Tobacco Harm Reduction and electronic cigarettes:

Towards a Public Health response

Martin Dockrell, Tobacco Control Programme Lead, Public Health England

The best thing a smoker can do is to quit completely, immediately and forever

2

The best thing a smoker can do is to quit completely, immediately and forever…

… but not all smokers feel willing or able to do that.

3

Tobacco harm reduction is nothing new

4

Over the years we have offered “alternatives” to stopping, completely, now and forever including:

• Smokefree homes

• Stop before the Op

• Cut Down To Quit

• Quitting during pregnancy

• even Stoptober

2008: Beyond Smoking Kills

5

6

2013: NICE Guidance

Immediately? Let’s make a date

Completely? Cut down (to quit)

Forever?

Or quit for a bit?

2014: A local approach

7

Anatomy of an e-cigarette

Development of devices

Toxicants in e-cigarettes?

Other than nicotine, what else do e-cigarettes deliver?

A number of studies have looked at this, with at least 8 toxic compounds identified

However all of these were at significantly lower levels than in conventional cigarettes

• Small study conducted by Goniewcz and colleagues involving 20 tobacco cigarette smokers

• Subjects were provided with electronic cigarettes with cartridges containing nicotine

• Subjects were asked to substitute their regular cigarettes with e-cigarettes for 2 weeks

• Researchers measured nicotine and selected carcinogens in their bodies

Exposure to toxicants after switching

Nicotine & Tobacco-specific Nitrosamines

2016 “Twin track” regulation

13

Medicine’s “walled garden”? • “Safe” and “effective”

• Therapeutic dose

• Advertising

• VAT 5%

EU’s “Nicotine Jungle”?

• Health warning on pack

• Concentration cap

• No health claims

• Ad ban

• 20% VAT

• Declaration of additives

Risks of e-cigarettes

14

What if…

• Marketing and use “Renormalise” smoking”?

• A “gateway” to smoking?

• Defers quit attempts?

• Undermines quit attempts (less effective than NRT)?

• Accidental poisonings?

• Big Tobacco’s Trojan Horse?

Opportunities of harm reduction

15

What if…

• Marketing and use “denormalise” smoking”?

• As effective as NRT, just much more popular?

• Even smokers who don’t intend to quit, just do?

• Smoking is denormalised because more smokers quit?

• They replace smoking?

Risks of over-regulation

16

What if…

• We rescue Big Tobacco from an “existential threat”

• We prevent smokers from modelling the denormalisation of smoking?

• We force half our quitters to stand with the smokers?

• We keep all but Big Tobacco out of the NCP market?

• We keep smokers smoking?

17

What does the evidence tell us?

E-cigarette use among smokers

18

ASH/YouGov March April 2014,

Current e-cigarette use among adults in England 2014

19

Non smokers Ex-smokers Current smokers0%

5%

18%

ASH/YouGov March April 2014, Sample in England 10,112

Use among children in GB 2013

95%

90%

4%

8%

1%

1%

0%

1%

0% 25% 50% 75% 100%

11 to 1

5 (

N=

804)16 to 1

8 (

N=

624)

I use them often(more than once aweek)

I use them sometimes(more than once amonth)

I have tried them onceor twice

I have never usedthem

99%92%

82%74%

59%

39%

8%

7% 18%37%

48%

6%4%

7%4%5%

0%

25%

50%

75%

100%

Neversmoked

Tried smokingonce

Used tosmoke

Smoke <1 aweek

Smoke 1-6 aweek

Smoke 6+ aweek

Don't know/Wouldn't say

I use them often(more than once aweek)

I use themsometimes (morethan once a month)

I have tried themonce or twice

I have never usedthem

Source: ASH, 2014

Frequency of e-cigaretteuse amongst 11-18 year oldswho had ever heard ofe-cigs

E-cigarette use by smokingstatus, 11-18 year olds

Use by children: USA

Source: US CDC data from National Youth Tobacco Survey 2011 and 2012. Graph from Bates & Rodu

