What we should know about vaping and e-cigarettes
01
Background Information
02
Evidence & Science
03
Prevalence
04
Marketing Tactics & Products
05
Economics
06
Regulations, Policy and Advocacy
1 Background information
1. Different names for different devices First electronic cigarettes appeared in the 1960’s; patented in the early 2000’s
• • • • • • • • • • • • •
e-cigs cigalikes e-hookahs e-shishahs mods pods vape pens e-pens vapes tank systems electronic nicotine delivery systems (ENDS) electronic non-nicotine delivery systems (ENNDS) …
>450 types of e-cigarettes
CDC, Oct 2015
1. How does it work?
• E-liquid or “juice” is heated at 200ºC • Tobacco in combustible cigarette is burnt at 800ºC
1. New products: Heated Tobacco Products (HTPs) Not to be confused with vaping (without tobacco or combustion)
iQOS (I Quit Ordinary Smoking) by Phillips Morris International
Glo by British American Tobacco
Ploom tech by Japan Tobacco International
A small stick containing tobacco is heated at 250ยบC instead of burnt at >800ยบC
1. Combustible cigarette versus e-cigarette Combustible cigarettes
Electronic cigarettes
Studied since >80 years (1934)
Studied since 2007
Tar, Carbon Monoxide, Nicotine + 70 known carcinogens
No Tar, No Carbon Monoxide
Effects: Stroke, heart diseases, blood vessel damages, COPD, bronchitis, etc‌ Cancers: lung, kidney, bladder, cervix, throat, stomach, trachea, oesophagus, pancreas, ‌ Source: ACS, CDC and IARC
Effects: Dyspnoea, Granulomatous Lung Disease, Emphysema, Asthma, increased bacterial infections Source: American Lung Association; Poponea et al, 2018, Bayly et al, 2019
Cancers:
?
2 Science & Evidence
2. What’s in the e-liquid and aerosol? • The e-cigarette smoke is not a “vapour” neither “steam” , it’s an AEROSOL containing many finely suspended particles of liquids and gases that are created from whatever is in the e-liquid Nicotine
Propylene Glycol ~50%
Glycerine ~35%
Anti-freeze
Shampoos, gels & soaps
Diacetyl
“Butter-like” flavour
E-liquid composition according to surveyed teens in US: 66% flavour, 13% nicotine, 6% marijuana, 13% “don’t know” Truthinitiative.org
2. What’s in the e-liquid and aerosol? • Nicotine and Nicotine salt Freebase Nicotine is the addictive substance of combustible cigarettes but when used in e-cigarettes, it gives a harsher taste in the mouth and irritate the throat and lungs. Nicotine salt is obtained by adding a specific acid to the “recipe”: e.g. Nicotine Benzoate, Nicotine lactate. It gives a smoother hit and goes deeply in the lungs, thus in the organism. Combustible cigarette : 0.1-0.6 percent E-cigarettes: 0.3-5 percent Nicotine content depends on e-cigarettes power and e-liquid content. DIY kits to increase power and nicotine content
2. Nicotine: from pleasure to addiction Pleasure: you decide to take the substance, when and how much.
Versus
Addiction: The substance decides that you must use it, and how frequently.
It takes 10-20 seconds to reach the brain • Nicotine has an effect on the prefrontal cortex and dopamine receptors (pleasure and relaxing). The rush of nicotine triggers the formation of more receptors to dopamine, thus a clear need to more nicotine. • Effects on : arousal, relaxation, cognitive enhancement, appetite suppression, learning and memory enhancement. Which is an issue on developing brains (individuals <25). • It leads to 3 types of addictions: Physical, psychological and behavioural On average, vaping deliver as much nicotine as 3–4 typical tobacco cigarettes St.Helen et al., 2016
2. It’s not only nicotine...“Cloud chasing” & “vape tricks”
• Competitions are supported & sponsored by e-cigarette industry • Specific names for tricks: rings, swirls, dragons, ghost, clouds, etc… • Influencers on social media spread the use of customized recipes (thicker smoke or coloured)
2. Other effects • E-cigarettes produce compounds that could reduce chemotherapy efficacy or facilitate the growth of established tumours Sanner et al, 2015 • Liquid tanks or cartridges were infected with either harmful bacteria or fungus. Bacteria were found to colonize lungs and trigger lung infections Lee et al, 2019 •
Environmental impact: Some pods and tanks are disposable (20 million sold in 2018, 33% of the market) Terramarproject.org
•
Indoor air quality: second-hand smoke contains nicotine, metals, polycyclic aromatic carbons, carbonyl. Schober et al, 2014
Chen et al., 2017
3 Prevalence
3. Prevalence
Since the mid 2000’s, e-cigarettes have been used by smokers and non-smokers • The number of users in the US reached 10.8 million, with 50% under 35 years of age • In the UK, the number of users reached 3 million compared to 7 million smokers • In 2017, 63 million Europeans aged 15 or older had ever used e-cigarettes, and 7.6 million were regular e-cigarette users. • It is projected that globally the number of e-cigarettes users could reach 55 million in 2021
3. Pattern of use: Youth
Reminder: Middle school: 11-13 years-old High school:14-18 years-old
Over 5,700 kids start vaping every day
3. Pattern of use: Adults
The data indicate that patterns of use are the opposite of what they expected to be
