Transcript Electronic cigarettes

Electronic cigarettes:
research, policy and
practice
Deborah Arnott
Chief Executive
Action on Smoking & Health
Use of electronic cigarettes
Growth in use of electronic
cigarettes in Britain
• E-cigarette use is growing rapidly: from 700k in
2012 to 1.3 million in 2013 to 2.1 million in 2014
• Two thirds of electronic cigarette users current
smokers and a third ex-smokers
• Little use by non-smokers either adults or young
people
• No evidence so far electronic cigarettes leading
to renormalisation of smoking
Use among British smokers has
grown rapidly
E-cigarette use among British smokers, 2010-14
Sustained use among adults is confined to
smokers & ex-smokers
E-cigarette use in Britain, 2014
(All adults)
Helping smokers to quit?
Most users motivated by
quitting or preventing relapse
Smokers motivated to quit and/
or reduce harm
Electronic cigarettes now most
popular support when quitting
N=4,540 adults who smoke and tried to stop or who stopped in the past year
RCT indicates as effective as
OTC NRT
Italian study (Caponnetto et al. 2013)
• 7.2mg nicotine EC vs. 4.8mg nicotine EC vs. no
nicotine EC
• 300 smokers (unwilling to quit)
• 1 year abstinence rates: 13%, 9% and 4%
Auckland study (Bullen et al. 2013)
• ‘Elusion’ 16mg nicotine EC vs. nicotine patch vs.
no nicotine EC
• 657 participants
• 6 month abstinence rates: 7.3%, 5.8% and 4.1%
Real world study indicates
more effective than OTC NRT
• Lowest
• Nothing or NRT bought from a store
• Higher
• Prescription NRT/medicine or e-cigarette
from a store (about 50% better)
• Highest
• Specialist support from NHS Stop-Smoking
Service (about 200% better)
Use of these methods since
advent of e-cigarettes
100%
90%
80%
The use of ‘higher’ success
methods has increased but use
of ‘highest’ success methods
remains very low
70%
60%
50%
40%
30%
20%
10%
0%
2009
2010
2011
2012
2013
2014
Smokers who don’t intend to quit
appear to be more likely to
Cigarette consumption after 24 weeks e-cig use among smokers not wanting to quit
35%
33%
30%
25%
23%
20%
15%
13%
10%
5%
0%
50% reduction
80% reduction
abstinence
Effect of e-cigarette on smoking reduction and cessation: a prospective 6-month pilot study. Polosa et al, BMC Public Health
2011;11:786
Increase in the rate of
quitting smoking
Cigarette consumption has
decreased as has overall
nicotine use
NCSCT guidance to stop
smoking services
• Electronic cigarettes can reduce urges to smoke
and can help smokers quit, although these data
are not as robust as those for licensed stop
smoking medicines
• Be open to electronic cigarette use in people
keen to try them; especially in those that have
tried, but not succeeded, in stopping smoking
with the use of licensed stop smoking medicines
• Provide advice on electronic cigarettes
16
NCSCT guidance to stop
smoking services
Advice to clients. Electronic cigarettes can:
• provide some of the nicotine that would have otherwise been
obtained from smoking regular cigarettes
• are not a magic cure, but some people find them helpful for
quitting, cutting down their nicotine intake and managing
temporary abstinence
• clients may need to try various brands, flavours and nicotine
dosages before they find a brand that they like
• Electronic cigarette use is not exactly like smoking and users may
need to experiment and learn to use them effectively
• Although some health risks from electronic cigarette use may yet
emerge, these are likely to be, at worst, only a small fraction of the
risks of smoking.
17
Normalising smoking?
Children who have never smoked
rarely use e-cigarettes
E-cigarette use among children in Britain, 2013
(Children who have heard of e-cigarettes, by smoking status)
100%
8%
4%
7%
6%
4%
5%
7%
Don't know/
Wouldn't say
18%
I use them often
(more than once a
week)
37%
75%
48%
50%
99%
I use them
sometimes (more
than once a month)
92%
82%
74%
I have tried them
once or twice
59%
25%
39%
I have never used
them
0%
Never
smoked
Tried smoking
once
N=1042
N=177
Used to
smoke
N=64
Smoke <1 a Smoke 1-6 a Smoke 6+ a
week
week
week
N=65
N=22
N=53
Weekly use is confined to older
children
11 to 15 (N=804)
16 to 18 (N=624)
E-cigarette use in Britain, 2013
(Children who have heard of e-cigarettes, by age)
1%
I use them often
(more than once a
week)
1%
8%
90%
I use them sometimes
(more than once a
month)
I have tried them once
or twice
0%
1%
I have never used
them
4%
95%
0%
25%
50%
75%
100%
If electronic cigarettes were
renormalising smoking…
What would be the proof?