Smoking prevalence is falling

22

2008 2009 2010 2011 2012 2013 20140%

5%

10%

15%

20%

25%

30%

24%22%

21% 21%

19% 17%16%

22%22%

21% 21%

20% 19%18%

21% 21%20% 20% 20%

ASH/YouGov

STS

GLS

ASH/YouGov, UCL Smoking Toolkit Study, General Lifestyle Survey

23

2011

-2

2011

-3

2011

-4

2012

-1

2012

-2

2012

-3

2012

-4

2013

-1

2013

-2

2013

-3

2013

-4

2014

-10

5

10

15

20

25

30

35

40

45

50

E-cigsNRT OTCNRT RxChampixBeh'l supp

Pe

rce

nt

of

smo

kers

try

ing

to

sto

p

Increase in use of e-cigarettes for quitting has been accompanied by a smaller reduction in use of other aids except behavioural support

NCPs have overtaken OTC NRT

Smoking Toolkit Study 2014 courtesy of Prof Robert West

More smokes are using “clean nicotine”

24

2011

-2

2011

-3

2011

-4

2012

-1

2012

-2

2012

-3

2012

-4

2013

-1

2013

-2

2013

-3

2013

-4

2014

-10

5

10

15

20

25

30

35

40

45

50

E-cigsNRTAll nicotine

Pe

rce

nt

of

smo

kers

Increase in use of e-cigarettes while smoking has more than offset a decrease in NRT use

Smoking Toolkit Study 2014 courtesy of Prof Robert West

25

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

0

1

2

3

4

5

6

7

8

9

10

Pe

rce

nt

wh

o h

ave

sm

oke

d in

th

e p

ast

ye

ar

wh

o d

o n

ot

smo

ke n

ow

There has been an increase in the rate of quitting smoking

More smokers are quitting

Smoking Toolkit Study 2014 courtesy of Prof Robert West

26

2011-2

2011-3

2011-4

2012-1

2012-2

2012-3

2012-4

2013-1

2013-2

2013-3

2013-4

2014-1

0

5

10

15

20

25

CigarettesNicotine or cigarettes

Pe

rce

nt

smo

kin

g c

igs

or

usi

ng

nic

otin

e

Cigarette consumption has decreased as has overall nicotine use

Fewer people are using nicotine

Smoking Toolkit Study 2014 courtesy of Prof Robert West

27

2007 (N=2533)

2008 (N=1829)

2009 (N=1833)

2010 (N=2068)

2011 (N=1637)

2012 (N=1627)

2013 (N=1729)

2014 (Feb)

(N=271)

0

5

10

15

20

25

30

15.714.1 13.6 13.4 13.7

17.615.8

22.3

Per

cent

Quit success has increased

Quit attempts are more effective

Smoking Toolkit Study 2014 courtesy of Prof Robert West

Evidence for optimism?

28

With 80,000 smoking deaths per year, the stakes are high but so far in England, NCPs

• Have not reduced quit attempts

• Have not made quit attempts less effective

• Have not increased nicotine addiction

• Have not caused smoking rates to rise

• Have not resulted in non smokers becoming smokers or even regular nicotine users

Marketing and use of NCPs have the potential both to denormalise and renormalise smoking

A Public Health response?

29

• It is always best for smokers to quit, immediately, completely and forever and we must remain vigilant

• Licensed NCPs can help smokers, even those who don’t want quit

• We can support denormalisation and prevent renormalisation

• Reduce public confusion: “Vaping” isn’t smoking

• Vaping may be safer than smoking, but we should always advise vapers to use the safe and effective option

• “Right touch” regulation can bring more products, smokers and choice into the “walled garden”.

Points for discussion

• In the struggle to reduce preventable mortality, how do we balance the risks?

• What are the ongoing evidence needs and how do we address them?

• Do we need to test diverse responses or do we need a “one size fits all” international response now?

• How do we manage tobacco industry involvement and what scope is there to use the Framework Convention on Tobacco Control?

30