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2
June 2017 NZ Med J;130 (1456)
Tobacco
consumption down 41%, cigarette prices up 230%: lessons
from 1985-1988: Life expectancy rises 3.6 years for
men.
Murray Laugesen and Randolph
C. Grace
New
Zealand men are living much longer due to giving up
tobacco smoking in the 1985–1995 period. Diet
had an improving effect. In 1988, men were living
3.6 years more than 10 years before, and women 2.8
years more. That is equal to three months gain in
life per person over these 10 years. Most of the effect
has benefited men. Tobacco consumption per adult fell
by 41% in these 10 years. To do that, the price of
cigarettes went up 230%, and we started eating more
vegetables and fruit and a variety of polyunsaturated
fats.
Aim. We compared
changes in tobacco consumption and diet in relation
to changes in life expectancy in 1988–1998 in
22 OECD (Organisation for Economic Cooperation and
Development) countries.
Method. Between
1985 and 1995 using regression analysis we estimated
differences in tobacco consumption per adult and the
differences in the sum of atherogenic and thrombogenic
indices against life expectancy. Each index was derived
from the various fats per gram of food from standard
texts, and from the annual measurements of fat in
the food balance sheets of each country.
Results. In
1985–1995, New Zealand showed the largest decrease
in tobacco consumption per adult (41%) and the greatest
decrease (except for Switzerland) in the sum of atherogenic
and thrombogenic indices (17%) as a measure of diet.
New Zealand ranked first for life expectancy increases
from 1988–1998 for men (3.6 years), women (2.8
years) and for both sexes combined. Regression analyses
revealed that increases in life expectancy across
the OECD for males, but not females, were strongly
associated with decreases in tobacco consumption,
with a weaker effect of diet improvement.
Conclusion. These
results suggest that reduced tobacco consumption in
1985–1995 likely contributed to New Zealand’s
gains in life expectancy from 1988–1998.
2 June 2017 NZ Med J 130 (1456) Reduced tobacco consumption,
improved diet and life expectancy for 1988-1998: analysis
of New Zealand and OECD data. The 3.6 years will be
included in an erratum submitted to the NZMJ.
6July 2017
End Smoking NZ
Submission to the
Inquiry into the Use of Electronic Cigarettes and
Personal Vaporisers in Australia
Who are we?
End Smoking NZ is an independent unfunded charitable
trust. Our members collaborate to conduct research
and provide up-to-date information to inform public
health policy and practice about reducing tobacco
smoking in New Zealand (NZ).
End Smoking as an organization has
no tobacco industry links, nor any commercial interest
in electronic cigarettes (e-cigarettes), or in nicotine
replacement therapy.
End Smoking NZ wasformed in 2006
to raise awareness of, and lobby for, the acceptance
of a harm reduction approach to reducing smoking-related
morbidity and mortality. At that time we advocated
for a law change to enable NZ smokers access to Snus.
Switching from smoking tobacco to
Snus has regrettably remained an option for Swedish
and Norwegian smokers only. Enviably, smoking prevalence
in Sweden has dropped to 5% - the rate of New Zealand's
2025 aspiration goal.
The lowered incidence of smoking-related
disease and life years saved in Sweden and Norway
is a buoy marking a lowered risk route all countries
could have followed. Instead, we in NZ and Australia
have let thousands of people continue smoking instead.
Tens of thousands of New Zealanders and Australians
have suffered longer and died earlier than they needed
to. The Swedish experience stands as a warning not
to make the same mistake again!
Our experience with electronic cigarettes
and vaping
Almost 10 years ago we began to investigate the potential
of e-cigarettes. Over the intervening years our members
have continued to conduct and support a range of studies
on e-cigarettes and vaping. On balance the evidence
has led us to become more convinced that e-cigarettes
present the first real threat to smoked tobacco.
E-cigarettes don't just have potential
as a smoking cessation tool, they can deliver the
Endgame.
Basic general points about electronic
vaporisers and vaping
1. E-cigarettes are not tobacco products.
2. Whilst nicotine is extracted from tobacco, or can
be synthesised, we do not consider nicotine liquid
produced for the purpose of vaping to fit the definition
of a tobacco product.
3. Electronic vaporisers are not
solely, nor necessarily, a smoking cessation device.
4. Electronic vaporisers were created
to be a safer alternative nicotine delivery device
compared to smoking tobacco products.
5. The use of nicotine replacement
products is well established as a safe practice.
6. Vaping nicotine is estimated to
be at least 95% safer than smoking tobacco. The estimated
risk is as low as many of the established nicotine
replacement products.
7. Millions of smokers worldwide
have found that vaping, with and without nicotine,
has enabled them to achieve sustained abstinence from
smoking tobacco. E-cigarettes are very clearly showing
their potential to significantly reduce smoking rates.
A significant proportion of these people go on to
stop vaping as well. Many others enjoy vaping and
have no intention to quit in the near future.
8. Vaping nicotine hasn't resulted
in sustained abstinence from smoking for all smokers
who have tried it. The devices have and continue to
vary greatly. Government restrictions are critical
to supporting or undermining switching from smoking
to vaping.
9. Other alternative nicotine delivery
products are in development, or are on the market
overseas. No one cessation product or alternative
nicotine delivery product will help every smoker either
switch off or abstain from smoking tobacco. A range
of products are required. We should not limit smokers
to just one type of e-cigarette or just one type of
greatly harm-reduced alternative to smoking product.
Tobacco control has irrevocably changed
with the introduction of greatly harm-reduced alternatives
to smoking tobacco, particularly the electronic nicotine
vaporisers. Smokers now have more alternatives to
smoking if allowed.
The huge difference between the alternative
nicotine delivery devices is that vaping nicotine
can (if allowed) provide an equal or better experience
than smoking tobacco. This is evidenced by the millions
of smokers who have already switched to vaping around
the world. Research shows clearly that the huge majority
of that use is for smoking replacement or for cessation.
Very few never-smokers use e-cigarettes.1
" Vaping, even with nicotine,
is likely to be less addictive than smoking tobacco.
There are good scientific reasons
from animal studies to suspect that e-cigarettes should
be less addictive than smoking , and some strong indications
from cessation trials and observational studies that
e-cigarettes will prove less addictive than smoking.
Smokers now have an option. They
can receive all of the benefits that they enjoyed
from smoking tobacco from a significantly less harmful
and probably less addictive behaviour.
New Zealand's position on e-cigarettes
and vaping
Following public consultation, the
NZ Government has opted to amend the Smoke-Free Environments
Act to permit and regulate the import, marketing and
sale of nicotine for vaping.
The NZ Ministry of Health is also
establishing an e cigarette product safety Technical
Expert Advisory Group. They are also progressing consultation
on what regulatory or other framework to use to determine
a NZ position on emerging tobacco and nicotine delivery
products.
Why Australia should support Australian
smokers to switch to vaping nicotine
Tobacco control policies have contributed
to reducing smoking rates in Australia. But, unacceptable
disparities in smoking prevalence by ethnicity remain.
Australian Indigenous and Torres Strait Islanders
have much higher rates of smoking than non-Indigenous
Australians. Some sub-groups, such as mental health
consumers also have disproportionately high smoking
rates.
We believe that nicotine liquid for
vaping and vaporisers should be legal to import for
sale and distribution in Australia.
Further, it would be unethical to
delay access to legal nicotine for vaping and instead
wait until the market provides pharmaceutically approved
nicotine containing e-cigarettes or other alternative
products. Vaporisers are already being used in Australia
by people who are trying to improve and protect their
health. The Australian society should help, not hinder,
this trend.
Australia and New Zealand have enjoyed
a history of alignment on our tobacco control programmes.
Since the 1980's, Australia and New Zealand have emulated
each other's policies resulting in both our countries
being seen to be world leaders in tobacco control.
Of relevance to your deliberations,
there are various trade and investment agreements
between Australia and New Zealand, such as the Australia
New Zealand Closer Economic Relations Trade Agreement
(1983) (CER) and The Trans-Tasman Mutual Recognition
Arrangement which established mutual recognition to
labelling and product standards, including those for
tobacco products.
Divergence on how Australia and New
Zealand regulate e-cigarettes needs to be considered
in light of the 2013 New Zealand-Australia CER Investment
Protocol and the great amount of work that has been
done towards New Zealand and Australia's commitment
to creating a seamless trans-Tasman business environment,
known as the Single Economic Market (SEM).
The appropriate regulatory framework
for E-cigarettes and personal vaporisers in Australia
An appropriate regulatory framework
for nicotine vaping products must:
1. Recognise that vaping e-cigarettes is significantly
less harmful than smoking tobacco.
2. Ensure it is easier, or at least
as easy, to find and buy vaping products as it is
to buy tobacco for smoking.
3. Avoid imposing any additional
or specific tax over and above GST on vaping products.
The initial setup cost for vaping has to be able to
be recouped within a short time frame, or people will
not switch.
4. Protect the opportunity for Australian
and foreign vaping product manufacturers and suppliers
who are independent of combustible tobacco product
companies to operate in Australia. Policies should
not favour established tobacco industry giants. E-cigarettes
represent a major threat to the tobacco industry.
5. The primary aim of any regulation
should be to enable current smokers to switch to vaping
and to have vaping products widely and readily accessible
for ex-smokers facing relapse to smoking.
Specific recommendations
1. Vaping products should be able to be sold wherever
tobacco products are sold and in additional retail
outlets that currently do not sell and have no desire
to sell tobacco products, such as dedicated vaping
product retailers (vape shops).
