Using evidence to negotiate new policies on harm reduction Linda Bauld With thanks to Ann McNeill, Hazel Cheeseman, Diane Dixon, Robert West & Martin Dockrell
Outline UK guidance on tobacco harm reduction: development & key evidence How it s been received and what the challenges of implementation are E-cigarettes and harm reduction common concerns Harm reduction and a tobacco free future
Background In order to consider how and where e-cigarettes feature in the current public health landscape, it s important to take into account recent developments in tobacco harm reduction (THR) Harm reduction measures are aimed at those smokers who, for whatever reason, are not able or willing to stop using tobacco or stop using nicotine. The UK has published national guidance on THR.
Harm reduction options in the guidance Stop smoking in one step then use licensed nicotine products, possibly indefinitely. Cut down prior to quitting with or without the help of licensed nicotine-containing products. Smoke less with or without the help of one or more licensed nicotine-containing products. Temporarily abstain with or without the help of one or more licensed nicotine-containing products.
NICE & Licensed Nicotine Products The harm reduction approaches in the NICE guidance can involve substituting the nicotine in tobacco with nicotine from less harmful, nicotine-containing products. These include NRT products that are licensed in the UK as pharmaceutical treatments for smoking. There are also unregulated products such as electronic cigarettes. The guidance only recommends use of licensed products recognising that when electronic cigarettes become licensed, they can be recommended for use. Nicotine-containing products might be used either temporarily or indefinitely and as a partial or complete substitute for tobacco
NICE & Nicotine-containing products The guidance states that: There is reason to believe that lifetime use of licensed nicotine-containing products will be considerably less harmful than smoking There is little direct evidence on the effectiveness, quality and safety of nicotinecontaining products that are not regulated by the MHRA. However, they are expected to be less harmful than tobacco.
% of cigarettes smokers (3 month moving average) Cutting down in England 60% 50% 40% Cutting down 30% 20% Using NRT to cut down Using ecigs to cut down 10% 0% Source: West, 2013, www.smokinginengland.info
Cutting down alone A number of studies have found little or no health benefits to cutting down Source: Godtfredsen et al, Am J Epidemiol 2002;156: 994-1001
Cutting down alone in Scotland: Hazard ratios of all-cause mortality Collaborative Renfrew & Paisley Increased 1.15 (0.97 1.35) 1.17 (1.04 1.32) Maintained 1 1 Reduced 0.91 (0.75 1.10) 1.08 (0.97 1.20) Quit 0.66 (0.56 0.78) 0.75 (0.67 0.84) Adjusted for age, sex, social class, cigarettes, cholesterol, systolic blood pressure, body mass index, diabetes, pre-existing CHD Source: Hart, Bauld and Gruer, AJE, 2013.
Percentage of smokers reporting a quit attempt in the previous 12 months Percentage of smokers reporting a previous quit attempt through harm reduction activities 80 70 60 50 40 30 20 10 0 Other smokers SR without NRT TA with NRT SR with NRT SR & TA with NRT Source: Beard, E., & West. R. (2012). Addiction
Key points In England as an example, many more smokers are trying to cut down tobacco consumption each year than trying to quit Cutting down alone (without a nicotine containing product) has few if any health benefits Cutting down with NRT may lead to cessation E-cigarettes may operate like NRT in this regard
Addressing concerns about nicotine: Smoking cessation staff views Source: Beard et al, 2012
Addressing concerns about nicotine use Nicotine use, including e-cigarettes, by never smokers is negligible Source: West et al, 2014 N=5,272 from Nov 2013
Use by children?
Youth Uptake Review published last month Identified 9 studies on use in children. Difficult to compare due to methods and questions asked. One UK study already described by Deborah In the studies we reviewed, with the exception of one Polish survey, ever use was reported by fewer than one in ten children and was concentrated in young people who smoke
E-cigarette/smoking by children: USA Source: US CDC data from National Youth Tobacco Survey 2011 and 2012. Graph from Bates & Rodu
Children in Wales by prior smoking Source: ASH Wales (2014) http://www.ashwales.org.uk/creo_files/upload/downloads/ young_people_and_e-cigarettes_in_wales_final_march_2014.pdf
What about the marketing? Countries vary in the extent to which they allow marketing Our team conducted a systematic audit and content analysis of all marketing in the UK from May 2012 to June 2013. Included: traditional media reports, press releases, web and trade press publications, magazines, tobacco industry periodicals, television adverts and social media platforms Marketing is extensive. Concerns about it need to be addressed and some discussion of the content as well as reach is required Countries need to consider what -if any - action to take. Source: de Andrade M, Hastings G, Angus K, Dixon D and Purves R (2013). The Marketing of Electronic Cigarettes in the UK. Cancer Research UK: London. http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@pol/documents/generalcontent/cr_115991.pdf
E-cigarette marketing: useful?
E-cigarette marketing: still useful?
E-cigarette marketing..
What about the vapour? Should we be concerned about e-cigarette vapour in enclosed public places? Lab studies suggest that the vapour contains nicotine and some toxic metals but levels are much lower than in second hand smoke No current evidence of health harms from occasional exposure Being clear with a range of audiences that the effects of regular exposure over many years are unknown.
Providing guidance on use in public places Multi-agency response to dealing with concerns about second hand vapour and denormalisation. Use of evidence and regular updates Engagement with environmental health officers and local area policy-makers.
Working with cessation services 20% use NRT from store 25% use e-cig 40% use nothing Source: West et al (2014) www.smokinginengland.info/lateststatistics
Cessation Services NICE THR guidance not well received by all smoking cessation services E-cigarettes even less so Downturn in client numbers ascribed to e- cigarettes However, views are changing Encouraging pilots of THR activity Emerging consensus on providing support to e- cigarette users who approach services
Monitoring attitudes to harm reduction Source: Cheeseman, H (2014) Implementing the NICE guidance on tobacco harm reduction, ASH, London.
Example of local approach London City: Service provided by community pharmacy offering two treatment pathways; cutting down and smoking cessation Cut Down: structured 4 week programme aiming for a decrease in cigarette use to an eventual quit Smoking Cessation: as with existing services, but with advisor discretion to provide a further 12 weeks of NRT to patients not ready to quit Electronic cigarettes are offered alongside NRT for both treatment pathways 6 month pilot of providing starter kits of e-cigarettes to smokers (with Peter Hajek and colleagues)
What about the tobacco industry? NicoventuresVoke inhaled nicotine
A Tobacco-free Scotland by 2034 My own country has set an ambitious target to be tobacco free in 20 years. Tobacco harm reduction can help achieve that target but ongoing evidence is needed to show what contribution it does make.
Thank you Linda.Bauld@stir.ac.uk