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E Cigarettes

E Cigarettes. Renee Bittoun No Conflicts of Interest-Pharmaceutical Companies, Tobacco Companies or their subsidiaries Not member of their Boards, do not receive hospitality or travel. Fundamentals. We ALL want to see less harm to the public and to smokers. Nicotine is crucial to smoking

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E Cigarettes

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  1. E Cigarettes Renee Bittoun No Conflicts of Interest-Pharmaceutical Companies, Tobacco Companies or their subsidiaries Not member of their Boards, do not receive hospitality or travel

  2. Fundamentals • We ALL want to see less harm to the public and to smokers. • Nicotine is crucial to smoking • Nicotine is sourced from tobacco plants hence the tobacco farmers and tobacco industry [There are no longer any legal tobacco farms in Australia, all legal tobacco is imported] • All NRTs (Nicotine Replacement Therapy) contain nicotine derived from tobacco plants, as a “pharmaceutical/therapeutic/medicinal nicotine formulation” which is TGA approved • Nicotine for SNUS comes directly from the plant • All nicotine for E cigarettes comes from the plant • Nicotine is extremely addictive in some individuals • Nicotine Addiction is not benign

  3. People always smoked: Not correct JAMA, COLE, FIORE ET AL 2016

  4. Prevalence drop is stalling or plateauing ; Fed Govt Midway Assessment Tobacco Control Strategy say not correct Smoking in Australia, persons aged 14+ 1991-2016 Source: Australian Institute of Health and Welfare

  5. Difficult patients should be offered E cigarettes because they don’t or wont quit, not correct: are easier to help than ever before • Highly dependent, fast metabolisers of nicotine, mental health comorbidities, drug and alcohol users can achieve > 50% abstinence rates • Combination treatments (TGA approved) achieve excellent results in this group – good evidence. • How do E Cigarettes compare with current approved treatments? No TGA approval (no Therapeutic proof)

  6. nationalacademies.org/eCigHealthEffects. PUBLIC HEALTH CONSEQUENCES OF E-CIGARETTES January 2018 Public Health Consequences of E-Cigarettes, an expert committee of the National Academies of Sciences, Engineering, and Medicine

  7. Toxicology of Constituents • Conclusive evidence that ... •  most e-cigarette products contain and emit numerous potentially toxic substances. [5-1] •  the number, quantity, and characteristics of [these] substances emitted ... is highly variable and depends on product characteristics ... and how the device is operated. [5-2] • Substantial evidence that ... under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes. [5-3] 10

  8. Nicotine • • Conclusive evidence that… exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics ... and how the device is operated. [4-1] • • Substantial evidence that… nicotine intake from e-cigarette devices among experienced adult e- cigarette users can be comparable to that from combustible tobacco cigarettes.[4-2]

  9. Dependence & Abuse Liability • • Substantial evidence that… e-cigarette use results in symptoms of dependence on e-cigarettes [8-1] • Quitline Access • • Moderate evidence that… risk and severity of dependence are lower for e- cigarettes than combustible tobacco cigarettes [8-2] • – variability in e-cigarette product characteristics ... is an important determinant of risk and severity [8-3]

  10. Cardiovascular Diseases • • No available evidence whether or not e- cigarette use is associated with clinical cardiovascular outcomes ... and subclinical atherosclerosis [9-1] • Substantial evidence that…heart rate increases after nicotine intake from e-cigarettes [9-2] • Moderate evidence that… diastolic blood pressure increases after nicotine intake from e-cigarettes [9-3]

  11. Adult Smoking Cessation • Limited evidence that e-cigarettes may be effective aids to promote smoking cessation overall [17-1] • Moderate evidence from randomized controlled trials that e- cigarettes with nicotine are more effective than e-cigarettes without nicotine for smoking cessation [17-2] • Insufficient evidence from randomized controlled trials about the effectiveness of e-cigarettes as cessation aids compared with no treatment or to FDA–approved smoking cessation treatments [17-3] • Moderate evidence from observational studies that more frequent use of e-cigarettes is associated with increased likelihood of cessation [17-4]