2. Advertising of vaping products
should not be restricted to the same extent as combustible
tobacco products. Applying the same type and level
of bans on advertising of tobacco products to vaping
products sends the misleading message that vaping
is as dangerous as smoking tobacco and this will put
some people off vaping. The primary purpose of controls
on advertising of vaping products should be to avoid
the promotion of tobacco products.
3. It is important that independent
vape shops be allowed to have a shop-front and/or
on-line presence, so people know where to get which
products and at what price. Vendors also need to provide
information to assist smokers to distinguish between
different types of products to ensure that they purchase
a vaping kit most likely to speed and assure their
complete transition from smoking to vaping.
4. E-cigarettes do not burn tobacco
and do not create smoke. There is no evidence of harm
to bystanders from exposure to e-cigarette vapour
and any risks to their health, if identified, are
likely to be extremely low. Bans on smoking should
not wholly be applied to vaping. Banning vaping wherever
smoking is currently banned contains several risks
for vapers. Bans on where people can smoke are extensive
in Australia. Despite this, Australia's smoking prevalence
has stalled. People who smoke are experiencing sometimes
extreme social exclusion, marginalisation and discrimination.
If vaping is similarly treated this sends a message
that vaping is as dangerous as smoking and that vapers
are no different from smokers (e.g. they're still
recalcitrant addicts). In this scenario, vapers are
also forced to retire to the same limited and increasingly
close number of areas that smokers have to go to.
As ex-smokers, this puts vapers at risk of relapse
to smoking.Anything that inhibits switching to vaping
is counterproductive. The ability to vape inside some
places, where it is allowed by the organisation or
venue offers a valuable advantage of vaping over smoking
tobacco.The main argument for banning vaping anywhere
that has any claim to a scientifically based theory,
though not proven, is that viewing adults vaping might
influence a child to initiate smoking. Firstly, vaping
is not smoking. Research with NZ children has shown
that they can distinguish between smoking and vaping.
They also really want their loved ones to stop smoking
and they, despite their young age, could see the sense
in vaping over smoking.
5. Organisations should be able to
set their own policies about vaping. This will enable
compassionate employers to allow vapers to vape inside.
Hospitals should be allowed to develop policies that
provide for vaping as an alternative to tobacco smoking
for patients who are unable to, or who are prohibited
to, go outside and off the grounds to smoke and potentially
for those patients who are not allowed to smoke prior
to surgery. Banning vaping in these institutions may
disproportionately affect more disadvantaged smokers,
such as those with mental health or drug and alcohol
conditions.
6. Vaping products should not be
required to display graphic health warnings. Vapour
is not smoke. The established dangers of tobacco smoking
cannot just be extrapolated over to vaping. It has
not been established that vaping, even with nicotine
is addictive.
Our members who are party to this
submission include:
Chair - Associate Professor Marewa
Glover, School of Public Health, Massey University
Dr Penny Truman, School of Public Health, Massey University
Dr Murray Laugesen, Adjunct Professor Dept. Psychology
University of Canterbury, Christchurch.
Dr George Laking, Medical Oncologist, Auckland
Professor Randolph Grace, University of Canterbury,Christchurch.
Greg Town, Medical Editor, Auckland.
Smoking biggest
risk factor for Sudden unexpected death in infancy
Smoking and bed-sharing
were now leading risk factors, and mothers doing both
at once increased their risk by a factor of 30. The
seasonal distribution seen in the 1980s has disappeared.
Total rate was 0.76 per 1000 births. Mitchell
E. et al. NZ Med J 2 June 2017;130.
2
June 2017 NZ Med J 130 (1456)
Very
low nicotine content cigarettes would need to be $15
cheaper
Trish
Fraser, Anette Kira.
VLNC
cigarettes do not taste as good as the real thing,
and would have to be much cheaper, according to smokers
tested for this study.
1
May 2017
For
publications of Dr Murray Laugesen please
see www.healthnz.co.nz/Publicnsall.htm
29
March 2017
Dr
Murray Laugesen backs Government move
"After 10
years of research in Christchurch I fully endorse
the government's move to legalise e-cigarettes",
he said.
29
March 2017
Chair
of End Smoking NZ backs the Government move
Legalising nicotine
for vaping is a very supportive move by Government,
says Dr Glover, chair of End Smoking NZ. Delays may
be created meantime with difficulties of importing.
29
March 2017
Philip
Morris says it "welcomes E-cigarette reforms
as a big step towards a Smokefree 2025."
It
says all smokers will need a range of smokefree alternatives,
including e-cigarettes and heated tobacco products,
and says small and local businesses should be encouraged.
Sale
of Nicotine e-cigarettes to be legalised in NZ - Associate
Minister.
The
sale of nicotine e-cigarettes will be legalised in
New Zealand, the Government has confirmed - and the
Associate Health Minister Nicky Wagner even encourages
reporters to try vaping.
A law change will be needed and is likely to be completed
next year, although the Government says it will do
so sooner if possible.
Today's announcement is a big win for the e-cigarette
industry - its products won't be in plain packaging,
nor will the hefty taxes on normal tobacco be applied.
Associate Health Minister Nicky Wagner said the change
came despite the fact scientific evidence of the safety
of e-cigarettes was still developing.
And despite stressing the "low risk" approach
taken because of that lack of certainty, Wagner encouraged
reporters at Parliament to try vaping.
"I have [tried vaping]. But I'm not very good
at it but I don't smoke either. I suggest anyone who
smokes here has a go at vaping, too. "Around
the world we can't get clear research about this.
But what we're thinking is they are about 95 per cent
less harmful than cigarettes."
She said the Government had considered applying the
same tobacco excise duties on vaping products but
had decided not to.
"I think that's an important thing so when a
smoker goes into the dairy he or she will see cigarettes
at a very high price and e-cigarettes much cheaper."
Wagner was not concerned that some big tobacco firms
were behind many e-cigarette products: "I think
the important thing is we want the health outcomes.
Whoever sells them...I don't think is really important."
The new rules for all e-cigarettes, whether they
contain nicotine or not, include restricting sales
to people 18 years and over, banning vaping in indoor
areas where smoking is prohibited, and restrictions
on advertising.
The Government had already announced its intention
to legalise e-cigarette sales, and today's decision
comes after consultation.
Nicotine patches and gum can be bought now, but nicotine
e-cigarette liquid must be bought from overseas.
Users "vape" on an e-cigarette, inhaling
its nicotine-containing vapour, in the way that smokers
inhale the smoke of a tobacco cigarette, which contains
nicotine plus many cancer-causing chemicals.
In England, e-cigarettes are the leading form of
quit-smoking aid, used by 35 per cent of smokers trying
to quit. However, some researchers argue that e-cigarettes
risk providing a "gateway" into smoking
for youth.
New Zealand's Ministry of Health has been monitoring
evidence on the role of e-cigarettes for smoking cessation.
Maori Party co-leader Marama Fox this month said
the Government should seriously consider subsidising
vaping as a tool to help quit smoking.
Today, Wagner said if an e-cigarette got approved
as a stop-smoking medicine under the Medicines Act
the Government may consider subsidising it.
About 546,000 Kiwis smoke daily, 15 per cent of the
adult population. Every day on average, at least 13
people die from a smoking-related disease - about
5000 a year.
Half of smokers die from a smoking-related illness
and on average their deaths will be 14 years earlier
than if they didn't smoke.
- Nicholas Jones, NZ Herald
29
March 2016
MoH
site: E-cigarettes to be regulated as consumer products
: The Government is planning to change
the law regulating e-cigarettes. These changes need
to go through Parliament before they can take effect.
This will likely happen from the middle of 2018 at
the earliest.
The proposed changes are to:
" legalise the sale and supply of nicotine e-cigarettes
and e-liquid as consumer products
" regulate nicotine and non-nicotine e-cigarettes
and e-liquid as follows:
" prohibit sale, and supply in a public place,
to under 18 year olds
" restrict sale via vending machines to R18 settings
" allow all retailers to display e-cigarettes
and e-liquid at point-of-sale
" allow R18 retail settings to display e-cigarettes
and e-liquid in-store (including window display),
promote products on the outside of the store, and
offer discounts, free samples, loyalty awards etc.
" prohibit broader advertising, e.g. billboards,
radio, TV, Internet (the rules above will apply to
retailers' websites)
" prohibit vaping in workplaces and other areas
where smoking is not allowed under the Smoke-free
Environments Act 1990 (SFEA)
" set requirements for product safety (e.g. nicotine
concentration, child-resistant closures etc.)
" In addition to these changes, a regulatory
framework will be developed to provide a pathway for
emerging tobacco and nicotine-delivery products to
be regulated as consumer products in future.
"
Cabinet paper: Improving the regulatory framework
for e-cigarettes and emerging tobacco and nicotine-delivery
products (Word, 129 KB)
" Regulatory impact statement - Regulation
of e-cigarettes and emerging tobacco and nicotine-delivery
products
Electronic cigarettes
Electronic cigarettes (or e-cigarettes) are electrical
devices that heat a solution (or e-liquid), which
produces a vapour that the user inhales or 'vapes'.
The ingredients of the liquid may vary, but currently
most e-liquids contain propylene glycol and flavouring
agents. Some e-liquids contain nicotine.
E-cigarettes come in a range of styles, from devices
that look similar to traditional cigarettes (first
generation or cig-a-like) to refillable-cartridge
'tank' systems (second generation) to highly advanced
appliances with larger batteries that allow the power
to be adjusted to meet an individual's specific vapour
requirements (third generation).
