Smoking Cessation: Current Guidance and Support in Cornwall & Isles of Scilly

1. Smoking cessation – current guidance • Wednesday 30th November 2016 • Presented by Gareth Walsh, Public Health • gwalsh@cornwall.gov.uk

2. ‘The cigarette is the only legally available consumer product which kills people, when used exactly as intended.’1 1. RCN Tobacco Education Project (2001). Clearing the air 2. Available at: www.rcn.org.uk/__data/assets/pdf_file/0011/78554/001945.pdf. Accessed June 2008.

3. The Weapon of Mass Destruction Example Acetone Ammonia Arsenic Benzene Benzo(a)pyrene Butane Cadmium Carbon Monoxide DDT Dieldrin Formaldehyde Hexamine Hydrogen Cyanide Magnesium Methane Methanol Naphthalene Nicotine Nitrobenzene Nitrous Oxide Phenols Polonium 210 Stearic Acid Titanium • Common Use • Nail polish remover • Floor and toilet cleaner • Rat poison • Industrial solvent • Diesel exhaust • Cigarette lighter fluid • Rechargeable batteries • Car exhaust • Insecticide • Insecticide • Preservative for dead bodies • Barbeque lighter • Gas chamber poison • Flares • Swamp gas • Rocket and car fuel • Moth balls • Insecticide and the addictive drug in tobacco • Petrol additive • Disinfectant • Radioactive compound • Candle wax • Aeroplane and missiles

4. Physical Problems Associated with Smoking

5. Smoking related deaths in the UK 106,000 Equivalent to a full jumbo jet crashing every day of every year with no survivors

7. THE SCALE OF THE LOCAL PROBLEM Smoking prevalence in adults: Cornwall & Isles of Scilly - 18.2% South West- 15.5% England average- 16.9% England worst- 26.8% *Data from the Annual Population Survey 2015 Available at:http://www.tobaccoprofiles.info/tobacco-control#page/0/gid/1938132885/pat/6/par/E12000009/ati/102/are/E06000052

8. THE SCALE OF THE LOCAL PROBLEM Smoking prevalence in adults in Routine & Manual occupations: Cornwall & Isles of Scilly* - 32.2% (c.1 in 3 people) South West- 26.6% England average- 26.5% England worst- 36.3% *Highest in the South West, from the Annual Population Survey 2015

9. Index of multiple deprivation score (IMD 2015) • 38 separate indicators, organised across 7 distinct domains of deprivation Domains include: Income Deprivation, Employment Deprivation, Health Deprivation and Disability, Education, Skills and Training Deprivation, Barriers to Housing and services, Living Environment Deprivation and Crime. These statistics allow the most, and least, deprived areas of the country to be identified as well as providing information about the issues faced by people living in different parts of the country.

10. Index of multiple deprivation score (IMD 2015) Cornwall* - 23.8 IOS- 12.0 England average- 21.8 England highest- 42 England lowest- 5.7 *4th highest out of 16 in the South West; from Department of Communities and Local Government (DCLG)

11. THE SCALE OF THE LOCAL PROBLEM 1. Estimates from ASH Ready Reckoner, December 2015

12. THE SCALE OF THE LOCAL PROBLEM 1. Estimates from ASH Ready Reckoner, December 2015

13. 1. Estimates from ASH Poverty Reckoner, June 2016

14. Always advise on benefits of stopping smoking Stopping Smoking is the number one thing a smoker can do to improve their health Encourage and assist employees where possible to access stop smoking advice and support, whether on site or referral to the local Stop Smoking Advisor (The Cornwall & Isles Scilly Stop Smoking Service 01209 313419) Be part of activities such as Stoptober, No Smoking Day etc. The Good News! 70% of smokers want to stop [1] [1] Lader D. Opinions Survey Report No. 40 Smoking-related behaviour and attitudes, 2008/09. Office for National Statistics.