2016 National Health Interview Survey
3. A help for quitting?
A study published in 2016 have shown that e-cigarettes with nicotine helped individuals quit better than e-cigarettes without nicotine
The 2018 NASEM (National Academies of Sciences, Engineering, and Medicine) reports that more frequent e-cigarette use may increase the likelihood to quit The truth Initiative org
3. Dual Use People can experience a period when they use both products while transitioning In 2015, almost 60% of e-cigarette adult users smoked combustible cigarettes in parallel. CDC MMWR, 2016
â&#x20AC;&#x153;Dual use was also associated with poorer general health and greater breathing difficulty in the past month compared to those who smoked only cigarettesâ&#x20AC;? Wang et al, 2018 On average dual users smoke one more cigarette than the combustible cigarettes smokers ( per day)
E-cigarettes can be seen as a cessation tool, but also a gateway to smoking and young people are taking up the habit
3. The gateway to smoking?
Teen e-cigarette users are more likely to start smoking combustible tobacco: 30.7% of users started smoking within 6 months while 8.1% of non-users started smoking. Through aggressive marketing of e-cigarettes, 7 in 10 teens are estimated to be exposed to e-cigarettes ads
This is called the â&#x20AC;&#x153;replacement generationâ&#x20AC;?
4 Marketing tactics & products
4. Marketing campaigns Themes: freedom, feel healthier, smart, pure & fresh, sweet flavours, glamour, tech, social, money-saving, eco-friendly, sports, celebrities, etcâ&#x20AC;Ś
Visit also : Stanford University Research into the Impact of Tobacco Advertising
4. Rise of e-cigarettes use as advertising grows
4. Products availability + 450 types of e-cigarettes • High tech design • Can be charged on USB port with monitoring functions such as the number of puffs and time of use • Colourful with glitters • Refillable • Customizable
4. e-liquids flavours Similarities with food products?
+15 000 flavours targeting: • Young people with gummi bear, oreo, pop-corn, skittles, fruit loops,… • Ex-smokers with tobacco, bourbon, cigar, mint… But that is one aspect of marketing…
4. The old book with a brand new shiny cover
Visit also : Stanford University Research into the Impact of Tobacco Advertising
4. The old book with…modern tools
14 JUUL-related Instagram accounts (feb 2018) Huang et al, 2018 • One official account with 32’000 followers • Other accounts: 4230 posts 278’172 followers 22’613 following 112’861 JUUL-focused hashtags (15 FEB 2018) th
JUUL related tweets
106’000 JUUL-related videos as of March 2018 35 videos had >100’000 views. These 35 videos had 8 300 000 views, with 51’294 likes and 5’808 dislike 20 videos were about “product reviews”
4. Where can you see e-cigarettes ads?
Source: Truthinitiative.org
4. “Unsmoke” Campaign These last months PMI declared:
Net revenue 2018, 29.6 Bn US$ 3.4% growth mainly driven by iQOS in the European region Heated Tobacco Units sales target in 2021 is 90-100 Bn PMI financial report
One HEETS pack is 20 sticks, ~8 CHF
Make smoking negative but not tobacco itself…and invested ~1 Billion US$ over 12 years in the Foundation for a Smoke-Free World
5 Economics
5. Market
The market is now estimated to be 22.6Bn USD with 3 main markets: USA, Japan and UK BBC and Euromonitor International
PMI, Japan Tobacco International, British American Tobacco, Imperial brands, etcâ&#x20AC;Ś The whole Tobacco Industry has developed or invested in e-cigarettes
5. Market forecast
The market is estimated to grow rapidly with a forecasted CAGR (compound annual growth rate) of 17-23.8% during the 2017/9-2024 period P&S Intelligence, Allied market research and Grandview Research
Major Players: Philip Morris International, British American Tobacco, Altria Group, Japan Tobacco, Imperial Brands, JUUL Labs, NJOY, Turning Point Brands, Vapor Hub International, FIN Branding Group, Shenzhen iSmoka Electronics, Shenzhen IVPS Technology Corporation, Innokin Technology, Shenzhen Kanger Technology
5. Example: JUUL
U.S. based start-up in the silicon valley. Arrived in 2015 on the market. Number #6 start-up behind Uber and Airbnb in October 2018. Get more than 73% of the market shares today. Forecast is 3.4 Billion US$ income for 2019. 35% was purchased by Altria (PMI in US) for 12.8 Bn US$ in Dec 2018 A starter kit costs 49.99$, and a pack of 4 flavours is 15.99$. Modular not refillable.
