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E-Cigarette Summit - Prof. Robert West

Chair: Our next speaker this morning is Professor Robert West who is Professor of Health Psychology and Director of Tobacco Studies at University College, London, who I think is going to give us a talk from his Smoker’s Toolkit Data from England and a more fine grained analysis of use, so thank you, Robert.


Prof West: Thanks very much indeed. Well, I think we’ve started the day with an excellent presentation which really summarises where we stand in the field, but it’s a very fast moving area as Lynne says, not only in the rate at which the products are developing but also in the population level data on what people are doing and how much they are using. So I just want to spend a few minutes talking to you about where we stand in England, where we’ve probably got the best data in the world on this, as of this month.


I’ll start with my declarations of competing interests. I do – my salary is covered by Cancer Research UK. I do do research and consultancy for companies that make smoking cessation products and I’m a Trustee of QUIT for charity.


The data I’m going to present to you is an on-going survey and we put the results up on the website which is at the bottom of the slide every month, so if you want to update your information after this talk every month we will keep doing that and we will keep doing that for the next three or four years at least. They are monthly household surveys; each sample is about 1800 people of whom about 450 are smokers or recent ex-smokers by which I mean they have smoked in the last year. I’m going to present you data which is aggregated quarterly since the second quarter of 2011 and the methods of this study are described in this paper by Jenny Fiddler which is open access and is in a journal called BMC Public Health.


So, where do we stand on the actual prevalence of use of electronic cigarettes in England, and what you see is a continued and pretty steady rise with something like 15 or 16% now of people who are last year smokers, either current smokers who stopped in the last year and using electronic cigarettes of some form, and approximately 10% using them daily. So you can see there is actually quite a large gap between the proportion of people who are using them and the proportion of people who use them every day, and that’s not something that you see with cigarettes; with cigarettes typically almost everyone who smokes in this country is a daily smoker. That’s not true throughout the world; in America there’s quite a lot of non-daily smokers but in this country not many.


If we look at the amount of electronic cigarette use, you can see that the modal amount is 2 – 5 a day and it’s slightly higher in ex-smokers, recent ex-smokers, than it is in smokers which is what you would expect because the recent ex-smokers cigarette and an electronic cigarette. But you can see there’s actually quite a few people in the population who are using them either weekly or less than weekly. Bear in mind that the average daily cigarette consumption is about 12 or 13 a day in this country so the usage of e-cigarettes is considerably lower than the use of actual cigarettes in terms of amount per day.


If we look specifically at the use of these products while still smoking, primarily for cutting down smoking or in situations when you are not allowed to smoke, what you can see there if you look at the green line first of all is the steady rise that I’ve already shown in electronic cigarette use, and the blue line shows what’s happened to licensed nicotine products for this purpose, and you can see that whereas the electronic cigarette use has gone up quite a bit the use of licensed nicotine products hasn’t really gone down very much at all, and what that means is that if you look at the red line that there’s now a lot more use of nicotine while still smoking to help you cut down or in situations where you are not allowed to smoke than there has been, and this rise looks pretty steady and is likely to continue. So what electronic cigarettes have done in this part of the market is to grow the market. Now this is not necessarily a bad thing; in fact, some of us think it’s a good thing because NICE recently reported in its public health guidance that the use of licensed nicotine products for cutting down if you are not ready to stop straightaway is actually likely to promote cessation later, so it’s a useful harm reduction technique.


If we look at, however, the prevalence of nicotine products in recent ex-smokers which is primarily for people wanting to stop, you see a slightly different pattern. You see the numbers are smaller and therefore you get more of a jitter around the quarterly figures, but what you see is that electronic cigarette use has gone up pretty markedly since 2011, currently standing at around 35% of recent ex-smokers using electronic cigarettes, while the use of licensed nicotine products has gone down, and so the overall effect on nicotine products has not changed very much at all.


So if we look at that specifically in the most recent quit attempt you can see a somewhat similar pattern, so you can see the meteoric rise of electronic cigarettes used by people trying to quit in the most recent quit attempt last year with more than 30% of quit attempts now involving the use of electronic cigarettes. You see that this has just overtaken nicotine replacement therapy bought over the counter which has gone down a bit, not very much but a bit, and that drugs such as Champix and the use of behavioural support and nicotine replacement therapy obtained on prescription has gone down significantly over that period. Now, that would be worrying to me, I think, something we can discuss this afternoon, if it were the case, and it may well be, that what we are seeing here is people substituting a way of stopping which may be effective but may not be the most effective way of stopping for one that is the most effective way of stopping and has a huge evidence base for it which is the NHS stop smoking services, which is where you get behavioural support and medication. So we need to keep an eye on that.


