e cigarettes: how can research inform public policy? · proportion of smokers believing...
TRANSCRIPT
E‐cigarettes: how can research ginform public policy?
Declaration of interestDeclaration of interest
• I have no links with any e‐cigarette manufacturers
• I have received no funding from the tobacco or pharmaceutical industriespharmaceutical industries
• My research is funded by Cancer Research UK, National Institute of Health Research RoyNational Institute of Health Research, Roy Castle, Chief Scientist’s Office, the EU and other government and charitable bodiesother government and charitable bodies.
OutlineOutline
• Context • Our Reportsp• Tobacco Dependence & NicotineE i tt• E‐cigarette use
• Safety• Smoking cessation• Harm perceptions• Harm perceptions• Conclusions
Source: Jonathan Gornall BMJ 2015;350:bmj.h2052
The international contextE‐cigarettes are illegal in morethan 50 countriesthan 50 countries
Health Secretary Vini Mhajan reacted: “Having done well i h fi ld f b l i l P j b i hin the field of tobacco control in general, Punjab, with this conviction, has shown the way to the entire country to end the nicotine‐delivery devices sold in the form of
e cigarettes”e‐cigarettes”
In India, 900,000 people die prematurely from tobacco use each year
Where we are now in the UK…
September 2015: The UK public health community issues a joint statement making clear that all the evidence suggests that e‐cigarettes are significantly lessharmful than smoking and current smokers should not be discouraged from using them.
Some of the organisations who endorsed this have a UK wide remit, others just England. However, the differences between England & Scotland are small compared with the
t t b t th UK & th t i R h h l d l t icontrast between the UK & other countries. Research has played a very large part in shaping our policy context and current policies on e‐cigarettes.
We had furthest to goWe had furthest to go
I h UK ( d S l d) i h 1950 80% f k dIn the UK (and Scotland) in the 1950s 80% of men smoked. Now it is fewer than one in five, but still far too many.
Michael Russell’s legacyg y
The UK’s approach to nicotine &tobacco harm reduction has its i i i th k f P forigins in the work of Professor
Mike Russell, who trained some ofour leading researchers
“Smokers smoke for the nicotine, but die from the tar”f , f
Professor Mike Russell, Maudsley Smokers Clinic, 1979
Harm reductionHarm reduction B 2006 ki t• By 2006, smoking rates were falling steadily, we had smokefree legislation in S tl d d kiScotland and smoking cessation service uptake was good
• But something was missing. The Royal College of Physicians made the case yfor tobacco harm reduction (THR) as part of comprehensive tobaccocomprehensive tobacco control.
NICE GuidanceNICE Guidance • This was followed by NICE• This was followed by NICE
guidance on THR • Our committee met for two years
to review all the evidenceto review all the evidence• We produced practical guidance
for the NHS and others• We remain the only country inWe remain the only country in
the world with a formal policy on THR
• Key elements of the NICE yguidance were adapted by Health Scotland and informed smoking cessation service guidance here.
What did the guidance say?What did the guidance say?
• Stopping smoking is a priority but for those who struggle…
• Cutting down to quit is a valid approach, when combined with nicotine containing products (atcombined with nicotine containing products (at the time, just NRT)NRT b d f t b ti• NRT can be used for temporary abstinence
• Longer term nicotine use (i.e NRT use after cessation, even for years) is far safer than continued smoking. g
E cigarettesE‐cigarettes
• When we developed the NICE guidance, e‐cigarettes were just emergingwere just emerging
• We used the term ‘nicotine containing products’ in the guidance, because we knew they may act like NRT andguidance, because we knew they may act like NRT and could become licensed
• Then their use escalated, none were licensed (despite , ( phopes, medicine regulation could not be adapted to be ‘light touch’) and the guidance was quickly outdated
• New evidence reviews & recommendations were urgently needed
Some of our reportsSome of our reports
Tobacco DependenceTobacco Dependence
Benowitz et al (1982) Clin Pharmacol Ther 32 758-764Benowitz et al. (1982). Clin Pharmacol Ther, 32, 758 764.
Nicotine DeliveryNicotine Delivery
E‐cigarette use
Current Figures in ScotlandCurrent Figures in Scotland Th S tti h H lth S i d t d b S tC• The Scottish Health Survey is conducted by ScotCenSocial Research. They added a question on e‐cigarette use in 2014.
• In the 2015 survey, published last month, 5000 adults were surveyed.
• 7% of adults said they currently use e‐cigarettes, compared with 5% in 2014.
• Current use of e cigarettes was most common among• Current use of e‐cigarettes was most common among adults aged 25‐64 (7‐9%), although those aged 16‐34 were the most likely to have ever tried e‐cigarettes (22‐y g (26% compared with 4‐10% of those aged 65 and over).
Current SmokersCurrent Smokers
The next four slides show more detailed analysis from the Smoking ToolkitSt d i E l d d t d b J i B R b t W t + ll tStudy in England, conducted by Jamie Brown, Robert West + colleagues at UCL and UKCTAS. We used these data in our RCP report ‘Nicotine without smoke’
Former Smokers (recent)Former Smokers (recent)
Former Smokers (long term)Former Smokers (long term)
Never SmokersNever Smokers
Regular e‐cigarette use among children is confined almost exclusively to those who have smokedexclusively to those who have smoked
Source: Bauld L, MacKintosh A, Ford A, McNeill A . Nicotine & Tobacco Research, 2015
Safety
Defining safetyDefining safety
• Are electronic cigarettes safer than tobacco cigarettes?