Second and third generation e-cigarettes generally
deliver more nicotine than first generation e cigarettes.
Risks with using e-cigarettes
There is evidence that e-cigarettes pose fewer
health risks to smokers who switch completely from
tobacco smoking to e-cigarette use. Tobacco smoking,
even at a reduced level, remains harmful.
Short-term use of e-cigarettes has been associated
with mild adverse effects such as headaches, dry mouth
or throat, and throat
or
mouth irritation. The health risks associated with
the long-term use of e-cigarettes are unknown. It
is only known that the risks of smoking are likely
to be much greater.
Some e-liquids contain nicotine. For smokers, the
nicotine in e-cigarettes poses little danger, however,
in excessive amounts it can be lethal, especially
for children. Nicotine products should be kept out
of reach of others, particularly children.
Use of e-cigarettes for stopping smoking
There is a good rationale for people to use e-cigarettes
to help them stop smoking as e cigarettes can provide
nicotine, which is what people desire from smoking.
Research into the effectiveness of e-cigarettes in
smoking cessation is growing, but the findings from
these studies are somewhat mixed and the quality of
the evidence is low overall. This is an active area
of research and more findings will become available
over the next few years. At this stage, the Ministry
of Health does not have enough evidence to recommend
e-cigarettes confidently as a smoking-cessation tool.
Smokers should use approved smoking-cessation medicines,
such as NRT, to support them to stop smoking and seek
behavioural support from stop-smoking services.
24
March 2017.
Cigarette
consumption down again by 5% in 2016
In
2016 cigarette and tobacco consumption per capita
decreased by a further five percent below the changes
noted in 2015. The average smoker smoked 704 cigarettes
per year (per adult in the population) in 2015 and
668 in 2016. Millions of cigarettes sold were 2358
in 2015 and 2304 in 2016. The greatest decrease was
in roll-your-owns, from 547 tonnes in 2015 to 512
tonnes in 2016.
These
data were collected by Dr Murray Laugesen from the
manufacturers returns to the Ministry of Health for
calendar year 2016.
As
14.2% of adults smoked in 2015-16, it means that the
average smoker smoked over 4700 cigarettes per year
or 13.2 cigarettes per day. Any increased use of e-cigarettes
may have occurred in 2017 rather than last year.
28 February 2017
Daily users compared
to less frequent users find vape as or more satisfying
and less dangerous than cigarettes, and are likelier
to use non-cig-alike vaping products
This report by Prof Lynn Koslowski et al on 105
adults in Preventive Medicine Reports http://dx.doi.org/10.1016/j.pmedr.2017.02.026
highlights what many vapers already know:
o Daily users of e-cigarettes found them at least
as satisfying as cigarettes.
o Satisfaction from e-cigarettes was more likely in
more frequent users.
o All daily users reported them as less dangerous
than cigarettes.
o Perceived danger from e-cigarettes was higher in
less frequent users.
o Daily users of e-cigarettes were more likely to
be using non-cig-alikes.
17 February 2017
Heets illegal for Heat
not Burn but does this apply to Nicotine Lactate?
According
to the NZ Herald on Feb 2, quoting the Ministry of
Health
''In
our view, Heets products are prohibited for sale in
New Zealand under the Smoke-free Environments Act.''
The ministry has now clarified its position and
says that while the battery-powered holder is legal,
the tobacco sticks, called Heets, are not, because
the tobacco in them is burnt rather than heated.
Comment:
1) This is illogical, because on this definition,
HEETS and HnB are both illegal because the device
heats up the air in it, and HEETs are only the mechanism
for extracting that vapour.
2) But the legality of Heat not Burn is
a matter of major importance, as 1 million Japanese
have switched off mainstream smoking, nearly 6% of
smokers having now switched. This is of major
public health importance.
3) HEETS in Nicotine Lactate cigarettes are legal,
because HEETS are heated to 100 deg C, and no tobacco
is burnt in that device.
15 February 2017
New Shadow Minister for
Tobacco Control
Hon Annette King Labour Spokesperson on Health
has replied on this topic today and says
"Yes, I am in favour of legislation of e-cigarettes,
and have been saying so since last year."
8 February 2017
New Minister for Tobacco
Control
Hon Nicky Wagner is the
new appointment to this task. We send her our best
wishes.
8 February 2017
Study of inhaled toxins
finds E-cigarettes are much safer than smoking
This challenges the "we just don't know"
school with what we can know if we look: that the
toxic exposures from inhaling e-cigarette aerosol
are much lower than for cigarette smoke. We don't
have to wait 20 years for a cohort study to know enough
to be confident these products are very much less
risky.
The effects of shifting completely to e-cigarettes
are marked but the effects of half switching (dual
smoking) are not.
Shahab L, Goniewicz ML, Blount BC, Brown J, McNeill
A, Alwis KU, et al. Nicotine, Carcinogen, and Toxin
Exposure in Long-Term E-Cigarette and Nicotine Replacement
Therapy Users. Ann Intern Med. 2017 Feb 7;24:442-8.
http://annals.org/aim/article/2599869/nicotine-carcinogen-toxin-exposure-long-term-e-cigarette-nicotine-replacement
For New Zealand, this information is confirmed
by Laugesen M. Nicotine and toxicant yield ratings
of electronic cigarette brands in New Zealand. NZ
Med J, 27 Mar 2015.
21 Jan 2017
Tobacco elimination:
an economic and public health imperative
- Murray Laugesen
Among the comments in a recent editorial in the
Lancet was this:
"A recent
comment in Lancet Public Health on the New
Zealand experience, points to the importance of political
champions, a government committed to dramatically
reducing tobacco use, and a tireless and fearless
non-government sector. Only with these types of leadership
can real progress be made."(1)
These comments came from Profs Robert Beaglehole
and Ruth Bonita, who pointed out that the most recent
surveys show that 14% of adults smoke daily, but 36%
of Maori and 23% of Pacific people also smoke daily,
and this needs attention.
Their solutions include this: "Electronic
nicotine-delivery devices and low nicotine cigarettes
may have a role to play in achieving the 2025 goal
by encouraging cessation." This is the first
time that New Zealand experts of conservative and
radical positions in tobacco control have voiced support
for e-cigarettes, and is almost 10 years since I conducted
the first research on them. All sides should take
note. We hope that the government will soon agree to
making such devices legal to be sold.
Recent moves to ban heat not burn cigarettes were
a local enforcement issue, and should not influence
approval of the nicotine lactate cigarette in the
next 12 months when it has passed its final tests
in Christchurch and elsewhere.
The price of combustible cigarettes has escalated
at a steady 10% per year since 2011, and in addition
to the 5% per annum decline since 2011, we will soon
know from 2016 data whether the decline is continuing.
Meantime, we need less harmful products such as e-cigarettes
and nicotine lactate to ease smokers off combustible
tobacco.
(1). Beaglehole R and Bonita R. Eliminating the
scourge of tobacco for a fairer and healthier world:
New Zealand leads the way. Lancet www.com/public
health v.2 January 2017.e-13.13.
13 Jan 2017
Heat not burn cigarettes
banned by Section 29(2) of the SFE Environments Act
: law fails to distinguish types of tobacco sold
See WWW.MOH.GOVT.NZ and use Heat not Burn to find
the topic, which was posted just before Christmas.
Ministry of Health in response to the manufacturers,
Philip Morris, has notified them that s.29(2) bans
Heat not Burn cigarettes, as it contains tobacco.
However the tobacco is not combusted. Thus Ministry
of Health has failed to make a distinction between tobacco-ignited
cigarettes and tobacco heat-not- burn cigarettes.
The former cause 5000 deaths a year, and the latter
do not cause cigarette deaths as far as is known.
The only solution to put HnB cigarettes on the market
here is to amend s.29(2).
In Japan HnB cigarettes have replaced 4.9% of
the combustibles sold in the past 6 months.
4 Jan 2017
Price changes 31
Dec 2016 to 1 Jan 2017
| |
2016 to 31 Dec |
2017 from 1 Jan |
% increase |
| Club 20s |
$19.50 |
$22.00 |
12.8% |
| Holiday 20s |
$22.80 |
$25.00 |
9.6% |
| Port Royal 30g |
$48.20 |
$52.90 |
9.75% |
| Port Royal 50g |
$78.00 |
$85.00 |
9.00% |
- Countdown
supermarkets.
2 Jan 2017
I’ll say it again:
E-cigarettes are still far safer than smoking
Linda Bauld. The Guardian.
Since I last wrote about e-cigarettes
one year ago, headlines about the dangers of these
devices have continued to appear and show no sign
of abating. The result is clear. More people believe
today, compared with a year ago, that e-cigarettes
are as harmful as smoking. In fact these incorrect
perceptions have risen year on year, from fewer than
one in ten adults in Great Britain in 2013 to one
in four this past summer. Surveys of smokers show
similar patterns, with an increasing proportion believing
that e-cigarettes are more or equally harmful than
tobacco.
Why can't scientists agree on e-cigarettes?
Yet we know that these harm perceptions are wrong.
There is now very strong evidence, from a range of
studies, that vaping - inhaling nicotine without the
combustion involved in smoking - is far less risky
than smoking cigarettes. Just a few months ago this
body of evidence was brought together by the Royal
College of Physicians who published an authoritative
report analysing dozens of studies and concluded that
the hazard to health arising from long term vapour
inhalation from e-cigarettes is unlikely to exceed
5% of the harm from smoking tobacco. The RCP, and
since then other UK doctor’s organisations such
as the Royal College of General Practitioners, have
made clear that it is important to promote the use
of e-cigarettes, along with other non-tobacco nicotine
products (like Nicotine Replacement Therapy such as
gum or inhalators) to smokers who are trying to quit.
