A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products

A Review of Pulmonary Toxicity of Electronic Cigarettes in the Context of Smoking: A Focus on Inflammation

The use of electronic cigarettes (e-cigs) is increasing rapidly, but their effects on lung toxicity are largely unknown. Smoking is a well-established cause of lung cancer and respiratory disease, in part through inflammation. It is plausible that e-cig use might affect similar inflammatory pathways. E-cigs are used by some smokers as an aid for quitting or smoking reduction, and by never smokers (e.g., adolescents and young adults). The relative effects for impacting disease risk may differ for these groups. Cell culture and experimental animal data indicate that e-cigs have the potential for inducing inflammation, albeit much less than smoking. Human studies show that e-cig use in smokers is associated with substantial reductions in blood or urinary biomarkers of tobacco toxicants when completely switching and somewhat for dual use. However, the extent to which these biomarkers are surrogates for potential lung toxicity remains unclear. The FDA now has regulatory authority over e-cigs and can regulate product and e-liquid design features, such as nicotine content and delivery, voltage, e-liquid formulations, and flavors. All of these factors may impact pulmonary toxicity. This review summarizes current data on pulmonary inflammation related to both smoking and e-cig use, with a focus on human lung biomarkers. Cancer Epidemiol Biomarkers Prev; 26(8); 1175-91. ©2017 AACR.

E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys

Objective To examine whether the increase in use of electronic cigarettes in the USA, which became noticeable around 2010 and increased dramatically by 2014, was associated with a change in overall smoking cessation rate at the population level.Design Population surveys with nationally representative samples.Setting Five of the US Current Population Survey-Tobacco Use Supplement (CPS-TUS) in 2001-02, 2003, 2006-07, 2010-11, and 2014-15.Participants Data on e-cigarette use were obtained from the total sample of the 2014-15 CPS-TUS (n=161 054). Smoking cessation rates were obtained from those who reported smoking cigarettes 12 months before the survey (n=23 270). Rates from 2014-15 CPS-TUS were then compared with those from 2010-11 CPS-TUS (n=27 280) and those from three other previous surveys.Main outcome measures Rate of attempt to quit cigarette smoking and the rate of successfully quitting smoking, defined as having quit smoking for at least three months.Results Of 161 054 respondents to the 2014-15 survey, 22 548 were current smokers and 2136 recent quitters. Among them, 38.2% of current smokers and 49.3% of recent quitters had tried e-cigarettes, and 11.5% and 19.0% used them currently (every day or some days). E-cigarette users were more likely than non-users to attempt to quit smoking, 65.1% v 40.1% (change=25.0%, 95% confidence interval 23.2% to 26.9%), and more likely to succeed in quitting, 8.2% v 4.8% (3.5%, 2.5% to 4.5%). The overall population cessation rate for 2014-15 was significantly higher than that for 2010-11, 5.6% v 4.5% (1.1%, 0.6% to 1.5%), and higher than those for all other survey years (range 4.3-4.5%).Conclusion The substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level. These findings need to be weighed carefully in regulatory policy making regarding e-cigarettes and in planning tobacco control interventions.

Electronic cigarettes—A review of the physiological health effects

Electronic cigarettes (ECs) are devices that are used recreationally or as smoking cessation tools, and have become increasingly popular in recent years. We conducted a review of the available literature to determine the health effects caused by the use of these devices. A heating element in the EC aerosolizes a solution of propylene glycol, glycerol, nicotine (optional), and flavouring (optional). These compounds are generally harmless on their own. However, upon heating, they produce various carcinogens and irritants. We found that concentrations of these toxicants vary significantly depending on the type of EC device, the type of EC liquid, and the smoking behaviour of the user. Exposure to these vapours can cause inflammation and oxidative damage to in vitro and in vivo cells. EC aerosol can also potentially affect organ systems and especially cardiovascular and lung function. We concluded that EC use causes acute effects on health but not as severe as those of conventional cigarettes (CCs). These devices could, therefore, be of use for smokers of CCs wishing to quit. However, as EC aerosol introduces new toxicants not found in CCs, long-term studies are needed to investigate possible chronic effects associated with EC use.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

E-cigarette use, perceptions, and cigarette smoking intentions in a community sample of young adult nondaily cigarette smokers

