E cigarettes: how can research inform public policy?

E cigarettes: how can research inform public policy?

Declaration of interest I have no links with any e cigarette manufacturers I have received no funding from the tobacco or pharmaceutical industries My research is funded by Cancer Research UK, NationalInstituteofHealthResearch of Research, Roy Castle, Chief Scientist s Office, the EU and othergovernment and charitablebodies.

Outline Context Our Reports Tobacco Dependence & Nicotine E cigarette use Safety Smoking cessation Harm perceptions Conclusions

Source: Jonathan Gornall BMJ 2015;350:bmj.h2052

The international context E cigarettes are illegal in more than 50 countries Health Secretary Vini Mhajan reacted: Having done well in the field of tobacco control in general, Punjab, with ih this conviction, has shown the way to the entire country to end the nicotine delivery devices sold in the form of 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 less harmful 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 contrast tbetween the UK & other countries. Research hhas played a very large part in shaping our policy context and current policies on e cigarettes.

We had furthest to go I h UK ( d S l d)i h 1950 80% f k d In 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 legacy The UK s approach to nicotine & tobacco harm reduction has its origins ii in the work of Professor Mike Russell, who trained some of our leading researchers Smokers smoke for the nicotine, but die from the tar Professor Mike Russell, Maudsley Smokers Clinic, 1979

Harm reduction By 2006, smoking rates were falling steadily, we had smokefree legislation in Scotland and smoking cessation service uptake was good But something was missing. The Royal College of Physicians made the case for tobacco harm reduction (THR) as part of comprehensive tobacco control.

NICE Guidance This was followed by NICE guidance on THR Our committee met for two years to review all the evidence We produced practical guidance for the NHS and others We remain the only country in the world with a formal policy on THR Key elements of the NICE guidance were adapted by Health Scotland and informed smoking cessation service guidance here.

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 nicotinecontaining containing products (at the time, just NRT) NRT can be used for temporary abstinence bti Longer term nicotine use (i.e NRT use after cessation, even for years) is far safer than continued smoking.

E cigarettes When we developed the NICE guidance, e cigarettes were just emerging We used the term nicotine containing products in the guidance, because we knew they may act like NRT and could become licensed Then their use escalated, none were licensed (despite hopes, 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 reports

Tobacco Dependence Benowitz et al. (1982). Clin Pharmacol Ther, 32, 758-764 764.

Nicotine Delivery

E cigarette use

Current Figures in Scotland The Scottish hhealth lthsurvey is conducted dby ScotCen Social 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 adults aged 25 64 (7 9%), although those aged 16 34 were the most likely to have ever tried e cigarettes (22 26% compared with 4 10% of those aged 65 and over).

Current Smokers The next four slides show more detailed analysis from the Smoking Toolkit Study in England, conducted dby Jamie Brown, Robert twest t+ colleagues at UCL and UKCTAS. We used these data in our RCP report Nicotine without smoke

Former Smokers (recent)

Former Smokers (long term)

Never Smokers

Regular e cigarette use among children is confined almost exclusively to those who have smoked Source: Bauld L, MacKintosh A, Ford A, McNeill A. Nicotine & Tobacco Research, 2015

Safety

Defining safety Are electronic cigarettes safer than tobacco cigarettes? Safer = less harmful In discussions of safety the appropriate a comparator 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 nottobacco tobacco products They contain nicotine and flavourings which can be toxicants, t but ttoxicants t present are at much lower levels than in tobacco All the evidence suggests e cigarettes are safer than tobacco cigarettes

Not harmless but around 5% of the risks of smoking EXTREME Toxicity Cigs Combustibles MUCH Less Harm No Harm Non combustible = no use at all Nutt DJ et al Estimating the Harms of Nicotine Containing Products Using the MCDA Approach European Addiction Research March 2014

Toxicants in vapour Source: Goniewicz et al, Tobacco Control, 2013

Risks to bystanders Several studies now exist comparing secondhandsmoke smoke to second hand vapour Overall they show that e cigarettes are a source of secondhand exposure to nicotine i but not to combustion toxicants Earlier studies have focused on vapour exhaled by users but an additional recent one measured PM2.5 levels in vaping, smoking & non smoking homes. PM2.5 levels were similar between non smoking &vaping homes but much higher in the homes of smokers. However, newer studies suggest we might need to find different ways of assessing particulate matter exposure from e cigs.

Smoking Cessation

Aids used in most recent quit attempt Perce ent of smok kers trying to stop 50 45 40 35 30 25 20 15 10 5 0 E cigarette use for quitting is still increasing E cigs NRT OTC NRT Rx Champix Beh'l supp N=11375 adults who smoke and tried idto stop or who stopped in the past year; method dis coded as any (not exclusive) use 33

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, Addiction, 2014) 2. 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 using varenicline/bupropion (Hitchman et al, 2015) 3 Newstudy 18 000 smokers quit in England using e cigarettes 3. 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 NICE Recommendation 5: Advising on licensed nicotine containing products PHE and Health Scotland agree that t cessation services can offer behavioural support to those using e-cigs in a quit attempt NCSCT Recommendations: Be open to e cig use Provide advice & support Bepositive aboute cigs Many cessation services in Scotland now adopting this approach.

But Harm Perceptions

Perception of harm is going the wrong way % of adul lts in GB 45 40 35 30 25 20 15 10 5 0 7 15 22 Perception of harm relative to cigarettes 25 35 34 30 22 21 17 19 15 10 2 2 1 More or Less harmful Lot less Completely Don't know equally harmful harmless harmful 39 30 23 28 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 less harmful than cigarettes 80 70 Perce ent 60 50 40 30 E cigarette user Non user Total 20 10 A declining minority of current smokers believe e cigarettes are less harmful than cigarettes 0 N=5544 current smokers, Smoking Toolkit, England only 40

The evidence on e cigarettes is developing rapidly with new studies published almost every week Led by Cancer Research UK, we have formed a national forum to keep people up to date. Next meeting is in Edinburgh, Jan 19 th 2017 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 are interested.

Conclusions E cigarette use is prevalent tin the UK, including Scotland, but confined to current or ex smokers E cigarettes are far safer than tobacco There is growing evidence of effectiveness for smoking cessation Worryingly, the general population and smokers have misperceptions regarding relative harms this needs to change New studies on e cigarettes are being published on an almost weekly basis, and keeping abreast of the evidence is challenging. However, networksandgoodinformation sharing both within Scotland, across the UK and (crucially) between countries can help and can continue to inform policy and practice.

Acknowledgements: Ann McNeill, Robert West, Marcus Munafo, John Britton, Maciej Goniewicz & colleagues Linda.Bauld@stir.ac.uk Linda.Bauld@cancer.org.uk