E-Cigarettes - how should Public Health respond - Martin Dockrell

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

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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

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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

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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

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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

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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

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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?

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What does the evidence tell us?

E-cigarette use among smokers

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ASH/YouGov March April 2014,

Current e-cigarette use among adults in England 2014

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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

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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

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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”

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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

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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

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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

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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?

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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?

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• 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?

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