E-cigarettes have been suggested as a strategy for reducing harm from cigarettes. Although e-cigarettes could be a less-harmful alternative to cigarettes for those trying to quit, there may also be costs that outweigh any benefits of reduction. The purpose of the present study was to prospectively investigate perceptions of e-cigarettes, cigarette smoking intentions, and their associations with e-cigarette use over time. Community participants (N = 348, 57% male) aged 18 to 24 years were recruited for a longitudinal study of tobacco use. Inclusion criteria included nondaily cigarette smoking for ≥ 6 months with no history of daily smoking. Participants reported e-cigarette use over the past 14 days at baseline, and for the past 9 days at 3, 6, and 9 months. Assessments were completed online or via mobile phone. Across the 4 assessments, 22% to 33% of participants reported recent e-cigarette use. Intent to quit smoking cigarettes and intent to maintain smoking were unrelated to e-cigarette frequency. E-cigarette frequency was positively associated with perceiving e-cigarettes as less harmful than cigarettes and more positive e-cigarette expectancies (ps < .05). E-cigarette use was also more frequent among those who smoked cigarettes frequently and who used e-cigarettes to circumvent cigarette bans more often (ps < .05). The combination of these findings suggests that, at least among nondaily smoking young adults, other factors may influence frequency of e-cigarette use more than harm reduction. Findings instead seem consistent with the hypothesis that e-cigarettes are more often used to complement ongoing cigarette smoking. (PsycINFO Database Record

A gateway to more productive research on e-cigarettes? Commentary on a comprehensive framework for evaluating public health impact

Commentary to: A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products

The need for a comprehensive framework

To facilitate individual and population-level behavior change, we need policies based on science. We must develop coherent policies that explicitly consider the benefits and risks of different classes of nicotine delivery products, rather than continuing the current ad-hoc approach which fails to adequately address the product itself.

Global approaches to regulating electronic cigarettes

Objectives

Classify and describe the policy approaches used by countries to regulate e-cigarettes.

Methods

National policies regulating e-cigarettes were identified by (1) conducting web searches on Ministry of Health websites, and (2) broad web searches. The mechanisms used to regulate e-cigarettes were classified as new/amended laws, or existing laws. The policy domains identified include restrictions or prohibitions on product: sale, manufacturing, importation, distribution, use, product design including e-liquid ingredients, advertising/promotion/sponsorship, trademarks, and regulation requiring: taxation, health warning labels and child-safety standards. The classification of the policy was reviewed by a country expert.

Results

The search identified 68 countries that regulate e-cigarettes: 22 countries regulate e-cigarettes using existing regulations; 25 countries enacted new policies to regulate e-cigarettes; 7 countries made amendments to existing legislation; 14 countries use a combination of new/amended and existing regulation. Common policies include a minimum-age-of-purchase, indoor-use (vape-free public places) bans and marketing restrictions. Few countries are applying a tax to e-cigarettes.

Conclusions

A range of regulatory approaches are being applied to e-cigarettes globally; many countries regulate e-cigarettes using legislation not written for e-cigarettes.

E-cigarette use among students and e-cigarette specialty retailer presence near schools

OBJECTIVE

This study examined the association between presence of e-cigarette specialty retailers near schools and e-cigarette use among middle and high school students in Orange County (OC), CA.

METHODS

The OC subsample of the 2013-2014 California Healthy Kids Survey (N=67,701) was combined with geocoded e-cigarette retailers to determine whether a retailer was present within one-quarter mile of each public school in OC. Multilevel logistic regression models evaluated individual-level and school-level e-cigarette use correlates among middle and high school students.

RESULTS

Among middle school students, the presence of an e-cigarette retailer within one-quarter mile of their school predicted lifetime e-cigarette use (OR=1.70, 95% CI=1.02, 2.83), controlling for confounders but no effect for current use. No significant effect was found for high school students.

CONCLUSIONS

E-cigarette specialty retailers clustered around schools may be an environmental influence on student e-cigarette experimentation.

Exploratory Analysis of Marketing and Non-marketing E-cigarette Themes on Twitter

Electronic cigarettes (e-cigs) have been gaining popularity and have emerged as a controversial tobacco product since their introduction in 2007 in the U.S. The smoke-free aspect of e-cigs renders them less harmful than conventional cigarettes and is one of the main reasons for their use by people who plan to quit smoking. The US food and drug administration (FDA) has introduced new regulations early May 2016 that went into effect on August 8, 2016. Given this important context, in this paper, we report results of a project to identify current themes in e-cig tweets in terms of semantic interpretations of topics generated with topic modeling. Given marketing/advertising tweets constitute almost half of all e-cig tweets, we first build a classifier that identifies marketing and non-marketing tweets based on a hand-built dataset of 1000 tweets. After applying the classifier to a dataset of over a million tweets (collected during 4/2015 - 6/2016), we conduct a preliminary content analysis and run topic models on the two sets of tweets separately after identifying the appropriate numbers of topics using topic coherence. We interpret the results of the topic modeling process by relating topics generated to specific e-cig themes. We also report on themes identified from e-cig tweets generated at particular places (such as schools and churches) for geo-tagged tweets found in our dataset using the GeoNames API. To our knowledge, this is the first effort that employs topic modeling to identify e-cig themes in general and in the context of geo-tagged tweets tied to specific places of interest.

Behavioral Economic Laboratory Research in Tobacco Regulatory Science

OBJECTIVES

Research that can provide a scientific foundation for the United States Food and Drug Administration (FDA) tobacco policy decisions is needed to inform tobacco regulatory policy. One factor that affects the impact of a tobacco product on public health is its intensity of use, which is determined, in part, by its abuse liability or reinforcing efficacy. Behavioral economic tasks have considerable utility for assessing the reinforcing efficacy of current and emerging tobacco products.