The work of these organisations is underpinned by
a consensus statement endorsed by many of the main
health charities and public health bodies in the UK.
They agree that vaping is safer than smoking, and
while these products are not risk free and should
not be promoted to children or never smokers, they
have a legitimate and positive role to play in tobacco
control.
But this consensus is not shared
around the world. The regular stream of media scare
stories driving harm perceptions often originates
in other countries where there is no such view about
relative risks. Some media headlines are driven by
poor science but others originate from reports by
credible organisations who focus on the absolute risk
of any e-cigarette use without comparing it to smoking
(which is uniquely deadly and kills one in two regular
users). 2016 saw at least two major reports of this
kind.
In September the World Health Organisation
published a report that set out a series of steps
on e-cigarette regulation for countries signed up
to the Framework Convention on Tobacco Control, a
global public health treaty. These options were primarily
about banning or severely restricting the sale, distribution
and marketing of e-cigarettes. The WHO report was
comprehensively critiqued by the UK Centre for Tobacco
and Alcohol Studies, but its findings mean that e-cigarettes
will continue to be unavailable to millions of smokers
in many countries who have banned these devices or
are considering doing so.
Does a tobacco-free world need to be nicotine free?
December 2016 saw the publication of a review authored
by the US Surgeon General, which focused on e-cigarette
use in young people. This described e-cigarette use
as a public health concern, arguing that e-cigarettes
are now the most commonly used tobacco product amongst
US youth and that nicotine use in any form is unsafe
for young people and also pregnant women. While some
of the science in the report is accurate, the conclusions
endorsing heavy regulation of e-cigarettes were not.
The report did not compare the risks of smoking and
vaping, failed to make clear that e-cigarettes are
not tobacco products, and drew conclusions about nicotine
that would also apply to Nicotine Replacement Therapy
- which is safe and licensed for use in pregnancy
and by young smokers. It also endorsed policies which
could deter current smokers from switching to e-cigarettes.
American scientists have critiqued data from the USA
that provided the basis for the Surgeon General’s
report, but it is likely that this publication will
contribute to public perceptions that e-cigarettes
are dangerous.
These two reports largely ignore
the fact that there are already measures in place
in many countries (including all of the EU) to protect
the public from any risks from e-cigarettes. These
include policies like age of sale, limits on advertising
and child- and tamper-proof packaging - all important
to protect children while still allowing sales to
adult smokers and ex-smokers. Concerns about exploding
batteries and nicotine poisoning can also be dealt
with by following simple safety rules, such as those
set out by the Royal Society for the Prevention of
Accidents.
I believe that e-cigarettes have
huge potential to save lives by providing an alternative
to smoking. Yet this can only be realised if we address
negative harm perceptions and communicate honestly
with the public. Ongoing research can help with this,
and 2016 has seen the start of important studies,
many commissioned by Cancer Research UK, which will
tell us more in the future. We also need to keep our
eye on new technology, such as heat not burn tobacco
products, which are emerging and about which we know
little. Only time will tell whether the UK’s
positive approach towards e-cigarettes strikes the
right balance between risks and benefits. For now,
however, we must do all we can to encourage smokers
to try to stop at New Year or any other time. For
those trying with e-cigarettes, this is a positive
choice that should be supported.
Linda Bauld is Professor of Health
Policy at the University of Stirling, Deputy Director
of the UK Centre for Tobacco and Alcohol Studies and
holds the CRUK/BUPA Chair in Behavioural Research
for Cancer Prevention at Cancer Research UK. She is
a former scientific adviser on tobacco control to
the UK government and chaired the NICE guidance group
on tobacco harm reduction.
NZ Health Survey July
2015- June 2016
Smoking
Total population: current 16.3% daily 14.2%. (2%
drop since 2011-12)
Maori population current 38.6%, daily 35.5%.
(2% drop since 2011-12)
Pacific population current 25.5%, daily 22.8%
(virtually no change).
Tobacco prices as from
1 Jan 2017
Customs Dept reports that duty on cigarettes and
tobacco will rise to $738.13 per 1000 cigarettes of
0.7g or roll-your-owns of 0.7g. This is a rise of
10.4% on the 2016 prices.
Tobacco manufacturers and importers are expected
to raise their prices by the same amount. The average
2016 price was $22.83 for 20 cigarettes.
November 2016
Fixing Medical Prices
- How Physicians are paid
Miriam J Laugesen Associate Professor Dept
of Health Policy and Management, Columbia Mailman
School of Public Health, New York NY.
Harvard University Press.
In Dec 2016 issue of Scientific American.
Sir David Hay 1927-2016
A pioneer of tobacco control in New Zealand, Sir
David Hay, had been ill for some weeks and died 3
December. His funeral was held on Thursday 1pm at
St Andrew's College chapel on Papanui Rd in Christchurch.
As in the case of Helen Kelly, the well-known trade
unionists, Sir David died of lung cancer, even though
his last cigarette was in his teens.
Qualified as a physician in the 1950s he was the first
person to ensure tobacco advertising on television
was banned in November 1962, and a member of the Advisory
Committee on Smoking and Health which gave its advice
to government in May 1985. In 1991 he told the incoming
National government their law to ban tobacco sponsorship
of sport was wrong. He was the first medical director
of the Heart Foundation and held this post for nearly
two decades. In 2005 he published his life story "Heart
Sounds" through Steele Roberts, Wellington.
26 Oct 2016
COMMENTARY ON WHO REPORT
ON ELECTRONIC NICOTINE DELIVERY SYSTEMS AND ELECTRONIC
NON-NICOTINE DELIVERY SYSTEMS
John Britton University of Nottingham, Ilze Bogdanovica
University of Nottingham, Ann McNeill King’s
College London, Linda Bauld University of Stirling,
from the UK Centre for Tobacco and Alcohol Studies
Document available online at: http://ukctas.net/news/commentary-on-WHO-report-on-ENDS&ENNDS.html
Positioning ENDS as a threat rather than opportunity.
Overall, the WHO report does not correctly position
ENDS primarily as an alternative to smoking and instead
focusses excessively on risks of ENDS use without
adequately recognising the deep reductions in health
risks when a smoker switches to ENDS. The FCTC itself
recognises ‘harm reduction’ as a key strategy
in tobacco control. But with minor exceptions, the
WHO report discusses ENDS as a threat, whereas in
fact they represent a major opportunity for public
health.
Failure to quantify risk. The WHO paper provides
a poor assessment of ENDS risks. In terms of toxicology,
the discussion is naïve and places excessive
emphasis on negligible risks arising from very low
exposures. In toxicology, the presence of a potentially
harmful agent does not necessarily establish a material
risk. This is because the level of exposure matters
and “the dose makes the poison”.
Inadequate comparisons with smoking. The WHO
paper does not systematically make meaningful comparisons
with exposures arising from inhaling tobacco smoke
or refer to other useful comparators such as occupational
exposure limits. However, data from around the world
shows that almost all ENDS users are smokers, ex-smokers
or would-be smokers. The most relevant comparison
for health policy purposes is with smoking.
Misrepresenting second hand ENDS vapour risks.
The section on risks of second-hand exposure to ENDS
aerosol provides no evidence that such exposures pose
any material risks to bystanders. The claim that ENDS
have the “potential to lead to adverse health
effects” in bystanders does not reflect the science
behind the cited source unless ‘potential’
is taken to mean any exposure, no matter how trivial.
Again, the issue is not the presence of particular
chemicals, but the magnitude of exposure.
Discounting the evidence that ENDS do help smokers
quit. The WHO paper does not properly assess the
role that ENDS play in quitting smoking and uncritically
repeats a number of methodological errors found in
the literature. Taking the totality of evidence including
controlled trials, observational studies, changes
in population smoking and ENDS use, the experience
of nicotine replacement therapy, and widely reported
user experience, there is confidence that ENDS are
helping many smokers to quit smoking and not having
negative effects like renormalising smoking, reducing
quit rates or creating gateway effects.
ENDS marketing can be anti-smoking advertising.
The vast majority of ENDS marketing is truthful promotion
of a low-risk alternative to smoking and targeted
at adult smokers. The evidence cited by WHO has been
misrepresented and does not make the case for any
systematic malpractice by ENDS vendors. However, the
WHO paper overlooks that most fundamental point, which
is that ENDS marketing is promoting an alternative
to smoking and may therefore be promoting desirable
changes in smoking behaviour. It may also reach people
who do not engage with conventional stop-smoking interventions.
Flavours are essential to the appeal of ENDS
as alternative to smoking. The section on ‘product
characteristics’ attempts to demonstrate a problem
with flavours appealing to teenagers. In fact, flavours
are integral to the appeal of ENDS to adults as an
alternative to smoking. The citations are selective
and findings misinterpreted and do not support this
claim. Several citations simply reflect opinions or
speculation, while important studies have been overlooked.
These do not show that any interest amongst teenagers
in ENDS flavours is resulting in regular use of ENDS
in this age group.
Mischaracterisation of the ENDS market and role
of tobacco transnationals. The WHO paper misinterprets
the ENDS market, makes misleading and unreferenced
statements about the role of transnational tobacco
companies in the market and is not grounded in an
understanding of how competitive markets function.