• Safer = less harmful• In discussions of safety the appropriate e app op a ecomparator is tobacco –both harm to users and bystanders
E‐cigarettes as a harm reduction strategy
• In contrast to ‘reduced risk’ cigarettes no combustion takes place in e‐cigarettes
• In contrast to smokeless tobacco, e‐cigarettes are not tobacco productsnot tobacco products
• They contain nicotine and flavourings which can b t i t b t t i t t t hbe toxicants, but toxicants present are at much lower levels than in tobacco
• All the evidence suggests e‐cigarettes are safer than tobacco cigarettesg
No HarmEXTREME MUCH Less Harm
Not harmless but around 5% of the risks of smokingNo Harm
= no use at all
EXTREMEToxicityCigs ‐ Combustibles
MUCH Less Harm
Non combustibleg Non combustible
Nutt DJ et al Estimating the Harms of Nicotine‐Containing Products Using the MCDA Approach – European Addiction Research March 2014
Toxicants in vapourToxicants in vapour
Source: Goniewicz et al, Tobacco Control, 2013
Risks to bystandersRisks to bystanders
S l di• Several studies now exist comparing second hand smoke tosecond hand smoke to second hand vapour
• Overall they show that ye‐cigarettes are a source of secondhand
i i
Earlier studies have focused on vapour exhaled by users but an additional recent
exposure to nicotine but not to combustion toxicants
one measured PM2.5 levels in vaping, smoking & non smoking homes. PM2.5 levels were similar between non smokingtoxicants levels were similar between non smoking & vaping homes but much higher in the homes of smokers. However, newerstudies suggest we might need to findstudies suggest we might need to find different ways of assessing particulate matter exposure from e‐cigs.
Smoking Cessation
Aids used in most recent quit attemptAids used in most recent quit attempt
404550
to stop
E‐cigarette use for quitting is still increasing
253035
kers trying
E‐cigsNRT OTC
152025
ento
f smok NRT OTC
NRT RxChampix
0510
Perce
Beh'l supp
0
N 11375 d l h k d i d h d i h h d i
33
N=11375 adults who smoke and tried to stop or who stopped in the past year; method is coded as any (not exclusive) use
UK observational studies(use during quit attempts)
1. Cross‐sectional study, smokers in England who used e‐cigarettes to quit were significantly more likely to quit than smokers using no help or OTC NRT (Brown et al Addictionsmokers using no help or OTC NRT (Brown et al, Addiction, 2014)
2 Cohort study International Tobacco Control Policy Evaluation2. Cohort study, International Tobacco Control Policy Evaluation Study, smokers in England and US who used e‐cigarettes to quit were more likely to quit than smokers using no help or NRT but no more or less likely than usingNRT but no more or less likely than using varenicline/bupropion (Hitchman et al, 2015)
3 New study 18 000 smokers quit in England using e‐cigarettes3. New study, 18,000 smokers quit in England using e‐cigarettes who would not otherwise have done so (Brown et al, BMJ, 2016)
Advising on E‐cigarette Use
NICENICE Recommendation 5: Advising on licensed gnicotine containing products
PHE and Health S tl d th t
NCSCT Recommendations:• Be open to e cig useScotland agree that
cessation services can offer
• Be open to e‐cig use• Provide advice & support• Be positive about e‐cigscan offer
behavioural support to those using e-cigs
Be positive about e cigs• Many cessation servicesin Scotland now adoptingto those using e cigs
in a quit attempt this approach.
But… Harm Perceptions
Perception of harm is going the wrong way
393540
45
Perception of harm relative to cigarettes
22 21
3530
22
34
192325
30 2825303540
lts in
GB
7
21
1015 17 19
15
101520
% of a
dul
2 2 105
More or Less harmful Lot less Completely Don't knowequally harmful
harmful harmless
2013 (n=8936) 2014 (n=11307) 2015 (n=11340) 2016 (n=11489)
ASH Fact Sheet on the use of electronic cigarettes among adults in Great Britain, May 2016
Proportion of smokers believing e‐cigarettes
80
less harmful than cigarettes
60
70
50
60
ent
E‐cigarette user
Non‐user
30
40
Perce
Total
10
20 A declining minority of current smokers believe e‐cigarettes are less harmful than cigarettes
0
40
N=5544 current smokers, Smoking Toolkit, England only
• The evidence on e‐cigarettes is developing rapidly with new studies published almost every week
• Led by Cancer Research UK, we have formed a l f k l dnational forum to keep people up to date. Next
meeting is in Edinburgh, Jan 19th 2017W l id thl id b i fi f th• We also provide a monthly evidence briefing of the latest studies from a range of countries. This can be sent to anyone so let me know if you aresent to anyone, so let me know if you are interested.
ConclusionsConclusionsE i tt i l t i th UK i l di S tl d• E‐cigarette use is prevalent in the UK, including Scotland, but confined to current or ex smokers
• E‐cigarettes are far safer than tobaccog• There is growing evidence of effectiveness for smoking
cessationW i l h l l i d k h• Worryingly, the general population and smokers have misperceptions regarding relative harms – this needs to changeg
• New studies on e‐cigarettes are being published on an almost weekly basis, and keeping abreast of the evidence is challenging However networks and good informationchallenging. However, networks and good information sharing both within Scotland, across the UK and (crucially) between countries can help and can continue to inform policy and practicepolicy and practice.
Acknowledgements: Ann McNeill, Robert West,
Marcus MunafoMarcus Munafo, John Britton, Maciej Goniewicz
& colleagues
[email protected]@cancer.org.uk