well as the relative risks, compared to smoking conventional cigarettes, in those switching products. ENDS are not without risk, although these are substantially less than those of conventional cigarettes. However, the difference in risk will depend on the health effect in question. There is little evidence that the short to medium term use of ENDS causes major harm, but there are significant data gaps, particularly on the effects of long-term use. In addition, the use of ENDS de novo by non-users of tobacco products is likely to be associated with some adverse health effects to which the user would not otherwise have been subject. The risks to bystanders for most health effects will be low in conventional exposure scenarios, although exposure to nicotine may result in pharmacological effects in some individuals.

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Cochrane reviews are accepted as the gold-standard for investigating the evidence of potential harms and benefits of healthcare interventions. The Cochrane review of electronic cigarettes for smoking cessation was first published in 2014. A recent update, published in October 2020, now finds increased evidence of benefit for e-cigarettes with nicotine when used to quit smoking. Many policymakers, however, remain reticent to encourage their use for this purpose, citing ongoing uncertainty. This presentation will include a summary of findings from the most recent update, and then compare the Cochrane reviews’ conclusions with that from key national and international policy documents, such as the US Surgeon General’s 2020 report on smoking cessation and recent statements from the World Health Organisation.

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VESUVIUS, the British Heart Foundation-funded clinical trial is believed to have been the largest study undertaken to-date in comparing the impact of  tobacco vs e-cigarettes on cardiovascular health, with the findings published by the Journal of the American College of Cardiology.

The SCHEER preliminary opinion on electronic cigarettes (EC) states that there is strong evidence for the long-term systemic impact of EC on the cardiovascular system. The conclusion drawn by this preliminary report is at odds with the report it purports to reference and the literature review was selective, of poor quality and concerningly unbalanced. The report fails to acknowledge that there are a significant number of human clinical trials that have demonstrated a beneficial effect of switching from tobacco cigarettes to EC as a harms reduction measure.

This discussion will present data on VESUVIUS and discuss the current state of evidence for the cardiovascular impact of e-cigarettes.

The lungs represent a vast interface between the outside world and the human body through which inhaled products can be absorbed. The risks posed by such inhalants have been considered by users, regulators, and researchers in attempts to quantify the risk and come up with sensible policy recommendations and advice on the relative risks and benefits.This discussion will review some of the evidence to date on the pulmonary effects of e-cigarettes.

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For a science press officer in the UK, there was no more boring subject in recent decades than smoking - until around 2013 when e-cigarettes began to take centre stage.  Governments and health bodies were divided, and a subject which had enjoyed almost universal consensus became suddenly controversial.  The UK government signalled their backing to e-cigarettes as a quitting aid and vape shops sprang up on every high street.  Journalists were interested again.  But media coverage has been mixed; editors are always attracted to a juicy scare story and some journalists remain deeply suspicious of the legacy of this new(ish) technology.  How should the scientific community communicate such a divisive and emotive subject to the public?  What does ‘good’ coverage look like when apparently even researchers can't agree?  And what can scientists do to ensure e-cigarettes are reported responsibly and accurately?  Tom Sheldon leads the work on e-cigarettes at the Science Media Centre and he will talk about his experience working with scientists and journalists on this battleground subject.

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The post implementation review of the UK’s Tobacco & Regulatory Products Directive - the regulations that transpose the EU Tobacco Products Directive - coincide with the UK leaving the EU and follows the publication Green Paper ambition to make smoked tobacco obsolete. What opportunities arise as these three events collide. Martin will no doubt offer more questions than answers

Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. Ideally, a justification for an intervention on snus flavours should demonstrate that this would in fact be appropriate for the protection of public health, and that it is reasonable to expect that the benefits will outweigh the harms. We compared use of flavoured snus among snus users with different smoking status. The overall probability of using flavoured snus was .45 (95 % CI: .44–.46), highest among daily (.51, 95 % CI: .47–.54) and former daily smokers (.50, 95 % CI: .48–.52), and lowest among never smokers (.41, 95 % CI: .39–.43). Regulation that would ban or limit flavoured snus use may affect smokers – an at risk population - more than never smokers. These results will be discussed within a public health framework to consider potential costs and benefits from flavour restrictions on snus. We conclude that the health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on non-combustible nicotine products.