  12. Harm Reduction: Complete Switching • Conclusive evidence that completely substituting e- cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes [18-1] • Substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems [18-2] 28 Harm Reduction: Dual Use • No available evidence whether or not long-term e- cigarette use among smokers (dual use) changes morbidity or mortality compared with those who only smoke combustible tobacco cigarettes [18-3] • Insufficient evidence that e-cigarette use changes short-term adverse health outcomes in several organ systems in smokers who continue to smoke combustible tobacco cigarettes (dual users) [18-4] 29

  13. Youth & Young Adult Smoking: Smoking Progression • Among youth and young adult e-cigarette users who ever use combustible tobacco cigarettes: • Moderate evidence that e-cigarette use increases the frequency and intensity of subsequent combustible tobacco cigarette smoking [16-2] • Normalisation /role modelling as yet to be determined

  14. The Tobacco Industry The ethical and moral issues of their involvement with E Cigarettes

  15. Tobacco Industry Involvement • Nicotine is addictive, comes from the tobacco plant, grown by tobacco farmers; a strong lobby group aimed at assuring the continuing use AND business growth of their product • “Electronic cigarettes, invented in 2003, are forecast to have annual sales exceeding $10 billion by 2017” Bloomberg Businessweek June, 2013. • Bloomberg Industries projects that at their current pace, e-cigarette sales will surpass those of traditional smokes by 2047

  16. The WHO FCTC is the world’s only tobacco control evidence based treaty and has been commended by global leaders as providing the primary roadmap to a tobacco-free world. • It has 181 Parties, representing 180 States ( NOT the USA) and the European Union, and is supported by numerous nongovernmental organizations. • Australia is an inaugural signatory

  17. CAN WE BELIEVE THE TOBACCO INDUSTRY? 7 CEOs of Big Tobacco (Now BAT). Their "nicotine is not addictive" testimony Waxman Hearings, April 14, 1994US House of Representatives Note- Attitudes and statements reversed very quickly.

  18. WHO's mandate on monitoring the tobacco industry Article 5.3 of the WHO Framework Convention on Tobacco Control Parties to the WHO Framework Convention on Tobacco Control have identified the tobacco industry as the primary driving agent of the tobacco epidemic. The preamble of the WHO FCTC emphasizes the need for Parties to be alert to any efforts by the tobacco industry to undermine or subvert tobacco control efforts and the need to be informed of activities of the tobacco industry that have a negative impact on tobacco control efforts. Understanding that public confidence would be enhanced by transparency of affiliation between delegates to the Health Assembly and other meetings of WHO and the tobacco industry”.

  19. The Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) notes the launch of the Foundation for a Smoke-Free World, led by a former official at the World Health Organization [Derek Yach]. The Convention Secretariat regards this tobacco industry-funded initiative as a naked attempt to breach the treaty by interfering in public policy. It is a deeply alarming development aimed at damaging WHO FCTC implementation, and the Secretariat must therefore alert countries to its potentially harmful impact, particularly through contentious research programmes. Philip Morris International is funding US$80 million annually for the next 12 years starting from 2018 The overt appearance of the tobacco industry at conferences (see BAT at the SRNT Florence 2017) infers a self-assurance and cockiness not seen for many decades.” These initiatives have successfully divided colleagues in Tobacco Control like never before.

  20. Guidelines for implementation of Article 13 • It is increasingly common for tobacco companies to seek to portray themselves as good corporate citizens by making contributions to deserving causes or by otherwise promoting “socially responsible” elements of their business practices. In Australia “ATHRA” Australian Tobacco Harm Reduction Association openly acknowledges funding from KAC (Knowledge Action Change) which is funded by BAT ( British American Tobacco) and “industry”. • Such contributions fall within the definition of tobacco sponsorship in Article 1(g) of the Convention and should be prohibited as part of a comprehensive ban, because the aim, effect or likely effect of such a contribution is to promote a tobacco product or tobacco use either directly or indirectly.

  21. Recommendation In accordance with Articles 5.3 and 13, of the FCTC, to which Australia is an inaugural signatory, health meetings, conferences and other legitimate public and private health groups should desist from giving legitimacy to any persons or groups directly or indirectly funded by the tobacco industry.

  22. Picture Courtesy: Isabel Chan obtained from Google.com

  23. Conclusion E Cigarettes may become the cigarettes of the 21st Century

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