WHO’s report fails to acknowledge the threat
of disruptive technology such as ENDS to the commercial
viability of the traditional cigarette business. Ironically,
the only references given to published papers point
out how regulations, such as those favoured by WHO,
actually help the cigarette trade. WHO should be aware
of the danger that its policy proposals may provide
the traditional tobacco industry with a twin advantage:
(1) slowing down the disruption of the cigarette market
by ENDS; (2) shaping the ENDS market to suit the ENDS
business model favoured by the tobacco industry.
Unjustified support for ENDS prohibition. In
the discussion of policy options, the opening paragraph
for each policy set implicitly endorses ENDS prohibition.
It does this by stating that “Parties that have
not banned the importation, sale, and distribution
of ENDS/ENNDS may consider the following options”.
Prohibition is one regulatory option among many that
ought to be discussed on its own merits, not taken
as a default. The merits of prohibition are exceedingly
poor given the pervasive availability of cigarettes
in all jurisdictions. WHO should not be endorsing
prohibitions, explicitly or implicitly. It is unethical
to deny smokers much lower risk options than cigarettes,
and there is no scientific support for ENDS prohibition
as a public health intervention. The WHO’s framing
suggests that a prohibition is something for Parties
to progress towards and should not be undone once
done. In fact, it is a policy that should be reversed.
Policy proposals made with no supporting policy
analysis. Numerous policies are proposed without
any supporting evidence for their effectiveness or
cost-effectiveness. Any policy proposal should be
subject to evidence-based justification, options appraisal
and analysis of trade-offs or distributional effects,
and impact assessment. Policies should be tested for
proportionality and possible unintended consequences.
The WHO has not applied any policy-making disciplines
to its menu of proposed policy options.
No assessment of unintended consequences. There
is no recognition of the likelihood of ‘unintended
consequences’ arising from the policies proposed
in the WHO paper. However, it is very likely that
some of the proposed policies would have the effect
of increasing smoking. The Royal College of Physicians
explains this in its 2016 Nicotine without Smoke2
report as follows:
"A risk-averse, precautionary approach to e-cigarette
regulation can be proposed as a means of minimising
the risk of avoidable harm, e.g. exposure to toxins
in e-cigarette vapour, renormalisation, gateway progression
to smoking, or other real or potential risks. However,
if this approach also makes e-cigarettes less easily
accessible, less palatable or acceptable, more expensive,
less consumer friendly or pharmacologically less effective,
or inhibits innovation and development of new and
improved products, then it causes harm by perpetuating
smoking. Getting this balance right is difficult."
(Section 12.10 page 187)
Almost every policy listed in the WHO’s paper
could easily have the effect of protecting the incumbent
cigarette trade, promoting smoking rather than vaping,
and lead to increases in non-communicable diseases.
It is very likely that widespread uptake of WHO’s
policy proposal would ‘reduce harm reduction’
and therefore increase harm.
Transparency and quality. The WHO report has
been made available without the four supporting papers
upon which it is supposed to be based. These papers
are still undergoing revision during peer review.
This is poor scientific practice and does not provide
a reliable basis for policy advice.
COMMENTARY ON WHO REPORT ON ELECTRONIC NICOTINE
DELIVERY SYSTEMS AND ELECTRONIC NON-NICOTINE DELIVERY
SYSTEMS (ENDS)
The Seventh Conference of the Parties (COP-7) of
the Framework Convention on Tobacco Control (FCTC),
to be held in Delhi between the 7th and 12th of November
2016, will discuss and formulate future policy on
the role of Electronic Nicotine Delivery Systems (ENDS;
also known as electronic cigarettes or e-cigarettes)
and Electronic Non-Nicotine Delivery Systems (ENNDS)
in tobacco control. In preparation for this discussion,
and in response to a request made by the COP at its
6th session (COP-6) in Moscow in 2014, the World Health
Organisation (WHO) has prepared a report providing
updates on evidence of the health impacts of ENDS/ENNDS;
on their potential role in smoking cessation and tobacco
control; and on policy options to achieve objectives
set at COP-6.
In our view, the WHO report succeeds in identifying
a range of areas of uncertainty over the potential
benefits and risks of ENDS to effective tobacco control
policy. However, by doing so from a position of emphasis
on the risks and disadvantages of these products which
disregards their potential to reduce consumption of
smoked tobacco, the report fails to deliver the equipoise
required for dispassionate formulation of public health
policy. The report also contains factual errors and
misinterpretations of evidence available in the public
domain; and refers at its outset to four reports,
including two systematic reviews, commissioned by
the WHO but as yet unpublished and hence unavailable
for scrutiny.
Oct 6, 2016.
Philip Morris calls for
light regulation of e-cigarettes
Rob Stock
International
cigarette giant Philip Morris has appealed to the
Government to go light when regulating its "heat
not burn" tobacco devices.
The
Ministry of Health is receiving submissions on how
to regulate e-cigarettes, which deliver nicotine-laden
vapour, providing a safer alternative to smoking.
But
Philip Morris is keen the Government does not overlook
its heat-not-burn cigarettes, which heat tobacco plugs
to deliver their nicotine hit without the smoke which
causes about 95 per cent of smoking-related disease.
The
submissions have not been made public yet, but Philip
Morris said: "Electronic cigarettes do not burn
tobacco and do not generate smoke."
Cigarette
companies are seeking viable new business models as
their traditional products go into terminal decline.
They have invested heavily in both e-cigarettes and
heat not burn devices, and want countries like New
Zealand not to regulate them in the same way as conventional
cigarettes.
Cigarette
companies are trying to transform themselves into
nicotine, not tobacco companies
"We
envision a smoke-free world in where a broad range
of safer alternatives to cigarettes fully satisfies
the continuing demand for tobacco and nicotine products,"
Philip Morris said.
"We
are keen that e-cigarettes should be at least as available
as cigarettes are, but we suggest that they should
be regulated differently from cigarettes in order
to encourage smokers to switch to them."
Regulating
e-cigarettes like cigarettes would "run contrary
to the science and public health purpose of tobacco
harm reduction".
The
company said e-cigarettes should not be covered by
the ban on cigarette advertising and sale.
Advertising
and in-store displays were important in promoting
e-cigarettes, it said.
Planned
plain packaging laws should also not be applied to
e-cigarette supplies.
Philip
Morris also did not want graphic health warnings on
e-cigarette supplies which would "relegate these
less harmful products to packaging that is effectively
equivalent to cigarettes". This
would make it difficult to differentiate the products
to smokers.
Philip
Morris also called for little or no excise tax to
be levied on e-liquids and heat not burn tobacco plugs
claiming it would discourage smokers from switching
from conventional cigarettes.
It
also said vaping, as the use of e-cigarettes is known,
should be permitted in some areas where smoking is
banned, though the company agreed their use should
be banned from places like schools.
New
regulations should also be flexible as nicotine-delivery
technology was developing fast, and innovation should
not be stifled. "Technological
innovation is transforming the tobacco industry,"
it said.
The
ministry plans to report its recommendations to the
Government in the next few weeks.f
26 September 2016
Christchurch group completes
another study on nicotine lactate
Christchurch Clinical Studies Trust Ltd today
announces the completion of a clinical study on an
innovative alternative to cigarettes.The product prototype,
designated"P3L" (Platform 3, Lactate) by
the technology owner Philip Morris International,
mixes nicotine with lactic acid to produce an inhalable
nicotine salt aerosol with faster absorption rates
than traditional nicotine replacement therapies. The
device is the product of technology developed by Professor
Jed Rose, co-inventor of the nicotine patch, and his
colleagues at Duke University. Previously tested in
Christchurch by Dr Chris Wynne and Dr Murray Laugesen,
New Zealand's leading public health specialist, the
study validated the belief that P3L can provide smokers
with a suitable alternative to smoking.
The study investigated nicotine absorption after a
single use of the product by 16 adult smokers in comparison
to the Nicorette® inhalator. Approximating the
rapid nicotine absorption rates and levels of cigarettes
is an important element of providing smokers with
a satisfactory alternative to smoking. With P3L, nicotine
absorption reached peak levels six times faster than
with the inhalator, suggesting easier absorption and
a significantly higher potential for acceptance by
smokers. The study also assessed a range of subjective
effects, as well as safety and tolerability. Compared
with use of the inhalator,the study participants found
the product a more satisfactory alternative and reported
less intention to smoke cigarettes; no relevant side
effects were reported.
Principal
study investigator Dr Chris Wynne, Medical Director
at St Georges Cancer Care Centre, Christchurch, commented
on the results:
"In addition to quitting, which remains the safest
way to reduce the harm from smoking, a tobacco harm
reduction strategy envisions the development of products
with the potential to reduce individual risk compared
to smoking. A critical element for acceptance by smokers
is nicotine delivery similar to cigarettes as well
as the rewarding of subjective effects, and this novel
nicotine-containing product has proven to perform
better than existing nicotine delivery systems in
both areas."
Given the promising results of this first clinical
study, Christchurch Clinical Studies Trust Ltd will
conduct further studies to assess in a larger population
the potential for smokers to substitute cigarettes
with the product.
4 August 2016
New Zealand to make nicotine
e-cigarettes legal
Scoop NZ release from End
Smoking NZ
End Smoking NZ applauds the Government (August 2)
on its decision to make nicotine for vaping (using
electronic cigarettes) legally available in New Zealand.
The Government has agreed in principle that nicotine
for e-cigarettes should be legally available for sale
with appropriate controls. Currently it can only be
imported for personal use creating often insurmountable
barriers preventing smokers from switching to vaping.
