Tobacco harm reduction: The need for new products that can compete with cigarettes

Highlights
• Tobacco harm reduction aims to reduce illness and death caused by smoking tobacco.
• The medical and regulatory consensus is that nicotine itself is relatively safe.
• Snus use in Sweden provides strong evidence in support of harm reduction.
• E-cigarettes are seen by many smokers as an attractive alternative to cigarettes.
• Regulated, safer nicotine alternatives may substantially improve public health.

Published: 10 November 2013

Positive:

Link to publication: http://www.sciencedirect.com/science/article/pii/S0306460313003729

Authors

Karl Olov Fagerström
Kevin Bridgman


Summary

Over the last 50 years, the concept of tobacco harm reduction has been well established. It is now understood that nicotine itself is not very harmful and nicotine replacement therapy products have been widely used as an aid to quit, reduce to quit or temporarily abstain from smoking for many years. The popularity of the unlicensed electronic cigarette has increased despite an unknown risk profile and snus use in Sweden provides strong evidence in support of a harm reduction strategy. The regulatory environment around harm reduction has changed in the UK and is continuing to evolve across the globe. The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. The significant positive impact on public health that could be gained from encouraging people to switch from cigarettes to licensed medicinal nicotine products cannot be ignored.


Conclusion

N/A

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Prevalence and characteristics of e-cigarette users in Great Britain: Findings from a general population survey of smokers

Highlights
• There is now near universal awareness of e-cigarettes.
• Use is common among smokers.
• Quarter of all smokers unsure as to whether they are less harmful than cigarettes.
• E-lites – a brand that delivers a low dose of nicotine – is the most popular.
• Users have higher SES, smoke more heavily and have attempted to quit recently.

Published: 11 March 2014

Positive:

Link to publication: http://www.sciencedirect.com/science/article/pii/S0306460314000744

Authors

Jamie Brown
Robert West
Emma Beard
Susan Michie
Lion Shahab
Ann McNeill


Summary

Background

E-cigarettes may be effective smoking cessation aids and their use by smokers has been growing rapidly. It is important to observe and assess natural patterns in the use of e-cigarettes whilst experimental data accumulates. This paper reports the prevalence of e-cigarette awareness, beliefs and usage, including brand choice, and characterises the socio-demographic and smoking profile associated with current use, among the general population of smokers and recent ex-smokers.

Methods

Data were obtained from 3538 current and 579 recent ex-smokers in a cross-sectional online survey of a national sample of smokers in Great Britain in November and December 2012. Differences between current and recent ex-smokers in the prevalence of e-cigarette awareness, beliefs and usage were examined and the socio-demographic and smoking profile associated with current use of e-cigarettes was assessed in a series of simple and multiple logistic regressions.

Results

Ninety-three percent of current and recent ex-smokers (n = 3841) were aware of e-cigarettes. Approximately a fifth (n = 884) were currently using e-cigarettes, whilst just over a third (n = 1507) had ever used them. Sixty-seven percent of the sample (n = 2758) believed e-cigarettes to be less harmful than cigarettes; however, almost a quarter (n = 994) remained unsure. Among both current and recent ex-smokers, the most popular reasons for using were health, cutting down and quitting (each > 80%) and 38% used the brand ‘E-lites’. Among current smokers who were aware of but had never used e-cigarettes, approximately half (n = 1040) were interested in using them in the future. Among current smokers, their use was associated with higher socio-economic status (OR = 1.48, 95%CI = 1.25–1.75), smoking more cigarettes (OR = 1.02, 95%CI = 1.01–1.03) and having a past-year quit attempt (OR = 2.82, 95%CI = 2.38–3.34).


Conclusions

There is a near universal awareness of e-cigarettes and their use appears to be common among smokers in Great Britain although a quarter of all smokers are unsure as to whether e-cigarettes are less harmful than cigarettes. E-lites – a brand that delivers a low dose of nicotine – is the most popular. E-cigarette users appear to have higher socio-economic status, to smoke more cigarettes per day and to have attempted to quit in the past year.


