E-Cigarettes: Minimizing the risks, Maximizing the potential

1. E-Cigarettes:Minimizing the risks, Maximizing the potential Non-Smokers’ Rights Association/Smoking and Health Action Foundation

2. cartridge + atomizer + battery cartomizer + battery Non-Smokers’ Rights Association/Smoking and Health Action Foundation

3. Innovations Non-Smokers’ Rights Association/Smoking and Health Action Foundation

4. Innovations—batteries • Adjustable voltage • Adjustable smoke volume • Improved battery life • Consistent charge Non-Smokers’ Rights Association/Smoking and Health Action Foundation

5. Innovations—flavours • Refillable cartridge • Refillable tank/clearomizer • Replaceable cartridge Non-Smokers’ Rights Association/Smoking and Health Action Foundation

6. Burgeoning popularity • US sales have doubled every year for past 3-4 years; 2013 sales estimated at $1.7B • Big Tobacco is buying e-cigarette companies • Major multinational tobacco companies—BAT, Imperial, Japan Tobacco–buying e-cigarette companies or developing their own products • Major US tobacco firms also getting involved (Lorillard bought Blu; Reynolds American launched Vuse; rumour of Altria takeover of NJOY) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

7. Awareness and use of e-cigarettes Internet Searches: E-Cigarettes, Snus, NRT, Champix (Ayers et al, American Journal of Preventive Medicine, April 2011) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

8. Awareness and use of e-cigarettes • Two large US surveys in 2010: national online study (n=2650) and Legacy Longitudinal Smoker Cohort (n=3650) (Pearson et al, AJPH, July 2011) • Ever-use = 11.4% current smokers; 2% former smokers; 0.8% for never smokers • Current use = 4.1% current smokers; 0.5% former smokers • Two large UK surveys in 2010 and 2012 (n=12,500 adults, incl 2,100 smokers) (Dockrell et al, N&TR, May 2013) • Ever use = 22% smokers; 0.5% non-smokers (2012) • Current use = 7% smokers (2012) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

9. Awareness and use of e-cigarettes • Little Canadian data; ITC 4 country survey, n=1500 (Adkison et al, AJPM , Mar 2013) • 40% Canadian smokers aware of e-cigs • 4% smokers ever use; 1% current use • 64% believe e-cigs are less harmful than cigarettes • E-cig users in all 4 countries: 85% use to help them quit; 80% use because they are less harmful; 75% use to cut down; 70% use when can’t smoke • Questions added to 2014 CTADS and next YSS—Quebec only Non-Smokers’ Rights Association/Smoking and Health Action Foundation

10. Awareness +use: youth/young adults • Canada: 1211 respondents, age 16-30; 456 smokers, 755 non-smokers (2012) (Czoli et al, SRNT 2013) • Ever use = 33% smokers; 6% non-smokers • Current use = 14% smokers; 1% non-smokers • France: 3400 students, age 12-19 (2012) (Dautzenberg, Open Journal of Respiratory Disease, 2013) • Ever use = 33% daily smokers, 16% non-daily, 4% non-smokers • Poland: 13,700 students, age 15-19/20-24 (2012) (Goniewicz et al, Pediatrics, Oct 2012) • Ever use = 23% youth; 19% young adults; 3% non-smokers • Current use = 8% high school; 6% young adults • US: 24,000+ students, grades 6-12 (2012) (MMWR, Sept 2013) • Ever use, high school = 10% (4.7% in 2011) • Current use, high school = 2.8% (1.5% in 2011) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

11. Health Canada’s position Non-Smokers’ Rights Association/Smoking and Health Action Foundation

12. Health claims are illegal, but … “While electronic cigarettes are technically a "smoking alternative" rather than a smoking cessation device, the range of nicotine strengths offers some obvious potential as an aid in one’s attempts to quit smoking….” (Wister Oct 2012) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

13. Sale with nicotine is illegal, but … (www.epuffer.com) (www.esteamcanada.com) Non-Smokers’ Rights Association/Smoking and Health Action Foundation