“The Associate Minister of Health, Peseta Sam
Lotu-Iiga has made the right decision.” Said
End Smoking’s Chairperson Associate Professor
Marewa Glover. “He has listened with compassion
to smokers and vapers. We are so relieved that our
pragmatic nature as a country has triumphed over the
negative misinformation and unfounded fears that have
dominated the debate for too long.”
Long-time advocate of nicotine e-cigarettes and founding
Board member, Dr Murray Laugesen started work on e-cigarettes
in 2007. “I’m absolutely delighted,”
he said. “This will be a turning point that will
have a significant impact on reducing the death and
disease caused by smoking. It also gives us a real
shot at achieving Smokefree 2025.” He said.
“This announcement by the Minister gives health
professionals a clear message that smokers who choose
to use vaping to help them quit can be supported to
do so.” Said Board member Dr George Laking.
The Ministry of Health is calling for submissions
on how to legislate electronic cigarette products
and what regulations or controls need to be in place.
“Vaping nicotine has been estimated to be 95%
safer than smoking tobacco, thus End Smoking doesn’t
believe we need overly restrictive or costly regulation
and controls of e-cigarette products.
However, some concerns such as restricting sales
to minors will be wise to prevent retailers who currently
sell tobacco to minors pushing e-cigarette products
on to kids.” Dr Glover said.
Some public health researchers and advocates in New
Zealand and around the world have concerns that vaping
will re-normalise smoking, be a gateway to smoking,
and establish nicotine addiction among new users.
However, there is no evidence that this is occurring
in countries where vaping is established.
Whilst there is still some way to go before nicotine
for vaping will be legally available in New Zealand,
End Smoking says the first steps are positive.
8 July 2016
Cigarette smoking prevalence
down 10% in USA
Cigarette smokers declined from 16.8% to
15.1% in 2014-5, with the greatest decline among young
people.
For e-cigarette smokers, the greatest increase
was among former (ex-) smokers, from 2.0 million to
2.5 million, and increase of 26%, with 66% using them
daily.
A survey of teenage smoking showed that from 2011
to 2014, regular cigarette smoking had fallen from
4.0% to 1.3%, and exclusive e-cigarette use had risen
from 0.3% to 2.7%.
The inescapable fact is that e-cigarettes, used
by, among others, 2.5 million former smokers, are
not impeding the dramatic, welcome decline in cigarette
smoking.
http://rodutobaccotruth.blogspot.co.nz/2016/07/how-many-americans-vape-cdc-data-show_7.html
____________________________
1 July 2016
Tobacco consumption in
NZ 5% down per year since 2010, and 5% down in 2015
According to 2015 statistics, tobacco consumption
per adult (including factory-made and roll-your-own
at 0.7 g tobacco per cigarette) declined 5% in 2015.
Consumption declined from 749 cigarettes per adult
in 2014 to an all time low of 712 cigarettes per adult
in 2015. This amounts to a 65% decrease since 1990.
The data, from Health NZ, will be found under www.moh.govt.nz/ourwork/
In addition,
assuming cigarette smoking prevalence declined to
14.86% in 2015, this means that of 541,000 smokers,
the average smoker in 2015 smoked 4791
cigarettes per year, or 13.13 cigarettes per day.
30% of tobacco smoked was sold as RYOs.
_________________________________
27 June 2016
New Study Finds Electronic
Cigarettes Helped 5 Million Quit Smoking
by Lindsey Stroud
The journal Addiction published a study in late June,
finding the use of electronic cigarettes and vaporized
nicotine products (VNPs) have helped 15 million smokers
quit smoking tobacco cigarettes and/or cut back, in
the European Union (E.U.). Using data from the 2014
Eurobarometer survey, which recorded responses of
27,460 participants, the study concluded that 48.5
million E.U. citizens had tried e-cigarettes and 7.5
million were currently vapers. Of the group reporting
regular e-cigarette usage, “35 percent reported
that e-cigarettes helped them quit smoking, while
32 percent said they were smoking less thanks to e-cigarettes.”
(2.6 and 2.4 million respectively)
This research comes on the heels of a study published
by the British Medical Journal earlier in June, that
measured the “effectiveness and safety of electronic
cigarettes at 24 months” using data from respondents
that used e-cigarettes and VNPs to quit smoking and
those that remained on traditional tobacco cigarettes.
The study concluded that 61 percent of respondents
had remained “abstinent from tobacco” and
that only 23.1 percent of tobacco users reported abstinence.
The study by Addiction is only the latest bit of
research concerning the health implications of electronic
cigarettes and VNPs. After U.S. Food and Drug Administration
(FDA) announced in May to regulate electronic cigarettes
as tobacco products, more studies have been finding
greater evidence that e-cigarettes and VNPs may actually
save more lives than endanger, and help ease the health
burdens that are associated with tobacco. Addiction.
2016 Jun 24. doi: 10.1111/add.13506. [Epub ahead of
print]
_______________________________________________________
18 June 2016
Butting out
The Ministry of Health's refusal to consider making
the sale of e-cigarettes here legal borders on the
indefensible.
On the evidence so far banning "vaping"
actually punishes those most likely to be well on
track to giving up smoking altogether.....
New Zealander Dr Murray Laugesen, supports e-cigarettes
as a prime and remarkably low-risk weapon against
the killer habit. It's time the ministry listened.
Butting out. Editorial. The Listener www.listener.co.nz
_________________________________________________
2 May 2016
Australian Health Organisations
wrong to go against e-cigarettes
According
to Dr Colin Mendelsohn an influential tobacco treatment
specialist from Sydney, the precautionary position
taken by Australian health organisations and governments
is not supported by the available evidence and overseas
experience. The growing evidence for safety and effectiveness
of e-cigarettes significantly outweighs any potential
risks to public health.
A rational, evidence-based approach
would be to make e-cigarettes available in Australia
as consumer products and to encourage their use while
minimising uptake by people who would not otherwise
have used nicotine products. Ongoing monitoring and
appropriate proportionate regulation would help minimise
any risks.
E-cigarettes represent a massive
opportunity for Australian smokers and have the potential
for large-scale improvements in individual and public
health, and social inequality. We cannot afford not
to embrace them.
-HTTPS://theconversation.com/australias-prohibition-of-e-cigarettes-is-out-of-step-with-the-evidence-58725
2 May
28 April 2016
PROMOTE E-CIGARETTES
WIDELY AS SUBSTITUTE FOR SMOKING SAYS NEW RCP REPORT
A new report released today from the Royal College
of Physicians, London, ‘Nicotine without smoke:
tobacco harm reduction’ concludes that e-cigarettes
are likely to be beneficial to UK public health. Smokers
can therefore be reassured and encouraged to use them,
and the public can be reassured that e-cigarettes
are much safer than smoking.
Tobacco smoking is addictive and lethal. Half of
all lifelong smokers die early, losing an average
of about 3 months of life expectancy for every year
smoked after the age of 35, some 10 years of life
in total. Although smoking prevalence in the UK has
reduced to 18%, 8.7 million people still smoke. Harm
reduction provides an additional strategy to protect
this group of smokers from disability and early death.
Since e-cigarettes became available in the UK in
2007, their use has been surrounded by medical and
public controversy. This new 200-page report examines
the science, public policy, regulation and ethics
surrounding e-cigarettes and other non-tobacco sources
of nicotine, and addresses these controversies and
misunderstandings with conclusions based on the latest
available evidence:
- E-cigarettes are not a gateway to smoking
– in the UK, use of e-cigarettes is limited almost
entirely to those who are already using, or have used,
tobacco
- E-cigarettes do not result in normalisation of
smoking – there is no evidence that either
nicotine replacement therapy (NRT) or e-cigarette
use has resulted in renormalisation of smoking. None
of these products has to date attracted significant
use among adult never-smokers, or demonstrated evidence
of significant gateway progression into smoking among
young people
- E-cigarettes and quitting smoking - among
smokers, e-cigarette use is likely to lead to quit
attempts that would not otherwise have happened, and
in a proportion of these to successful cessation.
In this way, e-cigarettes can act as a gateway from
smoking
- E-cigarettes and long-term harm - the possibility
of some harm from long-term e-cigarette use cannot
be dismissed due to inhalation of the ingredients
other than nicotine, but is likely to be very small,
and substantially smaller than that arising from tobacco
smoking.
With appropriate product standards to minimise exposure
to the other ingredients, it should be possible to
reduce risks of physical health still further. Although
it is not possible to estimate the long-term health
risks associated with e-cigarettes precisely, the
available data suggest that they are unlikely to exceed
5% of those associated with smoked tobacco products,
and may well be substantially lower than this figure.
The report acknowledges the need for proportionate
regulation, but suggests that regulation should not
be allowed significantly to inhibit the development
and use of harm-reduction products by smokers. A regulatory
strategy should take a balanced approach in seeking
to ensure product safety, enable and encourage smokers
to use the product instead of tobacco, and detect
and prevent effects that counter the overall goals
of tobacco control policy.
Professor John Britton, chair of the RCP’s Tobacco
Advisory Group, said:
‘The growing use of electronic cigarettes as
a substitute for tobacco smoking has been a topic
of great controversy, with much speculation over their
potential risks and benefits. This report lays to
rest almost all of the concerns over these products,
and concludes that, with sensible regulation, electronic
cigarettes have the potential to make a major contribution
towards preventing the premature death, disease and
social inequalities in health that smoking currently
causes in the UK. Smokers should be reassured that
these products can help them quit all tobacco use
forever.’
