HIT Hot Topics Conference 2014 Electronic cigarettes disruptive innovation, public health potential and regulatory challenge Prof Gerry Stimson Knowledge Action Change and Emeritus Professor Imperial College London; Visiting Professor London School of Hygiene and Tropical Medicine
Harm reduction Safer use Safer products
Tobacco harm reduction - origins Pioneer - Mike Russell Smokers cannot easily stop smoking because they are addicted to nicotine. People smoke for nicotine but they die from the tar 1976 BMJ 1: 1430-1433 4000 chemicals in tobacco smoke Rebalancing the market in favour of the safest nicotine products would provide choice, encourage safer nicotine use, and reduce morbidity and mortality. p240 Harm reduction in smoking can be achieved by providing smokers with safer sources of nicotine that are acceptable and effective cigarette substitutes. p241 2007 At the time apart from NRT (and snus) no attractive and viable sources of safer nicotine 3
But now! attractive and viable sources of safer nicotine Photos courtesy Lynne Dawkins
E-cigarettes a disruptive innovation* Biggest disruption to tobacco consumption since Bonsack invented the cigarette rolling machine in 1880 Disruptive for: Consumers an alternative safer source of nicotine Smoking/nicotine researchers new research agenda Tobacco companies upsets business model and profit source The public view of nicotine and addiction > recreational nicotine use Governments and regulators what to do about e-cigarettes? Public health and tobacco control organisations threat to tobacco control narrative * Stimson, G. V, Thom, B., & Costall, P. (2014). Disruptive innovations: The rise of the electronic cigarette. The International Journal on Drug Policy, 3 5. doi:10.1016/j.drugpo.2014.05.003
The big surprise: Rapid rise in popularity of e-cigarettes since 2007 They are popular: 29 million users in the EU * A large market: US sales = $20m in 2009, an estimated $2b in 2013 ** They work for some smokers at least as effective as NRT in RCT *** 2.1m users in UK 700,000 UK ex-smokers using e-cigs **** In real world more effective than no help/nrt ***** Many (ex) smokers like them, prefer them to other stop smoking aids *Vardavas, C.et al (2014). Determinants and prevalence of e-cigarette use throughout the European Union: a secondary analysis of 26 566 youth and adults from 27 Countries. Tobacco Control, 1 7. doi:10.1136/tobaccocontrol-2013-051394 **Herzog, B. (2014). Tobacco Talk: Vapors/Tanks Driving Next Wave Of E-Vapor Growth. ***Bullen, C. Ee al (2013). Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet, 382(9905) ****www.ash.org.uk/files/documents/ash_891.pdf *****Brown, J. et al (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction doi:10.1111/add.12623
2009-3 2009-4 2010-1 2010-2 2010-3 2010-4 2011-1 2011-2 2011-3 2011-4 2012-1 2012-2 2012-3 2012-4 2013-1 2013-2 2013-3 2013-4 2014-1 2014-2 2014-3 Percent of smokers trying to stop Aids used in most recent quit attempt 50 45 40 35 30 25 20 15 10 5 0 E-cigarettes are the most popular aid to cessation E-cigs NRT OTC NRT Rx Champix Beh'l supp N=9438 adults who smoke and tried to stop or who stopped in the past year Slide from Robert West
Safe or safer? The comparator is smoked tobacco 95-99% safer From analysis of the constituents of e-cigarette vapour, e- cigarette use from popular brands can be expected to be at least 20 times safer (and probably considerably more so) than smoking tobacco cigarettes in terms of long-term health risks Hajek P, Etter J-F, Benowitz N, McRobbie H (2014) Electronic cigarettes: review of use, content, safety, effects on smokers, and potential for harm and benefit. Addiction. Tests of contents of liquid and vaper suggest e-cigarettes 99% safer than smoked cigarettes. Konstantinos Farsalinos, 2014 Possible harm reversal when switching to e-cigarettes blood pressure, asthma. Riccardo Polosa. 2014
Continuum (or cliff) of harm for different nicotine containing products Graph from Nutt et al, adapted by GVS Smoke > smokeless> nicotine 11/18/2014 9 ENDS = Electronic Nicotine delivery Systems