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Characterisation of mainstream and passive vapours emitted by selected electronic cigarettes

Electronic cigarettes have achieved growing popularity since their introduction onto the European market. They are promoted by manufacturers as healthier alternatives to tobacco cigarettes, however debate among scientists and public health experts about their possible impact on health and indoor air quality means further research into the product is required to ensure decisions of policymakers, health care providers and consumers are based on sound science. This study investigated and characterised the impact of ‘vaping’ (using electronic cigarettes) on indoor environments under controlled conditions using a 30 m3 emission chamber. The study determined the composition of e-cigarette mainstream vapour in terms of propylene glycol, glycerol, carbonyls and nicotine emissions using a smoking machine with adapted smoking parameters. Two different base recipes for refill liquids, with three different amounts of nicotine each, were tested using two models of e-cigarettes. Refill liquids were analysed on their content of propylene glycol, glycerol, nicotine and qualitatively on their principal flavourings. Possible health effects of e-cigarette use are not discussed in this work. Electronic cigarettes tested in this study proved to be sources for propylene glycol, glycerol, nicotine, carbonyls and aerosol particulates. The extent of exposure differs significantly for active and passive ‘vapers’ (users of electronic cigarettes). Extrapolating from the average amounts of propylene glycol and glycerol condensed on the smoking machine filter pad to the resulting lung-concentration, estimated lung concentrations of 160 and 220 mg m−3 for propylene glycol and glycerol were obtained, respectively. Vaping refill liquids with nicotine concentrations of 9 mg mL−1 led to vapour condensate nicotine amounts comparable to those of low-nicotine regular cigarettes (0.15–0.2 mg). In chamber studies, peak concentrations of 2200 μg m−3 for propylene glycol, 136 μg m−3 for glycerol and 0.6 μg m−3 for nicotine were reached. Carbonyls were not detected above the detection limits in chamber studies. Particles in the size range of 20 nm to 300 nm constantly increased during vaping activity and reached final peak concentrations of 7 × 106 particles L−1. Moreover, the tested products showed design flaws such as leakages from the cartridge reservoirs. Possible long term effects of e-cigarettes on health are not yet known. E-cigarettes, the impact of vaping on health and the composition of refill liquids require therefore further research into the product characteristics. The consumers would benefit from harmonised quality and safety improvements of e-cigarettes and refill liquids.

Published: 13 October 2014

Positive:

Link to publication: http://www.sciencedirect.com/science/article/pii/S1438463914000972

Authors

Otmar Geiss
Ivana Bianchi
Francisco Barahona
Josefa Barrero-Moreno


Summary

Electronic cigarettes (e-cigarettes) have become increasingly popular since their introduction onto the European market in 2005. Use in Great Britain, for example, more than doubled from 2.7% of vapers in 2010 to 6.7% in 2012 (Dockrell et al., 2013).

They are frequently advertised by manufacturers as a healthier alternative to tobacco cigarettes (Ayers et al., 2011) and a smoking cessation tool, and have become a popular substitute for traditional tobacco because of indoor smoking restrictions on traditional tobacco cigarettes (Etter and Bullen, 2011).

Uncertainties about their impact on health and indoor air quality have caused debate among scientists and public health experts. Concerns most frequently relate to product safety in terms of product design, exposure to toxic products, potential for abuse (including dual use with tobacco products), use by young people and effectiveness in helping smokers to quit smoking tobacco cigarettes (Noel et al., 2011).

Although some studies have indicated that they are less harmful than smoking regular tobacco cigarettes (Caponetto et al., 2013 and Wagener et al., 2012), e-cigarettes and refill liquids nonetheless require further research into the detail and composition of the products, as will be required under the newly revised Tobacco Product Directive (2014/40/EU), to ensure that the decisions of policymakers, health care providers and consumers are based on sound science (Etter et al., 2011).

Only a few studies have reported on the impact of e-cigarette vaping on indoor air quality (passive vaping).Schripp et al. (2013) found that volatile organic compounds (VOCs) and ultrafine particles (UFP) were released from an e-cigarette while actively vaping in an 8 m3 emission chamber. Schober et al. (2014)reported on VOC, particle and polycyclic aromatic hydrocarbons (PAHs), carbonyls and metals releases into a real office environment. This study also monitored the effect of vaping on FeNO release and the urinary metabolite profile. McAuley et al. (2012) compared the effects of e-cigarettes vapour and cigarette smoke on indoor quality. In this study, vapours were generated using a smoking machine and were collected in a sampling bag for analysis. Fuoco et al. (2014) analysed e-cigarette generated aerosols in terms of particle number concentrations and size distribution.