The company was caught advertising to the youth, and had to change their marketing strategy but way after having reached a market monopoly position
The term vaping is being replaced by â&#x20AC;&#x153;Juulingâ&#x20AC;? in the US
5. What is the targeted market?
Geneva, June 2019
Push for cessation tool? Marketing seems to say â&#x20AC;&#x153;YESâ&#x20AC;? Does JUUL can be considered as a Nicotine Replacement Therapy (NRT)? Therapies like patches or nicotine gums, but needs medical agencies approval, with data coming from clinical trials.
5. Clinical trials Completed or recruiting clinical trials: For e-cigarettes: 242 studies as of 17th June 2019 worldwide. 39 funded by industry.
“Clinical Study Comparing 7 ENDS Products and 1 Combustible Cigarette Using 2 Delivery Methods.” sponsored by JUUL labs “Heated Tobacco Products vs Electronic Cigarettes” sponsored by PMI “A Study of Blood Levels of Nicotine Following an Electronic Cigarette” CN creative (e-cig and NRT manufacturer, acquired by British American Tobacco in 2012) E-cigarettes manufacturers and tobacco industry are putting millions in R&D and trials, but for what?
Source: Clinicaltrials.gov
6 Regulations & Policy
6. Regulations E-liquids package must display warning signs about nicotine.
Tobacco sticks must warn against tobacco effects
But nothing related to harmfulness of e-liquid components
Regulations depend on the national contexts
6. Regulations Should excise taxes, public use bans, and marketing restrictions be applied to e-cigarettes, and to what degree? • Multiple Members of the European Parliament raised their voices against e-cigarettes to dismiss them as a cessation tool or qualify them as tobacco products • Globally 36 countries ban e-cigarettes sales or ban sale of nicotine containing e-liquids Thetobaccoatlas.org
• “There are 98 countries that have national/federal laws regulating e-cigarettes including laws related to the sale (including minimum age), advertising, promotion, sponsorship, packaging (child safety packaging, health warning labelling and trademark), product regulation (nicotine volume/concentration, safety/hygiene, ingredients/flavours), reporting/notification, taxation, use (vape-free) and classification of e-cigarettes” Globaltobaccocontrol.org
6. A cost effective measure: Taxation
Excise tax on tobacco products has shown to be a cost effective intervention to decrease tobacco use Article 6 - Price and tax measures to reduce the demand for tobacco WHO FCTC
Jha et al., 2014 NEJM
In the European Union, e-cigarettes are not covered by excise tax as a tobacco product. It is suggested that member states could apply excise tax nationally. As of January 2018, 9 countries within EU applied excise tax on e-cigarettes (Italy, Portugal, Romania, Slovenia, Latvia, Hungary, Finland, Greece and Croatia) European commission Report on the structure and rates of excise duty applied to manufactured tobacco
6. Policy and Advocacy The WHO FCTC “is an evidence-based treaty that reaffirms the right of all people to the highest standard of health…was developed in response to the globalization of the tobacco epidemic” WHO FCTC The report from the 7th Conference of the Parties, held in 2016, included a comprehensive summary of the position of the secretariat : “There is an urgent need to elucidate the range of relative risks when using the diverse ENDS/ENNDS devices and e-liquids, and about user behaviour compared to smoking and use of other nicotine products…” And recommended the following to the 180 state members: (1) (2) (3) (4) (5) (6) (7) (8)
Banning the sale and distribution of ENDS to minors; Banning the possession of ENDS by minors; Banning or restricting advertising, promotion and sponsorship of ENDS; Taxing ENDS at a level that makes the devices and eliquids unaffordable to minors; Banning or restricting the use of flavors that appeal to minors; Prohibiting by law the use of ENDS in indoor spaces or at least where smoking is not permitted; Reducing the risk of accidental acute nicotine intoxication by requiring evident/child resistant packaging for e-liquids and leak-proof containers for devices and eliquids and limiting the nicotine concentration and total nicotine amount in devices and e-liquids; Testing heated and inhaled flavourants used in the e-liquids for safety, and banning or restricting the amount of those found to be of serious toxicological concern.
SUMMARY Harmfulness Evidence shows respiratory and cardiac deleterious effects of the e-cigarette However, thereâ&#x20AC;&#x2122;s a lack of evidence on cancer onset cases.
Marketing It is clear that the tobacco industry and e-cigarettes manufacturers advertisement and marketing campaigns are very similar and uses the same tools to hook their customers
Regulations Thereâ&#x20AC;&#x2122;s not yet a consensus on the ecigarettes regulations. However, countries are working on harmonization of the laws (EU example).
Civil society organisations can work together with the help of the WHO FCTC to raise awareness on that issue, and end the ecigarette and HTPs epidemic.
Excise tax? Public Use ban?
It takes several years/decades for cancer to develop with combustible cigarettes
Advocacy
Marketing restrictions?
Should we take the problem at its origins/roots and prevent any potential detrimental effects on health, economies and environment?
Thank you
Yannick Romero, PhD Advocacy Networks Manager romero@uicc.org
www.uicc.org
Union for International Cancer Control 31-33 Avenue Giuseppe Motta, 1202 Geneva, Switzerland T. +41 (0)22 809 1811 F. +41 (0)22 809 1810 E. info@uicc.org www.uicc.org