Concern has been raised about whether introducing electronic cigarettes into this market will reduce motivation to quit smoking altogether because people think, well, I can use an electronic cigarette when I want to do that, and that allows me to carry on smoking in situations where I’m allowed to smoke, and I’ll just mix and match. And what you can see from this slide is that, if anything, there has been a slight increase in motivation to quit over the period when there has been this huge rise in electronic cigarette use, so there’s no evidence at all that electronic cigarettes being brought onto the market has undermined motivation to quit so far. And this is shown as well with behavioural tests, the ultimate behavioural test which is whether people are trying to quit, which has stayed roughly the same quarterly at around 15%.


If you look annually, you actually see a significant rise in the rate at which people are trying to quit, but aggregated quarterly it doesn’t quite show up although it is actually statistically significant, these are very large samples.


In fact, if you look at quitting defined in terms of people who have smoked at some point in the last year but now say that they no longer smoke we are seeing a significant increase in population rates of quitting in the last couple of years. So if there is a problem in terms of undermining quitting, it’s not really showing it, quite the opposite in fact.


And then I just want to finish by looking at the prevalence of nicotine use. One of the things that I suspect is true, I can imagine it would be true for any commercial organisation that is involved in manufacturing cigarettes and nicotine products, is that they might want to grow the market for nicotine, for example, by taking a bit of a hit on cigarettes but actually more than compensating for that by growing the market for the nicotine non-cigarette nicotine devices. In public health terms, we could have a discussion this afternoon about what the impact of that would be, but we’re just going to start to look at it now so we’re getting effectively base line data. And what you can see is that the prevalence of cigarette smoking over the period that we’ve been looking at it has gone down, that’s the green line, that has actually – even in that short time period, a significant decrease. It doesn’t look like very much but over this time period you don’t get huge decreases. If you can get a decrease in cigarette prevalence in this country of 1% point a year then you can save in the long term 3000 lives a year, so these are not – the numbers may be small in terms of prevalence but in terms of peoples’ lives they are quite substantial. But what we notice is just in the last year a little bit of clear water emerging between the total prevalence of nicotine use and the use of smoked tobacco. So it’s possible, and we will clearly need to keep a close eye on it, that the total nicotine market may be declining more slowly than the market for cigarettes and may even increase. As I say, this is something that one will have to discuss in terms of the public health impact given what we know about nicotine versus tobacco safety.


And then if we try and gauge from the data that we’re getting from the smokers and users themselves what the total market looks like for nicotine and cigarettes, what I’ve done in this slide is take a bit of a liberty which I need to take because whereas with cigarettes you can count the number of cigarettes per day, doesn’t tell you necessarily how much nicotine people are taking because people are taking different amounts of nicotine from each cigarette, but at least you can count how many cigarettes they’ve smoked a day. With e-cigarettes, it’s more difficult because a lot of the time the e-cigarette users will use one in the whole day but that one is equivalent to a whole day’s worth of smoking. So treat these figures with some caution. What I’ve tried to do is to compartmentalise the electronic cigarette users, the people who are using these and not smoking, into those who use less than on a week, those who use weekly, and those who use daily, and if they say they use daily I’ve just counted how many they say they use a day so it’s probably an underestimate. But even with this very crude way of looking at it, you can see, I think, that we are beginning to see a specific market emerging for e-cigarettes, and this may be among people who are going to use it for a relatively short period of time by which I mean months or even possibly a few years or weeks, or it may be that we’re beginning to see a market of long term nicotine use. It’s very early days but at least we are starting to college the base line data.


So, where do we stand as of this month in England? An estimated one in six smokers and recent ex-smokers use electronic cigarettes, and about one in ten use them daily. It’s now the case that almost one in three quit attempts involves the use of an electronic cigarette and that’s quite an astounding transformation over a very short period of time. There has been a decrease in the use of other aids to smoking cessation and particularly prescription medications and use of behavioural support. And motivation to stop has increased slightly, it hasn’t gone down. And the quit rates have increased. So the ultimate test here is whether people are not smoking, that’s really the thing that matters more than anything else, and on that front the news is good. Per capita cigarette consumption has shrunk but per capita consumption of all nicotine products appears to have shrunk less. It has still shrunk but it has shrunk less. Thank you. [Applause]

Chair: Thank you very much, Robert, another excellent overview of what’s going on with e-cigarette use in England. Now, we have actually got a little bit of time before our next allocated speaker. So has anybody got any questions for Robert based on what you’ve just heard? I think – I hope we’ve got some roving microphones… have we got any roving microphones? I saw somebody here with a hand up and then somebody over there.