Consumer led public health revolution at no cost to taxpayer A viable, attractive and acceptable means of consuming nicotine For people who want to stop smoking but unable or unwilling to stop using nicotine Classic harm reduction providing a safer product, user/consumer led Classic public health - WHO Ottawa Charter for Health - Health promotion is the process of enabling people to increase control over, and to improve, their health... (some) consumers highly aware of science, policy, politics; a disorganised individualised social movement Vaper advocates = AIDS activists? (David Sweanor) For the first time stopping smoking is interesting, fun, communal (in a social media sense) >>>
For the 1st time in tobacco control, smokers talk to each other... Monthly users on the vapers' French forum (61,000 members) 900 000 interactions per month Slide from Jacques le Houezec 11/18/2014 11
Vaper activism 12
Health impact Will e-cigs overtake tobacco cigarettes and when? Stock market analysts predict 2021, 2015?* Continued declines in tobacco cigarette sales, and adult smoking prevalence >> *E-Cigarette Sales to Exceed Traditional Cigarettes by 2021 NACS Online
Percent Cigarette smoking prevalence 30 25 20 24,2 Slide from Robert West 22,0 21,5 21,4 20,7 20,0 19,3 18,5 15 10 5 0 2007 (N=22079) 2008 (N=18990) 2009 (N=21137) 2010 (N=24794) 2011 (N=21879) 2012 (N=21330) 2013 (N=22167) 2014 (Sep) (N=15206) Base: All adults Graph shows prevalence estimate and upper and lower 95% confidence intervals. England 14
Health impact And if they do replace tobacco cigarettes Currently 80 000 smoking related deaths in England pa Potential large impact on health for every 1m smokers who switch to e- cigarettes 6000 lives saved each year** Bigger potential impact than other tobacco control measures? eg EU Tobacco Products Directive estimated to reduce prevalence by 0.5% *** ** West, R, Brown, J (2014). Electronic cigarettes : fact and fiction. British Journal of General Practice, (September), 442 443. doi:10.3399/bjgp14x681253 ***Tiessen, J. A. N., Hunt, P., Celia, C., & Staetsky, L. (2010). Assessing the Impacts of Revising the Tobacco Products Directive Study to support a DG, (September). RAND TPD impact: mandatory pictorial warnings = a reduction of smoking prevalence across the EU by at least 0.5% likely, leading to around 900 fewer tobacco-related deaths and 9,300 fewer cases of lung cancer, aerodigestive cancer and COPD annually in the EU by 2027.
Regulatory quandary: What type of product are e-cigarettes? EU Tobacco Products Directive WHO * *WHO FCTC/COP/6/10 Electronic Nicotine Delivery Systems Medicines only/mainly Medicines if health claim made Tobacco product Proposed by EC, Rejected by European Parliament Yes In TPD but in separate category from other tobacco products Yes Yes (but never been explicitly agreed by Framework Convention on Tobacco Control) EU: a priori ENDs are not tobacco products, as defined in the FCTC context (9/9/2014) Consumer product Yes, sort of Not explicitly, but recommends consumer type regulations
But threats narrative dominates WHO, some public health and tobacco control organisations WHO, FCTC/COP/6/10 Electronic Nicotine Delivery Systems Little consideration of: the tobacco harm reduction potential of e-cigarettes Emphasis of is on threats and risks some small, some improbable, some important. Gateway to smoking Young people Nicotine addiction Renormalisation of smoking Tobacco industry Vaping in indoor public places Toxicity Safety
Is it just a matter of evidence? Threat and fear narratives Narrative HIV and drugs HR - Needles and syringes Undermines Gateway Prolongs/ increases Normalises Abstinence ambition Undermines antidrugs policy Encourages (young) people to inject, use drugs Prolongs addiction and delays recovery Normalises injecting, drug use Abstinence is the best option Smoking and E-cigarettes Undermines antismoking policy Encourages young people to smoke Prolongs smoking and delays quitting Normalises smoking Abstinence is the best option Public health issues are often driven by a moral agenda rather than by evidence Peter Hajek 11/18/2014 18
Harm reduction potential Perverse consequence of overregulating and un-selling e- cigarettes is to put them at a disadvantage compared to regular cigarettes Way forward is: Maximise public health potential + minimise risk (product standards) Letter from 53 Scientists to WHO * The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21 st Century perhaps saving * hundreds of millions of lives. http://nicotinepolicy.net/n-s-p/1853- letter-from-53-scientists-to-who-dg
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