The e-cigarette: opportunity or threat?

SSA Annual Symposium 2015Deborah ArnottChief ExecutiveAction on Smoking and Health

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

BUT: significant and widening gap between rich and poor

2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020

Year

0

10

20

30

40

Cig

aret

te s

mo

kin

g %

3533

32 32

34

31 3130

29 3028

2927

32

Routine & manual

20 21 20 1917

19 1817 17 16 16

15 16 16

Non-routine

11.3

25.3

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. BMJ1976;1:1430–3

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 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 and are using 2010 - 2015

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

10

N=10078 adults who smoke and tried to stop or who stopped in the past year

E-cigarette use for quitting is still increasing somewhat

Aids used in most recent quit attempt

11N=9783 adults who smoke and tried to stop or who stopped in the past year; 2009 is Jul to Dec

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

Least effective

Moderately effective

Most effective

Courtesy of Prof John Britton, Nottingham

Cigarette smoked

Study conclusion: “e-cigarettes used under real-conditions emit toxicants, including PM2.5”

E-cigarette puff

Children who have never smoked rarely use electronic cigarettes

14

Youth smoking in England

15

Yet controversy abounds

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:

•Harm caused by tobacco

•Nicotine addiction

•Tobacco industry

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

20

Tobacco Products Directive regulation of electronic cigarettes

MHRA licenced Nicotine Containing Products (NCPs) including e-cigs

Products not available on prescription Products available on prescription

20% VAT 5% VAT

Cross border advertising banned by 2016; up to Member States to decide on domestic advertising (billboards, Point of Sale, buses etc.)

Advertising allowed – under OTC rules so no celebrity endorsement or free samples and must be targeted at adult smokers etc.

Products widely available Products available on general sale (GSL)

Can’t make health claims Can make health claims

Upper limits for nicotine content will be set and likely to be in force by 2017.

MHRA regulation is flexible; there are no upper limits.

30% health warning on packs about nicotine on front and back of packs

No health warnings on 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 could be higher for electronic cigarettes.

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.arnott@ash.org.uk