Prof Jean Francois Etter. Professor of Public Health University of Geneva

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1 Prof Jean Francois Etter Professor of Public Health University of Geneva

2 Product diversity, user behavior, players in the e-cig market Prof. Jean-François ETTER, PhD Faculty of Medicine University of Geneva, Switzerland E-cigarette Summit, London November 13, 2014

3 Conflicts of Interest Tobacco industry: - never received any funding, no CoI Pharmaceutical industry - no funding in past 8 years, no CoI E-cigarette industry - plane ticket + hotel (London + China, 2013) - no honorarium

4 3 broad types of e-cigarettes, but no distinction is made in many sales statistics, user surveys Cig-alike: Mods: Tanks, vaporizers:

5 Speed of nicotine delivery to the blood: 1 st generation e-cig, 2 nd generation e-cig, tobacco cigarettes Source: Farsalinos et al Sci Rep. 2014; 4: 4133

6 Machine tests: depending on puff conditions and product features, ECIG can provide far less or far more nicotine than a tobacco cigarette (50-fold variation). Talih et al. Nicotine & Tobacco Research, Sept 2014

7 E-cig global sales, $ million 2014: probably $5 billion <1% of tobacco cigarette market USA China International (source: Philip Morris)

8 Percent of smokers and recent exsmokers England: prevalence of electronic cigarette use: smokers and recent ex-smokers Growth in prevalence of e-cigarette use has not increased since Q Any Daily N=14490 adults who smoke or who stopped in the past year; increase p<0.001 Source: STS - Smoking Toolkit Study 8

9 = cig-alike

10 USA: dollar share by company: convenience stores and XAOC = expanded all outlets combined (Nielsen bar code data) Reynolds NJoy Lorillard Logic Altria

11 UK e-cigarette retail market share (%) Total U.K. retail market, including U.K. Major Multiples, Household, Impulse and Chemist Channels, 52 weeks ending Sept Source: Wells Fargo UK Ecig Group (FIN, VIP, Ten Motives) Nicocig - PMI E-Lites - Japan Tob Halco blu - Lorillard Gamucci BAT Vapouriz Dekang NJOY Vapourlites Supreme Imports Other

12 Tobacco company Brands of e-cigarette / vaporizers Altria MarkTen Green Smoke Reynolds + Lorillard, merged July 2014 Vuse SkyCigs Imperial Tobacco Blu (sold by Lorillard) Puritane + intellectual rights on Dragonite Japan Tobacco Ploom (tobacco vaporizer) E-Lites Philip Morris Nicolite iqos (heat not burn) + partners with Altria / MarkTen British American Tobacco Vype Intellicig (CNCreative) Voke (Nicoventures) ITC (Imperial Tobacco Company of India) NTC (National Tobacco Company, distributor of Zig-Zag cig. paper) Eon V2 Cig

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14 New nicotine + tobacco vaporizers: no combustion of tobacco Nicotine vaporizers, without tobacco: 1. E-cigarettes (3 broad categories: cig-alike, tank, mod) 2. Nicotine vaporizer using the technology of asthma vaporizers VOKE (Nicoventures = BAT: British American Tobacco): 3. Nicotine pyruvate (chemical reaction that vaporizes nicotine, Jed Rose) (PMI: Philip Morris, under development) Tobacco vaporizers: 1. Heated tobacco products, «heat not burn»: - electric heating (e.g. iqos by PMI, Chinese models) - charcoal heating (ember) 2. Hot air flow - Nespresso-like cartridge (Ploom: distributed by Japan Tobacco) - loose tobacco (various brands of vaporizers)

15 iqos = Philip Morris heated tobacco product

16 = iqos Pharmacokinetics: Philip Morris iqos Same speed as tobacco cigarette

17 Voke = Nicoventures (BAT)

18 Voke: pharmacokinetics Delivery twice as quick as for Nicorette inhalator

19 Ploom: tobacco vaporizer commercialized by Japan Tobacco

20 Snus: first FDA application as reduced risk product (Swedish Match) For FDA registration as reduced risk product, applicant must show that: - the product is less harmful to the individual user - the total effect on the population is beneficial Very costly process, very long Will e-cig / vaporizers follow?

21 Philip Morris: 4 new reduced risk products iqos Coal ember Nicotine pyruvate E-cig cig-alike See presentation on PM Investor s day 2014:

22 Science + regulation are part of the tobacco industry s business model

23 Regulation: part of the tobacco industry business model

24 Tobacco industry involvement New situation: tobacco industry sells reduced risk vaporizers Science Huge investments in R&D on vaporizers ($2bn for PMI only) Regulation Intense lobbying (EU, US, nationally) Large numbers of experienced, professional lobbyists Long tradition, historically strong influence on tobacco laws Suspicion that aim of tobacco industry involvement in regulation is to:. avoid unfriendly rules. raise technical + legal barriers at entry in this market. eliminate (Chinese) competitors + small players

25 Tobacco industry: history Denied - that nicotine is addictive - risks of smoking - risks of passive smoking Produced bogus science Artificially created controversy, confusion Deception campaign to block smoking bans Will e-cig / vaporizers enable the tobacco industry to re-emerge as a legitimate stakeholder?

26 How to react to tobacco industry involvement? Science: Need for independent research, not just research conducted by tobacco industry + its subsidiaries If collaborations emerge between academy + industry, there is a need to define conditions / limits Transparency is crucial Follow example of guidelines for academic collaboration with pharma industry A framework is needed to manage conflicts of interest

27 Management of conflicts of interest Goals = protect the integrity of research, = preserve public trust Core principle = transparency Declaration of conflict of interest + registration of studies = insufficient Define policies, rules and restrictions, code of practice Rely on organizations / institutions that define + enforce + monitor these policies (national academy of sciences, ethics committees, etc.)

28 Perspectives New situation: are we prepared? We have no choice but to rethink academic + political interactions with the industries that produce nicotine + tobacco vaporizers Need for transparency Need to develop rules, policies Need for a debate involving all stakeholders