The ecigarette opportunity or threat SSA Annual Symposium

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The e-cigarette: opportunity or threat? SSA Annual Symposium 2015 Deborah Arnott Chief Executive Action

The e-cigarette: opportunity or threat? SSA Annual Symposium 2015 Deborah Arnott Chief Executive Action on Smoking and Health

What we’re going to cover • • • Tobacco use: the context Harm reduction:

What we’re going to cover • • • Tobacco use: the context Harm reduction: the obvious next step Why e-cigs challenge the consensus What’s the evidence Building support for an evidence-based approach • Lessons learnt

UK: world leader in TC

UK: world leader in TC

BUT: significant and widening gap between rich and poor

BUT: significant and widening gap between rich and poor

Harm reduction: obvious next step “People smoke for nicotine but they die from the

Harm reduction: obvious next step “People smoke for nicotine but they die from the tar” Russell MAH. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976; 1: 1430– 3

Key principles of THR • Smoke not nicotine primary cause of death and disease

Key principles of THR • Smoke not nicotine primary cause of death and disease • Quitting completely best option • Smokers switching to alternative nicotine sources can substantially reduce harm • Need to minimise risks of uptake by youth and never smokers

Solid foundations in England: Building support for harm reduction policy • MHRA remit to

Solid foundations in England: Building support for harm reduction policy • MHRA remit to protect public health – liberalises NRT regulation from 2005 on • RCP harm reduction report 2007 • Beyond Smoking Kills 2008 – harm reduction principles endorsed by over 100 health orgs • DH tobacco strategy endorses harm reduction 2010 and 2011

Principles into practice: e-cigarettes – a disruptive technology % of smokers who have tried

Principles into practice: e-cigarettes – a disruptive technology % of smokers who have tried and are using 2010 - 2015

Principles into practice: e-cigarettes % of ex-smokers and never smokers who have tried and

Principles into practice: e-cigarettes % of ex-smokers and never smokers who have tried and are using 2010 - 2015

Aids used in most recent quit attempt E-cigarette use for quitting is still increasing

Aids used in most recent quit attempt E-cigarette use for quitting is still increasing somewhat N=10078 adults who smoke and tried to stop or who stopped in the past year 10

Aids used in most recent quit attempt Least effective Moderately effective Most effective E-cigarettes

Aids used in most recent quit attempt Least effective Moderately effective Most effective E-cigarettes have grown the use of moderately effective aids to cessation from 24% to 35%; use of most effective methods has decreased from 4% to 3% At stable quit attempt rate of 37% this contributed 0. 05% to the decreased prevalence (~20, 000 additional ex-smokers) Approx odds of success relative to nothing and NRT-OTC: 1. 5 Moderately effective 3. 0 Most effective N=9783 adults who smoke and tried to stop or who stopped in the past year; 2009 is Jul to Dec 11

Courtesy of Prof John Britton, Nottingham

Courtesy of Prof John Britton, Nottingham

Cigarette smoked E-cigarette puff Study conclusion: “e-cigarettes used under realconditions emit toxicants, including PM

Cigarette smoked E-cigarette puff Study conclusion: “e-cigarettes used under realconditions emit toxicants, including PM 2. 5”

Children who have never smoked rarely use electronic cigarettes 45% Tried smoking 77% Regular

Children who have never smoked rarely use electronic cigarettes 45% Tried smoking 77% Regular smoker 61% Occasional smoker Former smoker 34% 4% Never smoker 0% % who have tried e-cigarettes 10% 20% 30% 40% 14 50% 60% 70% 80% 90%

Youth smoking in England 15

Youth smoking in England 15

Yet controversy abounds

Yet controversy abounds

Why the controversy? Historic goals of tobacco control are to eliminate: • Harm caused

Why the controversy? Historic goals of tobacco control are to eliminate: • Harm caused by tobacco • Nicotine addiction • Tobacco industry

Answer: ecigs threaten the consensus Historic goals of tobacco control are to eliminate: •

Answer: ecigs threaten the consensus Historic goals of tobacco control are to eliminate: • Harm caused by tobacco • Nicotine addiction • Tobacco industry

Harm reduction policy in England: Building on our foundations While ecigs banned in many

Harm reduction policy in England: Building on our foundations While ecigs banned in many jurisdictions not in UK: • DH tobacco strategy endorses harm reduction 2010 and 2011 • NICE guidance Tobacco Harm Reduction 2013 • PHE report and position statement 2015 • Prisons going smokefree allow ecig use October 2015 • UK pursuing twin track regulatory approach – opt in for medicines regulation • If not regulated as medicines then will come under the EU Tobacco Products Directive from 2016

Twin track regulatory approach from 2016 Tobacco Products Directive regulation of electronic cigarettes MHRA

Twin track regulatory approach from 2016 Tobacco Products Directive regulation of electronic cigarettes MHRA licenced Nicotine Containing Products (NCPs) including e-cigs Products not available on prescription 20% VAT Cross border advertising banned by 2016; up to Member States to decide on domestic advertising (billboards, Point of Sale, buses etc. ) Products available on prescription 5% VAT Advertising allowed – under OTC rules so no celebrity endorsement or free samples and must be targeted at adult smokers etc. Products widely available Can’t make health claims Upper limits for nicotine content will be set and likely to be in force by 2017. Products available on general sale (GSL) Can make health claims MHRA regulation is flexible; there are no upper limits. 30% health warning on packs about nicotine No health warnings on packs on front and back of packs Member States retain powers e. g. on flavours, domestic advertising. Flavours require a marketing authorisation Children and Families Bill allows for age of sale of 18 for nicotine products. Age of sale 12 but can be varied by product so 20 could be higher for electronic cigarettes.

Lessons learnt • Harm reduction has great potential to reduce the death and disease

Lessons learnt • Harm reduction has great potential to reduce the death and disease caused by smoking • Electronic cigarettes have a role to play Highly controversial so: • Building and disseminating evidence base essential if sensible policies are to prevail • It’s working in England to date… question is how do we ensure this continues in the new regulatory environment?

And finally…. www. ash. org. uk deborah. arnott@ash. org. uk

And finally…. www. ash. org. uk deborah. [email protected] org. uk

And finally…. www. ash. org. uk deborah. arnott@ash. org. uk

And finally…. www. ash. org. uk deborah. [email protected] org. uk