14. Current situation in Ontario • Retailers are openly selling and promoting e-cigarettes and related paraphernalia • Head shops • Flea markets • Mobile sales at workplaces • Kiosks in malls • Convenience stores • Gas stations • Specialty e-cigarette stores • Pharmacies • Internet Non-Smokers’ Rights Association/Smoking and Health Action Foundation

15. Superstore, southern ON, 2011 RexallPharmaPlus, Ottawa, Jan 2013 Website, London ON, retailer Sept 2011, http://noifsandsorbutts.ca Non-Smokers’ Rights Association/Smoking and Health Action Foundation

16. Current situation in Ontario Websites Blogs Testimonials YouTube videos Many forms of e-cigarette promotion Countertop displays Retail signage & billboards Newspaper ads Retail trade journal ads/articles Company brochures Celebrity endorsements E-cig company sponsorships Price discounting Fax blasts + mass emails Internet Non-Smokers’ Rights Association/Smoking and Health Action Foundation

17. Non-Smokers’ Rights Association/Smoking and Health Action Foundation

18. The controversy • E-cigarettes are unproven cessation devices; should be required to undergo same rigorous testing for safety/efficacy as other NRTs • E-cigarettes have potential to undermine major tobacco control gains • E-cigarettes are clean drug delivery device that can satisfy smokers’ addiction to nicotine and to smoking behaviours • Even if untested, health risks of e-cigarettes could not come close to those of cigarettes Opponents Proponents Non-Smokers’ Rights Association/Smoking and Health Action Foundation

19. Opponents • Long-term health risks of inhaling PG not known • Lack of quality controls, manufacturing standards • Misleading, false, incomplete labelling—ingredients not fully disclosed • Unproven cessation claims • Risks from nicotine e-liquid • Tobacco control successes may be undermined • Will increased social exposure and promotion of ‘smoking’ re-normalize smoking? • Will e-cigs lead to smoking/nic addiction among youth? • Will dual use increase tobacco consumption? • Will e-cig use complicate enforcement of smoking bans? Non-Smokers’ Rights Association/Smoking and Health Action Foundation

20. Proponents • Substantially lower health risks than cigarette—risks must be compared to cigarette • Exposure to all tobacco smoke toxicants significantly reduced • TSNAs in e-cigs are at levels are comparable to those in NRTs • Main ingredient (propylene glycol) safe for oral consumption; used as solvent in medications • Only 1 death, 1 hospitalization ever reported • Effective in helping smokers  cigarette use • Effective in helping smokers quit smoking Non-Smokers’ Rights Association/Smoking and Health Action Foundation

21. NSRA position on e-cigarettes Evidence-based Balanced—minimize risks, acknowledge potential benefits “E-cigarettes are almost certainly much safer than tobacco cigarettes, and to date there has been little real-world evidence of harm from e-cigarettes.” “E-cigarettes have tremendous potential to help smokers reduce their cigarette consumption and to quit smoking altogether.” Non-Smokers’ Rights Association/Smoking and Health Action Foundation

22. NSRA position on e-cigarettes • All e-cigarettes—with and without nicotine—should be subject to the same legal framework • E-cigarettes should be subject to the same regulatory controls as tobacco products: • cannot be sold to minors • cannot be displayed in retail stores • cannot be sold wherever tobacco sales are prohibited • cannot be promoted except in adults-only venues and in direct mail to a named adult • cannot be used in indoor public places & workplaces • cannot be used on school grounds Non-Smokers’ Rights Association/Smoking and Health Action Foundation

23. Conclusions • Early stage issue; much work remains to be done • Interests of smokers/tobacco control best served by providing balanced, accurate information • Health organizations and practitioners have role to play in advancing e-cigarette policy— • research • public opinion surveys • public education • local voluntary policies • local bylaws • advocacy for legislation Non-Smokers’ Rights Association/Smoking and Health Action Foundation