Electronic cigarettes: research, policy and practice

1. Electronic cigarettes: research, policy and practice Deborah ArnottChief ExecutiveAction on Smoking & Health

2. Use of electronic cigarettes

3. 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

4. Use among British smokers has grown rapidly E-cigarette use among British smokers, 2010-14

5. Sustained use among adults is confined to smokers & ex-smokers E-cigarette use in Britain, 2014(All adults)

6. Helping smokers to quit?

7. Most users motivated by quitting or preventing relapse

8. Smokers motivated to quit and/ or reduce harm

9. 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

10. 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% RCT indicates as effective as OTC NRT

11. 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) Real world study indicates more effective than OTC NRT

12. Use of these methods since advent of e-cigarettes The use of ‘higher’ success methods has increased but use of ‘highest’ success methods remains very low

13. Smokers who don’t intend to quit appear to be more likely to Effect of e-cigarette on smoking reduction and cessation: a prospective 6-month pilot study. Polosa et al, BMC Public Health 2011;11:786 

14. Increase in the rate of quitting smoking

15. Cigarette consumption has decreased as has overall nicotine use

16. 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 NCSCT guidance to stop smoking services

17. 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. NCSCT guidance to stop smoking services

18. Normalising smoking?

19. 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) N=1042 N=177 N=64 N=65 N=22 N=53

20. Weekly use is confined to older children E-cigarette use in Britain, 2013(Children who have heard of e-cigarettes, by age)

21. 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?

22. Adult and youth smoking in England % E-cig sales start taking off

23. 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

24. Electronic cigarettesuse in 11-18 year olds US CDC data from National Youth Tobacco Survey 2011 and 2012

25. US data from CDC shows similar pattern to England US CDC data from National Youth Tobacco Survey 2011 and 2012 analysis Clive Bates and Brad Rodu

26. 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

27. 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 non-tobacco users or children and young people.

28. Future regulation provides more protection

29. Use in public places

30. 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

31. 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?

32. 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

33. Organisational policy options if there isn’t a blanket prohibition • Where appropriate: Schools? • Who could benefit: Protect non-smoking young people • Who might it disadvantage: Young people and adults trying to quit Complete prohibition Qualified use Complete freedom • Where appropriate: Hospitals? Prisons? Adult only workplaces? • Who could benefit: Those trying to quit, smokers engaged in temporary abstinence • Who might it disadvantage: No-one? If in appropriate places? • Where appropriate: Adult only workplaces? • Who could benefit: Those trying to quit, smokers engaged in temporary abstinence • Who might it disadvantage: Co-workers irritated by vapour

34. 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/

35. 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?