METHODS

This paper provides a narrative review of several behavioral economic laboratory tasks and identifies important applications to tobacco regulatory science.

RESULTS

Behavioral economic laboratory assessments, including operant self-administration, choice tasks and purchase tasks, can be used generate behavioral economic data on the effect of price and other constraints on tobacco product consumption. These tasks could provide an expedited simulation of the effects of various tobacco control policies across populations of interest to the FDA.

CONCLUSIONS

Tobacco regulatory research questions that can be addressed with behavioral economic tasks include assessments of the impact of product characteristics on product demand, assessments of the abuse liability of novel and potential modified risk tobacco products (MRTPs), and assessments of the impact of conventional and novel products in vulnerable populations.

Complying with the framework convention for tobacco control: an application of the Abridged SimSmoke model to Israel

BACKGROUND

The World Health Organization Framework Convention for Tobacco Control (FCTC) established the MPOWER policy package to provide practical country-level guidance on implementing effective policies to reduce smoking rates. The Abridged SimSmoke tobacco control policy simulation model is applied to Israel to estimate the effects on reducing smoking-attributable mortality resulting from full implementation of MPOWER policies.

METHODS

Smoking prevalence from the 2014 Israel National Health Interview Survey 3 and population data from the Israel Central Bureau of Statistics were used to calculate the number of current smokers. The status of current Israeli policy was determined using information from MPOWER 2015 and from local sources. Based on existing knowledge that between 50 % and 65 % of smokers will die prematurely from smoking, the model is used to determine mortality reductions among current smokers from full implementation of MPOWER policies.

RESULTS

We estimate that between 547 and 711 thousand smokers of the current 1.1 million Israeli smokers will prematurely die due smoking. Within 40 years, complete implementation of MPOWER policies is projected to reduce smoking prevalence among current smokers by 34% and avert between 187 and 243 thousand deaths. Taxes, smoke-free air laws, marketing restrictions and media campaigns each reduce smoking by about 5 % within 5 years. Improved cessation treatment and health warnings each have smaller effects in the next five years, but their effects grow rapidly over time.

CONCLUSIONS

Israel Abridged SimSmoke shows that complete implementation of the MPOWER strategies has the potential to substantially reduce smoking prevalence, and avert premature deaths due to smoking. Additional benefits are also expected from reduced morbidity, reduced initiation among nonsmokers, and reduction in exposure of nonsmokers to tobacco smoke.

Concurrent E-Cigarette Use During Tobacco Dependence Treatment in Primary Care Settings: Association With Smoking Cessation at Three and Six Months

INTRODUCTION

Electronic cigarettes (e-cigarettes) are being used as cessation aids by many smokers despite a lack of empirical evidence regarding their safety and efficacy. We analyzed the association of e-cigarette use and smoking abstinence in a population of smokers accessing standard smoking cessation treatment (nicotine replacement therapy [NRT] plus behavioral counseling) through primary care clinics in Ontario, Canada.

METHODS

Participants were recruited through 187 primary care clinics across Ontario, Canada and were eligible for up to 26 weeks of brief behavioral counseling and individualized dosing of NRT at no cost. Adjusted logistic regression models were used to examine the association between concurrent e-cigarette use and smoking abstinence at 3- and 6-month follow-ups.

RESULTS

Of the 6526 participants who completed a 3-month follow-up, 18.1% reported using an e-cigarette while in treatment. The majority of e-cigarette users (78.2%) reported using an e-cigarette for smoking cessation. At 3-month follow-up, e-cigarette use was negatively associated with abstinence after controlling for confounders (adjusted odds ratio [AOR] = 0.706, p < .001, 95% confidence interval [CI] = 0.607-0.820). E-cigarette use was also negatively associated with abstinence at 6-month follow-up (AOR = 0.502, p < .001, 95% CI = 0.393-0.640).

CONCLUSION

E-cigarette use was negatively associated with successful quitting in this large community sample of smokers accessing standard evidence-based smoking cessation treatment through primary care clinics, even after adjusting for covariates such as severity of tobacco dependence, gender, and age. The findings suggest that concurrent use of e-cigarettes with NRT may harm cessation attempts.

IMPLICATIONS

This study confirms previous findings from observational studies regarding the negative association between e-cigarette use and smoking cessation, but in a large cohort of smokers enrolled in an evidence-based treatment program. The implications of these findings are that concurrent use of e-cigarettes during a quit attempt utilizing cost-free evidence-based treatment (NRT plus behavioral counseling) does not confer any added benefit and may hamper successful quitting.

Design and methods of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND

This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administration's (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat.

METHODS

The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Study's design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use.

CONCLUSIONS

The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDA's regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nation's burden of tobacco-related death and disease.