Tobacco risks and new nicotine products

1. Tobacco risks and new nicotine products Dr Ross Morgan MD FRCPI FCCP Consultant Respiratory Physician, Beaumont Hospital March 26th 2015

2. The Tobacco Century WHO, European Lung Foundation & others 2010

3. Outline • Burden of disease from smoking • 5,200 people die from smoking related disease in Ireland each year • 1 -2 billion euro is spent annually on treating the effects of smoking • Burden of lung disease from smoking • 2 common conditions; COPD and lung Cancer • Smoking prevalence and tobacco control • Impact of Quitting • Nicotine Replacement – Electronic Cigarette

4. Ireland needs Healthier Airways and Lung – The Evidence T O’Connor et al, INHALE II report 2008

5. 1 in 5 people in Ireland die from respiratory disease T O’Connor et al, INHALE II report 2008

6. Ireland has the highest death rate from respiratory disease in western Europe -- x 2 EU average. T O’Connor et al, INHALE II report 2008

7. T O’Connor et al, INHALE II report 2008

8. Economic Burden -EU 50 % of the economic burden of lung disease is due to smoking European Lung Foundation, White Book 2014

9. Chronic Obstructive Pulmonary DiseaseCOPD – on the rise Pauwels and Rabe, Lancet 2004

10. Chronic Obstructive Lung Disease - COPD • World Health Organization (W.H.O.) 2010: • COPD is 4th leading cause of death • On course to be no.3 by 2020 • In 2010 in the U.S. • 8 million doctors’ visits • 1.5 million emergency department visits • 726,000 hospitalisations (13% of total hospital admissions) • Second most common reason for payment of social security disability benefits

11. COPD and Multi-morbidity Smoking related chronic disease L Vanfleteren, April 2013, AJRCCM

12. Lung Cancer 1.6 million cases worldwide a year 65% presents with locally advanced or metastatic disease RISKS for Lung Cancer Smoking (90%) Radon gas exposure Asbestos exposure Other exposures:heavy metals/Cadmium Irelands Biggest cancer killer

14. Number of Lung Cancers Diagnosed in Ireland 1994-2010 1400 1200 1000 800 Number 600 400 200 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year females males Cancer in Ireland 2013, report of National Cancer Registry

15. Years of Life lost to cancer Cancer in Ireland 2013, report of National Cancer Registry

16. Survival with cancer – IrelandLung Cancer: - 20% of all cancer deaths- In 2013 became the most common cause of cancer death in women National Cancer Registry, 2013

17. What do we expect? LUNG FEMALE BREAST Cancer Cancer in Ireland 2013, report of National Cancer Registry

18. Lung Cancer Screening

19. LUNG CANCEREx- smokers too Effect of smoking cessation on lung cancer risk 1-20 10.3-fold 1.6-fold 20 21.2-fold 4.0-fold Cigarettessmoked/day Risk of developinglung cancer* Risk after 16 yearsof smoking cessation* *Data in women; risk compared to nonsmokers. Humphrey EW, et al. The American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;220-235.

20. Benefits of Stopping Smoking on Lung Cancer Risk New Engl J Med. Jan 2, 2014

22. Health Consequences of smoking U.S. Surgeon General 2014

23. The Tobacco Industry Merchants of Doubt

24. Tobacco addiction starts early in life

25. Health Effects of Second Hand Smoke on Children Sudden Infant Death Syndrome Low birth weight Lower respiratory illness Asthma Middle Ear Infections Preterm Birth Childhood cancers, leukaemia, lymphoma Congenital Malformations Premature atherosclerosis Pregnant women and children particularly vulnerable US surgeon generals report 2014 Gall S. Eur Heart Journal. March 2014

26. Ireland Work Place Smoke Ban 2004 Evaluation of impact Change in Indoor Air Quality Health Benefits For Bar workers (lung function) Health Benefits for All In the first year of the ban, hospital admissions for acute coronary events fell by 12% 32% fall in stroke admissions 38% reduction in COPD admissions Impact on Preterm deliveries and low birth weight 3, 726 fewer smoking related deaths than would have been expected Compliance 98% Stalling-Smith S et al, PLOS One 2013 Cronin EM, ClinCardiol. 2012;35:205–209. Kabir Z, BJOG. 2009;116

27. Ireland –consumption of Tobacco

28. Ireland – Fewer people smoking Office of Tobacco Control Omnibus Tracker Survey 2007 - 28% Office of Tobacco Control Omnibus Tracker Survey 2012 - 22% Source: www.ntco.ie

29. Tobacco Free Ireland 2025 Policy Document launched by the Minister for Health October 2013 “In Ireland a tobacco free society will mean the achievement of a smoking prevalence rate of less than 5% of the Irish population by 2025” Denormalisation of tobacco at every level of society

30. Ireland Smoking Prevalence 10 – 17 year olds

31. Ireland 2014:Tobacco Control Measures

32. Playground Initiative 2014 75% of County Councils and 60% of City Councils in Ireland have adopted smoke free playgrounds on a voluntary basis Malahide Castle, Dublin 2014

33. Nice, France 1967 Nice, France 2014 Extension of Smoke Free Places ?

34. Tobacco Dependence

36. Significant impact on survival from stopping smoking at ANY age

37. Getting people to Quit – Massachusetts Health

38. Getting people to Quit II – ‘Plain’ packaging

39. Components of cigarette – “ a dirty syringe” Nicotine = the component that causes addiction

40. Electronic Cigarettes- Electronic Nicotine Delivery Systems (ENDS) Promise or Public Threat? Tobacco product? Medicine? Electronic device? WHO 2013: 7% of EU citizens (doubled in 4 yrs) In U.K. - 1.3 million e-cigarette users compared with 9 million tobacco smokers

41. E Cigs : Are they a smoking cessation Aid? Do they Reduce Harm?

42. Smoking Cessation Aid? Bullen C et al. Lancet 2013;

43. Evidence based - Pharmacotherapy for Cessation

44. Rather than reducing or even replacing traditional smoking, e-cigarettes could increase smoking rates by attracting new recruits and reducing quit attempts. Electronic Cigarettes ? renormalising smoking

45. E. CigsCause For Concern • Strong regulatory framework needed • Clear need for independent Research. From U.S. National Youth Risk Behavior Survey 2013

46. Conclusions In Ireland, Tobacco Use is the biggest cause of preventable Premature Death (5,200/year) Inequality There is no risk-free level of tobacco smoke exposure Benefits of Quitting will be seen at any age Effective Cessation therapies exist Nicotine/E-Cigs have their own health risks; though they are small compared to tobacco smoking