• Smoking would start to go up again
• Amongst adults and youth
Is that what we’re seeing?
Adult and youth smoking in
England
%
E-cig sales
start taking off
What about e-cigs in the US?
“The % of US middle
and high school
students doubled from
2011 to 2012”
“The increased use of
e-cigarettes by teens is
deeply troubling”
Tom Frieden Director
CDC
US CDC data from National Youth Tobacco Survey 2011 and 2012
Electronic cigarettes
use in 11-18 year olds
US CDC data from National Youth Tobacco Survey 2011 and 2012
US data from CDC shows
similar pattern to England
Cigarette and e-cigarette prevalence in US youth
Percent using in last 30 days
18
0.3
16
1.2
0.6
14
2.2
12
10
8
6
4
2
E-cigarettes only
14.6
11.8
0.3
0.3
4.0
Cigarettes only
0.4
0.7
2.8
0
2011
2011
2012
Middle School (age 11-14)
Both
2012
High School (age 14-18)
CDC National Youth Tobacco Survey 2012 (US data: November 2013)
US CDC data from National Youth Tobacco Survey 2011 and 2012
analysis Clive Bates and Brad Rodu
Concerns about marketing of electronic
cigarettes to young people
• To smokers:
– Good for cutting down, switching,
using at times when cannot smoke
– Healthier than tobacco, less
expensive
• To young people/non-smokers:
– Socially attractive, pleasurable, cool
– Celebrity endorsement, sport
sponsorship
– Social media, price promotions
ASH response to CAP consultation
• Un-licenced NCPs should be consistent with that
for licenced products.
• NCPs should not be advertised or promoted in
ways that could reasonably be expected to
promote smoking of tobacco products.
• Advertised as an alternative to smoking
cigarettes or other tobacco products.
• Not advertised in ways that could reasonably be
expected to make them appealing to nontobacco users or children and young people.
Future regulation provides more
protection
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
could be higher for electronic cigarettes.
Use in public places
Undermining smokefree
legislation?
• No evidence of decrease in compliance to
date apart from anecdote
• CIEH have stated that officers should be
able to tell the difference
• Individual organisations free to create their
own policy
Is there a case for prohibiting
use in work places?
• Harm from secondhand vapour?
PHE review of the evidence “The health risks of passive
exposure to electronic cigarette vapour are… likely to
be extremely low”.
• Normalise smoking for children?
No evidence of this to date – youth smoking rates
continue to decline.
• Undermine smokefree legislation?
No evidence to date
• Others irritated by vapour
A matter for legislation?
Are there risks from prohibiting
use in workplaces?
• Sets a poor precedent if not an evidence based policy
• Penalise those quitting by encouraging vapours and
smokers to share the same space
• Communicate wrong message about relative safety
compared with tobacco
• Reinforces similarities between products rather than
emphasises differences
• Missed opportunity of attracting smokers not ready to
quit to a harm reduction approach
• Challenges from those prescribed or using licenced
medicines to quit smoking
Organisational policy options if
there isn’t a blanket prohibition
Complete
prohibition
•
•
•
Where
appropriate:
Schools?
Who could
benefit: Protect
non-smoking
young people
Who might it
disadvantage:
Young people and
adults trying to quit
Qualified use
• Where appropriate:
Hospitals? Prisons?
Adult only
workplaces?
• Who could benefit:
Those trying to quit,
smokers engaged in
temporary
abstinence
• Who might it
disadvantage: Noone? If in
appropriate places?
Complete
freedom
• Where appropriate:
Adult only workplaces?
• Who could benefit:
Those trying to quit,
smokers engaged in
temporary abstinence
• Who might it
disadvantage: Coworkers irritated by
vapour
Useful evidence + policy positions
• Public Health England
– Evidence papers. Policy position in favour of regulation of electronic cigarettes as
medicines. http://tinyurl.com/qfgtcww
• NICE guidance on tobacco harm reduction
– Prioritises quitting but supports harm reduction approaches for
smokers currently unable or unwilling to quit. http://www.nice.org.uk/PH45
• NCSCT briefing
– Summarises evidence with helpful advice for stop smoking
advisers http://tinyurl.com/ovwcnny
• MHRA regulatory approach http://tinyurl.com/l4h8xom
• ASH briefings and research www.ash.org.uk
• Smoking in England toolkit data
http://www.smokinginengland.info/latest-statistics/
Questions for workshop
Use in workplaces
• How could policy maximise the opportunities of
electronic cigarettes while minimising the risks?
Protecting Children
• How can we best protect children from e-cigarette
marketing and promotion
Uptake
• How do we encourage more smokers to access higher
(prescription NRT/ electronic cigarettes) and highest
(smoking cessation services) forms of support?