15. Most effective way of stopping is using medication and the help and support of a trained Stop Smoking Advisor… Long term quit rates Source Information Taken from Dr Alex Bobek’s presentation “How Best to help Smoker’s Quit”

16. Nicotine Replacement products (NRT) • Patch • Gum • Lozenge • Mini-lozenge • Mouth spray • Nasal spray • Microtab • Strip • Inhalator N.B. NRT contains nicotine only Allows smokers to quit smoking in two stages: behaviour then drug

17. Champix • Licensed in September 2006 • Available on prescription only • Relieves craving • Relieves withdrawal • Releases some dopamine • Blocks receptor sites

18. CHAMPIX is a non-nicotine treatment with a dual mode of action Development of nicotine dependence CHAMPIX is a non-nicotine treatment 1.Jarvis MJ. BMJ 2004; 328: 277–279. 2. Zaniewska M et al. Pharmacol Rep 2009; 61: 957–965. 3. Picciotto MR et al. Nicotine Tob Res 1999; 1: S121–S125. 4. Dani JA et al. Nature Neuroscience 2005; 8: 1465–1470. 5. CHAMPIX. Summary of Product Characteristics. Pfizer Ltd. 6. Coe JW et al. J Med Chem 2005; 48: 3472–3477. 7. Jorenby DE et al. JAMA 2006; 296: 56–63. 8 West R. Psychopharmacology 2008; 197: 371–377.

19. Zyban - Bupropion • Sustained release Bupropion, Wellbutrin • Nicotine free therapy • Prescription-only for over 18s • Antidepressant • Help to reduce the cravings and withdrawal symptoms • Can also help prevent the weight gain

20. E-cigarette – first generation Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek 20

21. E-cigarettes - second generation Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek 21

22. E-cigarettes - third generation Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek 22

23. MHRA licensed product • E-Voke produced by BAT • 15mg of nicotine per cartridge • SPC states • on repeated use, peak plasma 6 ng/ml • T-max 8 minutes • Much slower than tank EC; very low dose; looks like cig; produced by tobacco company • Services may be forced to use this rather than better products Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

24. E-cigarettes -Adverse effects • No serious adverse effect in any study • Some irritation and cough, same in control conditions and on online forums • FDA monitoring: 47 reports, 8 serious, 2 linked to EC (infant choking on EC cartridge and burns from exploding EC) • Cochrane review: No safety concerns emerged with use over short to mid-term Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

25. Smokers using EC for 4 weeks and abstinent from smoking

26. Smokers using EC for 4 weeks and still smoking (dual users)

27. Summary of EC safety • There is no known passive exposure risk • Little risk of nicotine poisoning for users (but e-liquid should be in child-proof containers) • Effects of long-term use, especially on users with asthma/lung diseases are not known. Main ingredients unlikely to pose risks, but some flavourings/contaminants or materials used in EC manufacture may do so Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

28. Summary of EC safety • Monitoring is needed to detect and remove any emerging risk • The estimate that EC are at least 95% safer than cigarettes takes this future uncertainty into account • Smokers need not wait for further proofs to switch to vaping Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

29. Harm perceptions among adults (ASH YouGov adult surveys 2013-15) Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

30. Harm perceptions among youth (ASH YouGovyouth surveys 2013-15) Eastwood B, Dockrell M, Arnott D, Britton J, Cheeseman H, Jarvis M, McNeill A . Public Health, 2015

31. Comparison to smoking • Some 50% of adolescents who try a cigarette become daily smokers • Despite increasing experimentation with EC, few if any non-smoking adolescents became daily vapers of nicotine EC • So far, EC are not a gateway even to vaping, and may even deter those who would otherwise smoke • However, vigilance is needed Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

32. E liquids • From consumers’ perspective, a general labelling of e-liquids strength (mild, moderate, strong) provides sufficient information • Quitting with EC may improve overall cardiovascular and metabolic risk profile (Russo et al. Sci Rep. 2016 Jan) Taken from the presentation "Electronic Cigarettes and Public Health" by Professor Peter Hajek