Clive Bates: Robert, Clive Bates. Is it right to talk about the use of e-cigarettes as quit attempts using the language of smoking cessation and giving up and everything? Isn’t it a completely different behaviour in which people are substituting the experience of using an e-cigarette for smoking and doing something rather different?

Prof West: I think time will tell and that must be true for at least some people who are using e-cigarettes, but the data at the moment on people who are using e-cigarettes is that overwhelmingly they are using them to stop smoking. Now, one can use all sorts of different terms to describe the experience and, of course, being a dyed in the wool smoking cessation researcher I revert to the terminology that I’m used to. I’m perfectly happy for people to use a different terminology like substituting or taking up some other behaviour, and we’ll see how it goes. If I read into your question a slight concern that my medical model of this and public health model may in some way dampen down the market for what may be a huge public health boom. I think that the evidence so far suggests that people don’t care what I think. [Laughter]

Chair: Okay, just a reminder please to say where you are from. Clive is actually on the programme and he is a public health commentator down here.

Riccardo Polosa: University of Catania, Italy: I do care what you are saying, Robert. I think trying to bring together your talk and Lynne’s talk would be very interesting to try in the sector to what kind of e-cigarette usage is in your data. So there’s a plea to try and include in your questionnaires whether you’re using sort of different cessations for cigalikes versus second generation, because the picture will change dramatically, and many vapers in the room will know that.

Prof West: It will, and we do have other data from a study that Ann is leading on and Jamie Brown, and hopefully there will be a paper published soon on this, looking at the types of brands that are currently being used, and the dominant brand from the smoker’s perspective that we are hearing is E-Lites at the moment which is I think you would consider a first generation product.

Chair: That was November last year.

Prof West: That was November last year. We’ve got another one coming out – being done this year.

Chair: Yes, in the field very soon.

Sue Wilson: Thanks very much. Sue Wilson, University of Birmingham. I think my question really follows on from the first comment that I think it’s difficult to talk about people who use electronic cigarettes as one complete group, and there are people, as you say, who want to use them to quit smoking cigarettes but it’s potentially that there’s a much larger group of people who didn’t want to give up smoking but have substituted using an electronic cigarette for smoking, and that group have got no intention of ever stopping using the electronic cigarette, and that’s why potentially you’ll see the use of nicotine stays stable or not fall as much as actual smoking.

Prof West: I think that may happen in the future and clearly there is – that group does exist in the population at the moment, but we do ask what lead you to start using an electronic cigarette in the first place and I think from Ann’s and Jamie’s study it was about 85% said that it was to stop smoking. Of course, the way you’ve phrased the question can make a difference so I completely agree that a deeper exploration of what is going on would be helpful and things may change in the future.

Chair: I can see one more question and then we’ll move on, just here at the front, thank you.

A Coghlan: Andy Coghlan, New Scientist. What evidence has there been so far or comparing e-cigarettes with the patches and nicotine chewing gum and so on that are already cleared as products as quitting aids, what sort of comparisons are we getting there? Are e-cigarettes as good or better than those? Prof West: Well, I don’t know if you were here for – you might not have been here for Lynne’s talk earlier, because Lynne described there are a couple of randomised trials. Do you want to just say something, Lynne?

Dr Dawkins: Yes, I don’t know if you heard my talk, Chris Bullen’s study in New Zealand was a large randomised controlled trial of over 600 smokers who were allocated to either the 21mg nicotine patch or a nicotine or a placebo cigarette. The quit rates at six months were fairly similar, slightly higher but not statistically higher, in the nicotine e-cigarette group compared to the patch.

Prof West: I should say to add to that, Clive will probably say it later on, there is an issue about whether our classic randomised control trial methodology is going to work very well – service very well in this field, and partly because of the reasons that Lynne talked about which were that by the time you’ve finished your RCT, got the funding and so on, you are testing an outmoded product. but also, and this is something that I think is increasingly true for a lot of the things that I have to deal with, you are not – it’s not like a pill where you’ve got one thing and you can randomly allocate people who don’t care whether they get the pill or the placebo or they’d probably rather get the pill, some would rather get the placebo… It’s very, very difficult. I think we’re going to have to rely more and more on real world type studies, quasi experimental studies and the sort of things that we do with the Smoking Toolkit Study which is to look at a population level as to whether people using these things are more likely to stop. You can’t fully control for all the confounders but you can do quite a job, and you can test that methodology. And we will be reporting early next year on our findings relating to whether using that methodology e-cigarettes are shaping up well or badly, so you’ll have to watch this space.

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