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A Summary of the E-cigarettes Summit 2016

by Jasmine Khouja @jasmine_khouja

On the 17th November I attended the E-cigarette Summit 2016 at the Royal Society in London. The summit brought together researchers, policy-makers, smoking cessation services and industry members to hear about the latest research, developments and challenges in the e-cigarette domain.

The summit was a one-day event packed full of information with 20 fast-paced (10-20 minutes) talks and 4 panel discussions. My five take home points from the summit were:

  1. Communication

One point which was raised on multiple occasions was that good communication of the research into e-cigarettes is key to the public understanding the risks and benefits of e-cigarette use. Unfortunately, the consensus was that the communication of e-cigarette research to the public is poor. Astonishingly, one speaker commented that someone had asked their daughter: “Is your dad still selling e-cigarettes and killing people?” This demonstrates how badly e-cigarettes have been portrayed, despite general consensus that they are much less harmful than cigarettes. Researchers are trying to communicate their research but face hurdles; some journals may be less likely to publish articles that are positive about vaping, meaning that it is harder to publish evidence that vaping is not as bad for you as cigarettes. The media are also hampering researchers’ efforts as they prefer stories which are anti-vaping and sometimes draw inaccurate conclusions from the evidence, which makes for more interesting stories. However, effective communication of the research is possible: Professor Peter Hajek and Dr Alex Freeman provided some useful advice to researchers which included not inferring human risks from animal studies, ensuring risks are directly compared to those of smoking, being a trustworthy source by being competent, honest and reliable, and providing neutral information without recommendations allowing the public to make their own informed decisions.

  1. The British Medical Association’s Guidelines

Communication of the benefits and risks of e-cigarettes isn’t limited to publications and the media; doctors are being asked about e-cigarettes by patients. Despite the evidence that the research community has provided that e-cigarettes are less harmful than cigarettes, the British Medical Association are yet to update their guidelines to encourage smokers to switch to e-cigarettes. There seemed to be apprehension stemming from the lack of known long-term effects, despite the fact that we know there are vastly fewer and reduced amounts of toxicants in e-cigarettes compared to cigarettes meaning the likelihood of long-term effects as bad as or worse than smoking are extremely unlikely.

  1. Recent Research

Many new studies were presented but the study that really caught my attention was discussed by Dr Lynne Dawkins. Lynne provided evidence for increased puffing behavior when participants are given lower doses of nicotine in their e-cigarettes [1]. She concluded that inhaling more vapour to receive the same amount of nicotine exposes vapers to unnecessary amounts of toxicants. This is very topical as the regulations set out by the Tobacco Products Directive (TPD) which will be fully implemented by May 2017 limit doses to 20 mg/mL meaning that some higher dosage (36 mg/mL) users may expose themselves to extra toxicants to receive the levels of nicotine they need when the higher dosage product become unavailable in the next six months.

  1. The Tobacco Products Directive

The TPD provides some form of regulation for e-cigarette manufacturers and distributors. The inclusion of e-cigarettes in the TPD was controversial due to e-cigarettes not containing tobacco and the restrictive nature of the regulations which were seen as unnecessary by some users and industry members. Part of the regulations included the thorough testing of e-cigarette products to ensure they were safe and the publication of the contents (including toxicants) so that the public could make informed decisions. To my dismay, I was informed that the information submitted by the e-cigarette companies so far will not be made publically accessible for roughly six months due to a system error. I was also informed that compliance with the regulations was low and that age of sale restrictions in particular did not seem to be being enforced. The system and enforcement of the TPD in relation to e-cigarettes needs improving so that consumers can access the information which the TPD states they should have access to and to protect young people whose brain development may be adversely affected by consuming nicotine.

  1. New Systems

As restrictive as the TPD is, new products are still being developed. A new type of e-cigarette is emerging onto the market called pods. These devices are small and similar in size to older less effective designs of e-cigarettes (cigalikes) but have the power and nicotine delivery of the newer more effective tank systems. The sleek, compact designs combined with the improved nicotine delivery systems which prevent overheating (which is associated with harmful byproducts such as formaldehyde) are likely to be very popular. These systems can also record information on how the devices are used (how long individuals puff for and how many puffs they take etc.) which could provide essential information to researchers on how e-cigarettes are used in real life situations.

The day culminated in a key note speech by the Attorney General for Iowa, Tom Miller. He commended the UK’s focus on e-cigarette research and the general positive stance our public health officials have taken in terms of e-cigarettes. He concluded his speech by asking for help from the UK to bring the US up to the same standards.

References

  1. PMID: 27650300

New evidence on the effects of plain cigarette packaging in Australia

By Olivia Maynard @OliviaMaynard17 

This blog originally appeared on the Mental Elf site on 27th March 2015

Last week I was lucky enough to attend the 15th Annual World Conference on Tobacco or Health in Abu Dhabi. With both Ireland and the UK announcing in the weeks leading up to the conference that they would implement plain (or ‘standardised’) packaging of cigarettes, it wasn’t surprising that this was one of the conference’s hot topics.