RCP president Professor Jane Dacre said:
‘Since the RCP’s first report on tobacco,
Smoking and health, in 1962, we have argued consistently
for more and better policies and services to prevent
people from taking up smoking, and help existing smokers
to quit. This new report builds on that work and concludes
that, for all the potential risks involved, harm reduction
has huge potential to prevent death and disability
from tobacco use, and to hasten our progress to a
tobacco-free society. With careful management and
proportionate regulation, harm reduction provides
an opportunity to improve the lives of millions of
people. It is an opportunity that, with care, we should
take.’
Report summary
Smoking is the biggest avoidable cause of death and
disability, and social inequality in health, in the
UK.
Most of the harm to society and to individuals caused
by smoking in the near-term future will occur in people
who are smoking today.
Vigorous pursuit of conventional tobacco control policies
encourages more smokers to quit smoking.
Quitting smoking is very difficult and most adults
who smoke today will continue to smoke for many years.
People smoke because they are addicted to nicotine,
but are harmed by other constituents of tobacco smoke.
Provision of the nicotine that smokers are addicted
to without the harmful components of tobacco smoke
can prevent most of the harm from smoking.
Until recently, nicotine products have been marketed
as medicines to help people to quit.
NRT is most effective in helping people to stop smoking
when used together with health professional input
and support, but much less so when used on its own.
E-cigarettes are marketed as consumer products and
are proving much more popular than NRT as a substitute
and competitor for tobacco cigarettes.
E-cigarettes appear to be effective when used by smokers
as an aid to quitting smoking.
E-cigarettes are not currently made to medicines standards
and are probably more hazardous than NRT.
However, the hazard to health arising from long-term
vapour inhalation from the e-cigarettes available
today is unlikely to exceed 5% of the harm from smoking
tobacco.
"...the hazard to health arising from long-term
vapour inhalation from the e-cigarettes available
today is unlikely to exceed 5% of the harm from smoking
tobacco"
Technological developments and improved production
standards could reduce the long-term hazard of e-cigarettes.
There are concerns that e-cigarettes will increase
tobacco smoking by renormalising the act of smoking,
acting as a gateway to smoking in young people, and
being used for temporary, not permanent, abstinence
from smoking.
To date, there is no evidence that any of these processes
is occurring to any significant degree in the UK.
Rather, the available evidence to date indicates that
e-cigarettes are being used almost exclusively as
safer alternatives to smoked tobacco, by confirmed
smokers who are trying to reduce harm to themselves
or others from smoking, or to quit smoking completely.
There is a need for regulation to reduce direct and
indirect adverse effects of e-cigarette use, but this
regulation should not be allowed significantly to
inhibit the development and use of harm-reduction
products by smokers.
A regulatory strategy should, therefore, take a balanced
approach in seeking to ensure product safety, enable
and encourage smokers to use the product instead of
tobacco, and detect and prevent effects that counter
the overall goals of tobacco control policy.
The tobacco industry has become involved in the e-cigarette
market and can be expected to try to exploit these
products to market tobacco cigarettes, and to undermine
wider tobacco control work.
However, in the interests of public health it is important
to promote the use of e-cigarettes, NRT and other
non-tobacco nicotine products as widely as possible
as a substitute for smoking in the UK.
21 April 2016
New study finds exhaled
e-cigarette vapour particles disappear within seconds
A new study being presented today at the 4th Workplace
and Indoor Aerosols conference in Barcelona shows,
for the first time, that exhaled e-cigarette particles
are liquid droplets that evaporate within seconds.
The research - a collaboration between Kaunas University
of Technology in Lithuania, EMPA Swiss Federal Laboratories
for Materials Science and Technology, ETH Zurich the
Swiss Federal Institute of Technology and Fontem Ventures
- is the first detailed study of its kind conducted
to investigate particles in exhaled e-cigarette vapour.
Speaking from the conference today, Professor Dainius
Martuzevicius, Vice Dean for Research at the Faculty
of Chemical Technology, Kaunas University of Technology
and leading expert on indoor air quality, said: "There
is little data available on the properties of exhaled
e-cigarette 'particles' in the scientific literature
and as a result there is a growing discussion amongst
the public health community as to whether the 'particles'
exhaled following use of vaping products have potential
implications for indoor air quality."
12 April 2006
Are E-Cigarettes a Healthy
Way to Quit Smoking?
Electronic cigarettes have an unparalleled potential
to reduce the public-health impact of smoking, by
allowing smokers to replace the habit and nicotine
of smoking without the toxic effects of combustion.
-
Dr. Rose is a professor of psychiatry and behavioral
sciences and director of the Duke Center for Smoking
Cessation at Duke University. He can be reached at
reports@wsj.com.
10
April 2016
Wellington
City Council to discuss banning smoking and also e-cigarettes
(Vaping)
Question
to the Committee: what is the harm of developing dependence
on a low cost non-fatal device?
A
committee of the Wellington City Council is about
to ban use of e-cigarettes on its properties. The
debate is on 13 April.
According
to Dr Joe Nitzkin, former chair of tobacco control
for the College of Public Health Medicine in the USA:
The
bottom lines are these:
1)Imposing
restrictions and increasing taxes on cigarettes and
smoking will reduce tobacco-related addiction, illness
and death.
2)Imposing
these same restrictions and taxes on e-cigs will have
the opposite effect. It will discourage smokers who
would otherwise switch to keepsmoking.
3)
Vaping is not smoking and should not be defined as
such.
1
January 2016
Prices
exceed $1 per cigarette
As
from 1 January 2016 the following prices have been
charged, representing a 10.3% in excise and inflation
as well as similar increases in ex-factory price.
Port
Royal $78 for 50 g. ($1.09 per cigarette of 0.7 g).
Pall
Mall $21.60 for 20 cigarettes.($1.08 per cigarette).
7
December 2015
NHS to give out e-Voke
E-voke has been licensed by Medicines and Healthcare
Regulatory Agency for medicinal use. The aim
is to have these gadgets available for prescription
by GPs in 2016.
E-vokes are not an e-cig. They rely on producing
a powder, like an inhaler.
Vype e-cigarettes have been licensed but will not be
available for some time.
Both
products are produced by BAT.
C. Wheeler. Express. 7 December
and ASH UK 8 December.
1 December 2015
Excise expected
to rise 10.3%
on 1 Jan 2016
According to NZ Customs Service the
new rates will be $668.51 per 1000 cigarettes as from
1 January. Smoking tobacco will cost $666.83 per kg
of tobacco content. This amounts to an increase of
10.3% in tobacco price since 1 January 2015. This
means a cigarette costing $20 in 2015 could cost $22.06
in 2016, assuming tobacco companies also raise their
price by the same percentage.
30
November 2015
Viewpoints:
Is the jury still out on e-cigarettes?
Monday, November 30, 2015
http://www.drugfoundation.org.nz/matters-of-substance/november-2015/viewpoints/e-cigarettes
Short of a pill that will magically take addiction
away, are e-cigarettes the best smoking cessation
device since the humble patch? Or are they just another
dangerous addiction,?a gateway device for children
or, worse, a sneaky attempt by Big Tobacco to renormalise
smoking?
In the May 2012 Viewpoints, Matters of Substance
compared the arguments and decided the jury was still
probably out on e-cigarettes. A recent report by Public
Health England, however, has become the first authoritative
declaration that e-cigarettes are safer than cigarettes
and by a significant margin.
In this edition, we take a look at the English report
and at one of its detractors. Is the jury still out,
and should we bother waiting?
Public Health England
In August 2015, Public Health England (PHE) published
its commissioned report E-cigarettes: an evidence
update, which summarised the findings from two extensive
literature reviews.
The report’s conclusions were almost startling.
It said the evidence suggests using e-cigarettes is
95 percent safer than smoking and that e-cigarettes
have the potential to make a significant contribution
to the endgame for tobacco. Its policy recommendations
included making e-cigarettes much more prominent in
smoking cessation initiatives and streamlining convoluted
processes for them to be licensed as quit-smoking
aids.
Among the report’s findings was that e-cigarette
use by people who had never smoked was extremely low,
at around 0.2 percent. Regular use (at least once
weekly) by young people is also very rare at just
2 percent, and while there is some youthful experimentation,
only 0.3 percent of young people who used e-cigarettes
had never smoked tobacco before. It said the most
important reason people use e-cigarettes is to reduce
smoking- related harms and that, while curiosity plays
a role in why some people experiment with them, most
of these experiments did not lead to regular use.
It concluded from this that e-cigarettes are “not
undermining, and may even be contributing to, the
long-term decline in cigarette smoking”.
The report made much of a September 2014 Cochrane
Review, Electronic cigarettes for smoking cessation
and reduction, featuring New Zealanders Hayden McRobbie
and Chris Bullen amongst its authors. The review’s
meta-analysis of 600 records found that e-cigarettes
can “help smokers unable to stop smoking ...
to reduce their cigarette consumption when compared
with placebo e-cigarettes and nicotine patches”.
The PHE report also found e-cigarettes do not replicate
the problems of second-?hand smoke. They release “negligible
levels of nicotine into ambient air with no identified
health risks to bystanders”. No concerns were
found around the labelling of nicotine cartridges
or ‘e-liquids’, and when they were poorly
labelled, they mostly contained less nicotine than
declared. While acknowledging nicotine is a poison,
the report found no evidence of nicotine poisoning
to users. The risks of poisoning to others (such as
children) or of evices causing fires were found to
be on a par with other household electrical goods
or substances.
