Japan EC Seminar (September 20th, 2018)

New evidence on e-cigarettes
Professor Peter Hajek
Wolfson Institute of Preventive Medicine

Declaration of interest
 I have no links with any e-cigarette ortobacco manufacturers
 My research into safety and effects of

EC is funded by the National Institute of
Health Research, Public HealthEngland, UK Centre for Tobacco andAlcohol Studies and UK Medicines
Regulatory Agency
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Developments since 2016
 Controversy continues
 New nicotine delivery products
 New data on safety New data on ‘gateway hypothesis’ New data on effects on smokers
 What to tell smokers
 If time allows: Varenicline for dual users

Controversy continues Pragmatic stance: E-cigarettes (EC) andother lower risk products can reducesmoking-related death and disease Moralist (abstinence-only) stance: Lower

risk products are a threat to the goal oferadicating nicotine use

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Some changes over the past
two years
 WHO remains anti-vaping and developing

countries that take WHO advice ban EC(Cambodia, Brazil, Egypt etc.)
 Australia and Japan ban EC with nicotine (butJapan allows HnB) New Zealand and Canada are lifting bans,Iceland refused EC-hostile TPD
 UK now supports smokers wishing to switch
to vaping

Stoptober 2017, PHE Report
2018, Parliament Enquiry 20183

Conclusions of UK reviews
 Vaping is likely to be at least 95% less risky

than smoking over long-term use
 So far, there is no evidence that EC provide
a gateway to smoking for young people Vaping regulation should be riskproportionate
 Smokers who cannot/do not want to quit
should be encouraged to switch to vaping

Time will tell
 If lower risk products (ENDS) are agateway to smoking and risky, ENDSfriendly countries will see increase insmoking and in smoking and ENDS-use
related diseases
 If the UK interpretation of evidence iscorrect, smoking rates and smokingrelated morbidity will go the opposite
way, as it did in Sweden with snus4UK experience so far
 2015: 850,000 smokers switched to vaping

plus 710,000 stopped both, smoking rate
dropped to 16.9%
 2016: Smoking prevalence 15.8%
 2017: Smoking prevalence 14.9%, biggest
drops in 18-24 year olds
 2018: 3.2 million vapers, most stoppedsmoking
 Eurobarometer 2017: UK now second lowest

smoking prevalence in EU (Sweden 5% daily-dueto Snus)

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Saving NHS money

Eurobarometer 2017
 7% of ex-smokers in EU quit with all

licensed meds together
 Some available for >35 years and widely

recommended and used in all EU countries
 6% quit with EC (at no cost to healthcare systems)
Special Eurobarometer 458, 20176

Smoking in countries that allow (UK and US)
and ban (Australia) vaping

HnB is reducing
cigarette smoking in Japan
 Advertising and information about lowerrisk is allowed; no EC with nicotine soHnB has no low risk competition
 January-July total domestic cigarettesales declined by 24% compared to thesame period in 2016
 From a typical rate of decline (2-3% peryear) to unprecedented (11-14% peryear), may be slowing down now
Japanese Domestic Cigarette Sales Results for July 2018
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Cigarette sales decline
Japan 2014-2018
20142015

2016

2017

2018

0‐2YoY % Change‐4‐6‐8‐10‐12‐14‐16Year

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Tobacco industry
 Will eventually have to switch to low risk

products. Bets on HnB, did not manage
to keep pace with EC innovations
 ‘Barriers to entry’ and bans on EC protect
cigarettes from EC competition and keepsmoking alive. In this sense, WHO andregulators in some countries (FDA) are
helping TI interests

Developments in ENDS
products since 20169

Heat not Burn products Philip Morris’ iQOS
 Extensive researchby PM and someindependent data
 Not as safe as EC,
likely to be more addictive, but much lessrisky than cigarettes
 If regulators strangle EC, this will be the(tobacco industry dominated) futureToxin levels in cigarettes,
EC and HNB (industry data)

Murphy et al. Reg Toxicology and Pharmacology 201710

Independent assessment ofrelative cancer potency

Stephens, Tobacco Control 2017

New review• HnB expose users and bystanders to
substantially fewer harmful compounds thancigarettes.
• The evidence is primarily from tobacco
industry data
• The HnB harm profile needs to becompared with other alternative nicotine
products that have reduced health risk
exposure profiles.
Simonavicius et al. Tob. Control 4 September 201811

IQOS is allowed to inform
smokers about relative risks

GLOBritish American Tobacco

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Cigarettes, IQOS and GLO
use in JapanAn interesting curio An unsuccessful murder attempt byputting mercury in an HnB product
Hitosugi et al. Int J Legal Med. 2018

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Juul
PAX Labs/Juul Labs (not TI)
 ‘Vaporizer’ using nicotine salt,

launched in US in 2016
 50mg/ml nicotine, 200 puffs
 Seems more effective thanother ECs – huge sales UK version only 19mg/ml
 First study of nicotine delivery

Urine cotinine in Juul users
 N=22, <21 year olds whoused Juul in past week
 245 ng/ml (no NNAL)
 Authors refer to teenage
smokers from a different study: 155 ng/ml
Goniewitz et al. Tobacco Control 2018
 But adult daily smokers: 1,448 ng/ml
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Juul outsells TI cig-a-likes(easy to use, more nicotine)

Nicotine salt vs freebase
 Freebase: Slower absorption; higher

nicotine concentration feels too harsh
 Salt (added benzoic acid): Faster, allows

stronger e-liquid, allows lower e-liquid
consumption, needs less battery power;
but less vapour

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