One of the sessions that focused on plain packaging was organised by Professor Melanie Wakefield’s team at the Cancer Council Victoria in Australia. As the first country in the world to introduce plain packaging, Australian data on its real-world effectiveness is of keen interest to policy-makers worldwide.

These researchers published a supplement to the journal Tobacco Control last week, including 12 new studies on plain packaging in Australia (more details about each of the 12 studies and their methodologies are given at the end of this blog). The majority of these used a ‘pre-post’ methodology, which means that they assessed behaviours and attitudes to smoking before plain packaging was introduced and compared with these same attitudes and behaviours afterwards.

At their conference session, some of these studies were discussed in more detail, with one in particular (Durkin et al., 2015), which investigated the impact of plain packaging on quitting-related cognitions, catching my attention. This study seemed like the logical extension of my most recently published paper on plain packaging, which reports the results of randomising UK smokers to use either a branded or a plain pack of cigarettes for a day and measuring smoking behaviour and attitudes to smoking and quitting.

As I’ll discuss later on, it’s important that we use a range of methodologies, including laboratory based experiments (such as those I’ve conducted) and real-world investigations (such as those conducted by the Australian researchers) to investigate the possible impact of plain packaging.

Plain (or ‘standardised’) packaging would mean standardising the size, shape, colour and method of opening of all tobacco products.

Methods

Data for this study were obtained as part of a continuous cross-sectional telephone based survey. Participants were called twice, one month apart, first for a baseline survey and then for a follow-up. Participants were aged between 18 and 69 and all participants were required to be cigarette smokers at the baseline call.

All calls were made between April 2012 and March 2014 and participants were split into 4 groups according to when their two phone calls were made:

  1. Those who had both their baseline and follow-up phone calls before plain packaging was introduced
  2. Participants’ baseline call was made before plain packaging was introduced and their follow-up was during a transitional period where both plain and branded packs were available for purchase
  3. Baseline phone calls were made during the transitional period, whilst follow-up calls were made either during the transitional period or after plain packaging had been fully implemented (November 2012)
  4. Both baseline and follow-up calls were made within the first year of plain packaging being fully implemented

At both the baseline and follow-up stages, participants were asked about quitting related cognitions, micro-indicators of concern and quit attempts. Logistic regression was used to analyse the data and participants’ baseline scores were included as predictors for their follow-up scores (after accounting for potential confounders). Essentially, this means that follow-up scores between participants in the four groups could be directly compared, accounting for any differences at baseline. Responses from participants in Groups 2, 3 and 4 were compared with those of the participants in Group 1.

Results

In total, 5,137 participants completed both the baseline and follow-up calls. At follow-up, approximately 6% of participants across all groups had quit smoking. The following results were found for each of outcome measures:

Quitting related cognitions

  • No differences in thoughts about quitting, or plans to quit in the next month were observed between the groups. However, higher intentions to quit were observed among those in Group 3 as compared with those in Group 1

Micro-indicators of concern

  • Participants in Groups 3 and 4 were more likely to conceal their pack than those in Group 1
  • Those in Group 4 reported higher levels of stubbing out cigarettes early than those in Group 1
  • Higher rate of forgoing cigarettes were observed amongst participants in Group 2 than Group 1

Quit attempts

  • More quit attempts were reported among participants in Groups 2 and 4 as compared with those in Group 1

Given that results are likely to be closely scrutinised by researchers, policy makers and the tobacco industry, it is important to carefully consider their implications and not overstate the findings.

Conclusions

This study provides modest statistical evidence that plain packaging in Australia has increased micro-indicators of concern, increased quit attempts and increased some quitting related cognitions among smokers.

The authors describe the outcomes they measured in the current study as being ‘downstream’ from the more immediate effects of plain packaging, which they have found evidence for in their other studies. These include:

It is possible that more substantial changes in the downstream effects such as those measured in this study may take longer to emerge.

Plain packaging: putting these results in context

Investigating the impact of plain packaging in the ‘real-world’ using this pre-post technique has its limitations. Unlike the laboratory, the real-world isn’t tightly controlled and although the researchers tried to account for other factors which may have influenced the results, such as changes in the price of tobacco and other tobacco control measures such as mass media campaigns, it’s impossible to completely control for the effect of these, making causal interpretations difficult.

Obviously we cannot randomise whole countries to either introduce or not introduce plain packaging (which would address these limitations), and examine what happens to smoking prevalence in these countries. Studies like that by Durkin and colleagues are therefore probably the best that we can do in the real world. Moreover, no one piece of research will give us the full picture when it comes to the potential impact of plain packaging.