The report’s authors discount recent news headlines
reporting high levels of formaldehyde found in e-cigarettes
as misinterpretations of research findings. They found
no indication electronic cigarette users are exposed
to dangerous levels of aldehydes and said this could
only happen when e-liquid was heated to “levels
unpalatable to users”. Instead, they assert that
most of the chemicals causing smoking-related diseases
are absent in e-cigarettes and that those that are
present pose limited danger.
PHE’s findings have been supported by a number
of high-profile medical experts, including UK’s
Chief Medical Officer Dame Sally Davies. A September
2015 British Journal of General Practice editorial
concluded that, for every million smokers who switched
from tobacco to e-cigarettes, more than 6,000 premature
deaths would be prevented in the UK every year. If
all 9 million smokers took up e-cigarettes instead,
54,000 lives could be saved.
Critique of PHE
The PHE research will probably be music to the ears
of the millions of smokers around the world who have
turned to e-cigarettes but who may still have niggling
doubts that their new drug delivery device is really
all that better for their health.
But in one of the greatest parade-raining articles
so far this century, Martin McKee and Simon Capewell,
writing in the British Medical Journal, are scornful
of the research and suggest its foundation is built
on sand.
First, they say a recent cohort study shows most
smokers who switch to e-cigarettes (80 percent) are
still also smoking cigarettes at 12 months (dual use)
and that reduced smoking may not reduce overall risk
of death.
Next, they attack the Cochrane report, on which the
PHE report relies heavily, by pointing out that it
included only two randomised controlled trials and
that, by its own admission, its evidence had limitations
and was of “low or very low” quality.
The claim that e-cigarettes are 95 percent safer
gets a particular hiding. McKee and Capewell cite
a recent systematic review in Preventative Medicine
that found serious methodological problems in many
of the studies it reviewed and so many conflicts of
interest “that no firm conclusions can be drawn
about the safety of e-cigarettes” but that “they
can hardly be considered harmless”. They also
point out the 95 percent figure does not come from
a review of the evidence but from a single meeting
of 12 people convened to synthesise their opinions
on the harms associated with different products containing
nicotine. They point out two of those present had
received tobacco industry funding in the past and
that some other attendees were known e-cigarette champions
McKee and Capewell also dispute the report’s
finding that e-cigarettes are not helping to renormalise
smoking. They say a July 2015 survey by the Health
and Social Care Information Centre showed more than
20 percent of 11–15-year-olds had used e-cigarettes,
and 73 percent of these were non-smokers. An American
study, published after the PHE report, they say, concluded
that “those who had ever used e-cigarettes at
baseline compared with non-users were more likely
to report initiation of combustible tobacco use over
the next year”.
The McKee and Capewell rebuttal, which points out
a number of further perceived problems and inconsistencies,
does not claim to prove e-cigarettes are as harmful
as smoking tobacco. Rather,?its contention is that
the PHE report isn’t sufficiently evidence based
to underpin changes in public health policy. And therein
lies the rub.
The precautionary principle: for
Many of those opposing e-cigarettes rely pretty heavily
on the precautionary principle. It’s a bit like
insisting that policy must be evidence based but goes
a small step further.
The precautionary principle states that, if an action
or policy has a suspected risk of causing harm and
there is no scientific consensus that the action or
policy is not harmful, the burden of proof that it
is not harmful falls on those taking an action. In
other words, it doesn’t matter that common sense
suggests breathing in vapour containing a handful
of chemicals is better than breathing in smoke containing
hundreds. Until there is enough evidence to provide
scientific consensus that e-cigarettes are safe, we
cannot endorse them. This is the view taken by the
World Health Organization and by our own Ministry
of Health, which currently refuses to recommend any?use
of e-cigarettes.
That sort of scientific consensus is probably a long
way off. There is little available research on the
long-term effects of e-cigarettes because they just
haven’t been around long enough.
The precautionary principle: against
Massey University Associate Professor Marewa Glover,
who also chairs End Smoking NZ, is less a fan
of the precautionary principle when it comes to public
health policy. She points out the precautionary principle
was used first in the environmental risk arena and
that there aren’t any real grounds for transferring
it to public health.
“Disease and illness are well established areas,
and we have well established practices determining
risks to health so we don’t need to rely so heavily
on such a ‘guilty until proven innocent’
approach,” she says.
In a randomised controlled trial, where the particular
new drug being investigated is clearly working and
alleviating harm for the intervention group receiving
it, a point is reached where it becomes unethical
to continue withholding that drug from the control
group. Glover thinks the situation is very similar
with e-cigarettes.
“E-cigarettes are clearly working in terms of
helping people stop smoking – far more than anything
we’ve seen so far. We may not have had many randomised
controlled trials yet, but the evidence is definitely
mounting, so why make it difficult for people who
want to use them?”
She also points out there’s an “uncanny
exchange” between falls in smoking rates and
rising e-cigarette use in the US and the UK that strongly
suggests e-cigarettes help people quit.
“And then there’s the anecdotal stories
from millions of people who say their health has improved
or that e-cigarettes have saved their lives.?The precautionary
principle is being used by people who fear another
industry-driven epidemic. But an epidemic of what?
What’s the disease?”
Is the jury still out in terms of the safety of e-cigarettes?
Not at all, Glover says.
“But the jury is absolutely in on how dangerous
smoking is, and there’s ample evidence of its
harm. With e-cigarettes, there is no evidence of acute
or longitudinal harm whatsoever, even though researchers
are looking for it.”
You can buy e-cigarette devices in New Zealand, but
nicotine must be ordered in from overseas because
it is not licensed here for non-medicinal sale. The
case is similar in most jurisdictions, and it’s
a major impediment, especially if you’re not
well off.
Nevertheless, e-cigarette use is growing just about
everywhere, suggesting a lot of smokers aren’t
bothering to wait for the jury. The day is probably
coming when stances soften and e-cigarettes become
more officially sanctioned – perhaps not because
there’s been a rush of irrefutable evidence but
because our government and Ministry of Health suddenly
find themselves woefully behind the times. There’s
little doubt e-cigarettes are here to stay.
9
November 2015
How
cigarette mortality applies to NZ
smokers
Knowing
that smoking kills half of current
smokers,
but e-cigarettes do not, it can be
calculated
that if NZ has 0.6 million smokers
as
at present, a total switch of those smokers
to
e-cigarettes would have the eventual effect of saving
half
of those smokers (300,000) from predictable
deaths
due to smoking. If however,
only half
switch
to E-cigarettes, smoking deaths
would
decrease by 150,000 over the
next
15 years.
2
October 2015
Cigarette
consumption, NZ 2014
For
the years 2010-2014 the average drop
in consumption was 6.3% across New Zealand,
and
the fall was 23%. For 2013-4 the fall was 3.8%.
This
was the sum of changes in factory-made and
roll-your-own
cigarettes. In March 2013 the Census
showed
that a total of 15.1% of adults smoked daily.
In
2014 a total of 1% of smokers consumed e-cigarettes
daily.
1
Oct 2015
Reduced
nicotine cigarettes reduces nicotine exposure
In
this 6-week study 780 smokers (unwilling to quit smoking)
of reduced nicotine cigarettes versus standard cigarettes,
reduced their nicotine exposure, and dependence on
nicotine, and number of cigarettes smoked, as well
as craving during abstinence from smoking. Compensation
was minimal.
Donny
E. et al. Randomised trial of reduced-nicotine standards
for cigarettes. N. Engl J Med 2015 Oct 1;313:
340-349.
http://www.nejm.org/doi/pdf/10.1056/NEJMsa1502403
NB:
this study argues that reduced nicotine in the cigarette
means reduced addiction, and increased effect from
increased taxation.
19 August 2015
Give
out e-cigarettes free in England, doctors told
Doctors
should be able to prescribe
E-cigarettes
says Public Health England,
as
it tried to debunk the myth that 'vaping'
was
as bad for health as inhaling tobacco
smoke..
If all of England's eight million
smokers
switched to e-cigarettes overnight,
over
75,000 lives a year would be saved,
experts
say. Not only are e-cigarettes 20
times
less dangerous than tobacco, they
are
also among the most effective quitting
aids,
they added.
Kim
Lay, The Times London.
http://www.thetimes.co.uk/tto/health/
news/article4531500.ece
17 July 2015
Ex-smokers
know a thing or two about nicotine!
In
the USA, in 2014, 16.7% of adults smoked.
In
the USA, 6.3 million smokers used e-cigarettes, and
22% used them daily.
Of
nearly 2 million ex-smokers 63% use e-cigarettes daily,
and obtained their nicotine only from e-cigarettes.
(Vaping
nicotine e-cigarettes is illegal in NZ, but smoking
cigarettes which gives more nicotine is legal!)
Rodu
B. 30 million US adults have used e-cigarettes, unpublicised
CDC data reveals. Tobacco Truth. 14 July 2015.
(based on the 2014 National Health Interview Survey,
released June 29).
http://rodutobaccotruth.blogspot.co.nz/2015/07/30-million-have-used.e.html
1 Jan 2015
Excise and price up again
in 2015
Excise up 10% and price of 20 cigarettes reaches
$20, and for 30g RYOs, reaches $30.50. Excise will
increase again on 1 Jan 2016.
2 Jan 2014
Murray Laugesen. Nicotine and Health – American Council on Science and
Health, New York.
Of
special interest to smoking cessation experts and
policy makers.
This world-first publication
(71 pages, 137
references) details
1 How nicotine affects your
health
2 How smokeless affects your
health
3 Electronic cigarettes.
To view the free copy see http://acsh.org/2014/01/effects-nicotine-human-health/
(and download.)
For
more details please see
www.healthnz.co.nz/News2013
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