Other studies have focused on safety and quality aspects of refill liquids. They reported inconsistent levels of nicotine (Goniewicz et al., 2013) and nicotine impurities (Trehy et al., 2011, Etter et al., 2013 and Hutzler et al., 2014) among batches/brands. Williams et al. (2013) described the possibility of metals, or chemicals from plastics in the delivery system, leaching into the vapour before inhalation. Behar et al. (2014)identified toxicants in cinnamon-flavoured e-cigarette refill liquids.

This study proposes a systematic approach to characterise e-cigarette emissions under controlled conditions using a smoking machine with adapted smoking parameters for the generation of vapours from well characterised refill-liquids. The impact of vaping on the indoor environment was investigated introducing the generated vapours into a 30 m3 walk-in emission chamber operated under defined conditions (temperature, relative humidity and ventilation rate). The composition of e-cigarette mainstream vapours in terms of propylene glycol, glycerol, low molecular carbonyls and nicotine emissions was determined applying an adapted standardised smoking protocol for regular cigarettes. Two models of e-cigarettes were used in this study, differing primarily by the way in which refill liquids are evaporated. In order to cover the widest range possible, two very different base recipes for the refill liquid, each with three different amounts of nicotine, were used for the emission testing. Possible health effects of e-cigarette use are not discussed in this work.


Conclusion

Electronic cigarettes tested in this study proved to be sources of propylene glycol, glycerol, nicotine, carbonyls and aerosol particulates. The extent to which people could be passively exposed to these depends on the ventilation rate, room size, indoor climate, room equipment and number of e-cigarettes in use. In addition to exposure to toxicants, consideration must also be given to the generally perceived air quality in microenvironments where vaping is permitted (independently of its toxicity). Sensory assessment of the acceptability of air quality or odour intensity by a human panel could answer this question and should be further explored.

In addition to considering exposure to second-hand vapour, this study shows that active vapers inhale relatively high concentrations of propylene glycol, glycerol, aerosol particulates and certain carbonyls. This exposure might require further toxicological evaluation.

Possible long term effects of e-cigarettes health are not yet known. E-cigarettes, the impact of vaping on health and the composition of refill liquids require therefore further research into the product characteristics. For the benefit of consumers, quality and safety requirements of e-cigarettes and refill liquids should be harmonised.


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A systematic review of health effects of electronic cigarettes

Highlights
No firm conclusions can be drawn on the safety of electronic cigarettes.
The findings in the 76 studies were often inconsistent and contradictory.
Serious methodological problems were identified and there is no long-term follow-up.
In 34% of the articles the authors had a conflict of interest.
Electronic cigarettes can hardly be considered harmless.

Published: 16 October 2014

Positive: No

Link to publication: http://www.sciencedirect.com/science/article/pii/S0091743514003739

Authors

Charlotta Pisingera
Martin Døssingb


Summary

Objective

To provide a systematic review of the existing literature on health consequences of vaporing of electronic cigarettes (ECs).

Methods

Search in: Pub Med, EMBASE and CINAHL. Inclusion criteria: Original publications describing a health-related topic, published before 14 August 2014. PRISMA recommendations were followed. We identified 1101 studies; 271 relevant after screening; 94 eligible.

Results

We included 76 studies investigating content of fluid/vapor of ECs, reports on adverse events and human and animal experimental studies. Serious methodological problems were identified. In 34% of the articles the authors had a conflict of interest. Studies found fine/ultrafine particles, harmful metals, carcinogenic tobacco-specific nitrosamines, volatile organic compounds, carcinogenic carbonyls (some in high but most in low/trace concentrations), cytotoxicity and changed gene expression. Of special concern are compounds not found in CCs, e.g. propylene glycol. Experimental studies found pulmonary obstruction after short-term exposure. Reports on short-term adverse events were often flawed by selection bias.


Conclusions

Due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up no firm conclusions can be drawn on the safety of ECs. However, they can hardly be considered harmless.


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