Although, on their own, these findings do not provide overwhelming support for a beneficial impact of plain packaging, when they are considered together with the other studies in theTobacco Control supplement, and with data from the Australian government (which this year reported record lows in tobacco sales and smoking prevalence) along with findings fromlaboratory-based experiments and surveys, the evidence looks more compelling.

Now that both the UK and Ireland have announced plans to introduce plain packaging in May 2016, with other countries likely to follow suit, it will be important to continue to monitor the longer-term impacts of this tobacco control measure, making use of the wide range of research tools and methodologies available to us.

Plain packaging will become

Links

Primary study

Durbin S, Brennan E, Coomber K, Zacher M, Scollo M, Wakefield M. Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: findings from a national cohort study with Australian adult smokersTobacco Control 2015;24:Suppl 2 ii26ii32 doi:10.1136/tobaccocontrol-2014-052058

Other references

Research papers included in the Tobacco Control plain packaging Supplement:

Two paper-based surveys of adolescents:

Six telephone survey-based studies:

One in-depth interview:

One analysis of tobacco retailer journals:

Two observational studies:

Conferencing in South America: A tale of cocaine, capuchins, cachaça and chupacabra

I have to admit, I’d been a little apprehensive about this trip. This was the first time I’d visited South America, let alone solo, and since that initial invitation to present arrived in my inbox a little over a month ago, my head had been filled with cautionary tales from everyone with whom I’d shared my travel plans.

Now, on the penultimate day of my visit to Belo Horizonte, I can honestly say I am devastated to be leaving. Despite my eleventh hour travel and lodging arrangements and sparse audience (problems exacerbated, or indeed caused, by my woefully inadequate grasp of Portuguese), I can honestly say that I’ve never before had such a rich and eye-opening conference experience.

favela

This has been nothing like the traditional, slick, and sanitised Western conference experience to which I’ve grown accustomed. The programme was no more than a loose hint at timings (Brazilians, I have learned, are very relaxed about punctuality), posters were strung wildly with (what appeared to be) repurposed wire coat-hangers, and there were no lavish spreads of patisseries and exotic teas during symposium breaks (that is not to say, of course, that Brazilian cuisine is lacking – more on that later).

What there was, however, was a gathering of incredibly hospitable and astute neuroscientists, all with a keen interest in a shared cause – drug abuse. A carefully selected programme of speakers, hailing from multiple continents and disciplines, presenting cutting-edge science, was matched by an equally impressive daily schedule of cultural events. These included a moving performance from Orquestra Jovem de Contagem. This is an orchestra of children hailing from the very poorest areas of the city (the favelas), tutored and directed by a Professor of Music at our host institution, the Universidade Federal de Minas Gerais. Their forthcoming US tour stands testament to their talent.

But enough of the conference. I learnt more outside of the classroom. I spent one evening with my hosts at a beautiful local restaurant discussing Brazilian drug culture and political corruption, being treated to traditional Brazilian cuisine. I sampled my first (and second and third) caipirinha(s). I stayed up until the early hours with six wonderful Professors kind enough to tolerate my naive (but enthusiastic) ramblings, ensconced in an impassioned discussion of science and policy. I was driven to the beautiful Inhotim Institute, a botanical garden and contemporary art gallery, and to Ouro Preto (“Black Gold”), an 18th century mining town famous for its exquisite Baroque architecture, by three American Professors sweet enough to take me under their wing for the week.

Inhotim

 

I was struck by the immediate contrast between first and third world, painfully apparent on even the shortest journey through this city. I watched wild capuchins play in the rafters of a local restaurant, drank freshly pressed sugarcane juice (delicious) and coconut milk (less enjoyable –see picture) by the roadside, and cycled up russet-red dirt tracks into the mountains encircling the city to greet a sunset never to be paralleled. And there may or may not have been a sighting of a chupacabra. Oh, wait, a capybara.

coconut milk

If you’ve persevered through my confused ramblings this far, thank you. If you’ve skipped ahead to what appears to be the concluding paragraph, nice work. It is. So here I sum up: This trip has taught me two things, which I hope to share. Firstly, don’t limit your travel to the ‘Western’ world – you’ll be missing out, you just don’t know it yet (I didn’t). Secondly, embrace opportunities to travel to conferences alone – you’ll make so much more of the experience, and meet so many more people, when pushed outside of the comfortable and familiar. Frederico, David, Colin, Bob, Monica, Sarah, Yael, Analice, Ricardo, Reinaldo – if you happen to stumble upon this, thank you for making my time in Brazil such an incredible and memorable experience. I can’t wait to see you all again. Finally, I want to thank our TARG Prof, Marcus, for very generously letting me travel in his place. This was an incredible opportunity. I hope you enjoyed the cachaça!

caipirinha

 

Obrigado por ler!

 

This article is posted by Jen Ware