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Nicotine is a cultural drug like caffeine and alcohol but nowadays much contested.  In certain places it looks like cannabis is filling its void.  Data on its harmfulness on the population level will be presented. Nicotine’s dependence potential is related to its administration form.  Roughly the dependence potential is associated with amount of behaviour that goes with administration of nicotine.  As much as there is a continuum of harm from nicotine containing products there is also a continuum of dependence.  In the low end of the of the continuum we have nicotine patches and in the high end traditional cigarettes.  Comparisons of dependence across some nicotine containing products and to caffeine will be presented

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This presentation will describe: 1) the need to “devaluing” combusted products to expedite quitting smoking or if needed, facilitate the uptake of less harmful nicotine-containing products (e.g., electronic cigarettes; 2) the importance of regulating less harmful nicotine products, and 3) the need to develop more effective nicotine replacement therapies.   The presentation will be framed in the context of the continuum of risk of nicotine-containing products.  To date, too little attention has been paid to how to alter the most deadly and addictive tobacco product, cigarettes, to reduce their use. Devaluing the combusted products could include reducing their appeal (e.g., eliminating characterizing flavors, sugars) and/or addictiveness (e.g., reducing nicotine in cigarettes).   This approach would facilitate the shift towards harm reduction products among smoker unwilling or unable to quit nicotine.  However, attention needs to be paid to the concerns associated with harm reduction products, particularly e-cigarettes.  These concerns include addicting youth to nicotine, serving as a gateway to combusted products and dissuading smokers from quitting nicotine products altogether.  Potential ways to allay these concerns surround e-cigarettes involve establishing product standards, reducing access and promotion to youth and more proactively discussing and providing treatments for the cessation of all nicotine containing products.  Finding more effective treatments for smoking and for cessation of e-cigarette use is clearly needed to shift smokers down to the products with the lowest risk and optimally to nicotine abstinence.

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This paper reports findings from a simulation analysis that compares potential life-years gained by vaping-induced smoking cessation with potential life-years lost by vaping-induced smoking initiation in the U.S. through the year 2100. In addition to varying assumptions about the effect of vaping on smoking cessation and initiation, and the mortality implications, the analysis considers the effects of variables previously never included in such simulations; for example, which types of smokers, defined by difficulty quitting smoking, are most aided by vaping. Out of 360 possible scenarios. 357 (99%) yield positive estimates of life-years saved (LYS), most scenarios resulting in millions of individuals quitting smoking due to vaping through the year 2100. On average, vaping-induced quitters gain an extra 1.2-2.0 years of life compared to smokers who quit without vaping. While the numbers of LYS are generally large across all scenarios, they often represent a small fraction of the toll of smoking. Thus, while vaping is highly likely to reduce smoking-produced mortality, it is not “the” answer to the public health crisis created by smoking. Rather, it may well be an important tool to add to the armamentarium of effective tobacco control measures.

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The starting point for US policy towards e-cigarettes has been and continues to be the notion of an emerging epidemic of youth addiction to nicotine.  This epidemic is taken to be a matter of fact, and is evidenced by the recent rapid increase in past 30 day e-cigarette use in high school students, peaking at 27% in 2019. However, youth tobacco use in the USA is characterized by a diverse range of products, both combustible and non-combustible, traditional and novel,  with prevalence and patterns of use evolving rapidly over time.

The National Youth Tobacco Survey (NYTS) includes two well-established self-report indicators of nicotine dependence (craving for tobacco; time to first use of the day).  This paper reports NYTS data from high school students and examines self-reported dependence by product used and over time, and attempts to estimate the evolving overall burden of nicotine dependence in the whole population.  Dependence in otherwise tobacco-naïve e-cigarette users appears to be low, and there is little evidence for any substantial change in population burden of nicotine dependence over time as product preference has shifted from cigarettes towards e-cigarettes.

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This presentation will highlight data from an observational study of adult dual cigarette and e-cigarette users, focusing on multi-level factors that might enhance complete switching to e-cigarette use and implications for research and intervention designs. Opportunities for enhancing switching during the time of COVID-19 will be discussed.

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Australia has effectively banned the sale of electronic nicotine delivery devices (ENDS) by using poisons regulations that only allow access to ENDS products demonstrated in randomized control trials to improve smoking cessation. No such products are available. Smokers can, with difficulty, import nicotine if they have a prescription, but few doctors are prepared to prescribe it. The minority of smokers who use ENDS have often illicitly accessed nicotine over the internet. This restrictive policy has been supported by the most of the Australian tobacco control community. Alarm at increased ENDS use among Australian adolescents has prompted a proposal to make access even more difficult by abolishing personal importation and only allowing dispensing of approved products by pharmacists on a prescription.  Illicit importation will attract fines of up to AUD200,000. This paper critically analyses the arguments used to justify Australian ENDS policy and describes how ENDS could be regulated for recreational use in ways that address the concerns about adolescent use raised by those who support a ban.

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