33. Smokers are quitting with EC • Source: Smoking Toolkit Study • N=10756 adults who smoke and tried to stop or who stopped in the past year • Method is coded as any (not exclusive) use

34. Use of nicotine products in recent quitters N=1159 adults who stopped in the past year; increase p<0.001 for e-cigs and all nicotine; decrease p<0.001 for NRT

35. What should Stop Smoking Services do? • Champix and NRT remain treatments with the best evidence for safety and efficacy • Be supportive of those vaping to stop smoking and continue to offer the behavioural support • This may increase the reach and possibly efficacy and help more smokers

36. Workplaces and Vaping (1) • The ban on smoking in public places was introduced in 2007 to protect people from the harmful effects of second hand smoke • E-cigarettes are not cigarettes and therefore do not result in the same harmful effects of second hand smoke and are not legally covered by the legislation on smoke free public places

37. Workplaces and Vaping (2) • Vapour emitted from e-cigarettes can create some confusion and uncertainty in workplaces and enclosed public spaces because the vapour, at first glance, can resemble cigarette smoke • Some non-users may also find the emitted vapour and fragrance offensive although there are no known harmful effects of second-hand vapour

38. Workplaces and Vaping (3) • Many organisations require e-cigarette users to ‘vape’ outside but not always at a distance away from buildings as the vapour dissipates quickly without the effects of second-hand smoke • Expecting Vapers to congregate with smokers may also undermine the harm reduction and quitting potential of e-cigarette use.

39. Workplaces and Vaping (4) • There is currently no national legislation in place anywhere in the UK which determines whether organisations should allow products to be used on their premises or not. • ASH and the Chartered Institute of Environmental Health have provided guidance to help make effective decisions In order to establish a sensible and justifiable policy, ASH advise you first consider the following five questions…

40. Workplaces and Vaping (5) 1. What are the issues you trying to deal with? 2. What do you think you need to control? 3. Do you have concerns about the possibility of harm from electronic cigarettes? 4. Will restricting or prohibiting use of electronic cigarettes support compliance with smokefree policies? 5. Do you want your policy to help to improve people’s health?

41. Workplaces and Vaping (6) • E-cigarettes are not cigarettes and are exempt from Smoke free legislation that bans smoking in enclosed spaces. There are no known harm to others from second hand vapour emitted from e-cigarettes • Some e-cigarettes will be regarded as Nicotine Containing Products (NCPs) in the future and available on prescription, so may be requested to be used within the workplace

42. Workplaces and Vaping (7) • E-cigarette use in the workplace may demand a new etiquette by controlling the amount of vapour and odour emitted (where possible) to retain respect for others within the work environment • As with all chargeable devices, the correct and appropriate charger must be used for the e-cigarette and should only be charged in the workplace in accordance with company policy

43. Workplaces and Vaping (8) • Companies, under their social responsibility should be dedicated to supporting its workforce to quit smoking where employers who smoke have a desire to do so. This includes enabling staff to access stop smoking support , use NRT in the workplace where this is safe to do so and to use e-cigarettes as a device to assist in smoking cessation

44. Workplaces and Vaping (9) Workplace environments vary greatly and there is no standard approach that will suit all A factory or warehouse is a very different setting to a nursery school – with very different considerations at stake. PHE Guidance- E-cigarettes in public places and workplaces: a 5-point guide to policy making

45. Workplaces and Vaping (10) These examples would all be consistent with PHE’s advice: • A town council prohibits smoking indoors and outdoors on their grounds, while prohibiting e-cigarettes indoors but allowing them outdoors • A school treats e-cigarettes as they would any other age-restricted product and prohibits their possession anywhere on school property • A mental health trust with a completely smokefree policy allows e-cigarette use in specific parts of the hospital grounds and in designated places indoors, such as single occupancy bedrooms

46. Useful links PHE Guidance- E-cigarettes in public places and workplaces: a 5-point guide to policy making https://www.gov.uk/government/publications/use-of-e-cigarettes-in-public-places-and-workplaces Electronic cigarettes (also known as vapourisers) http://www.ash.org.uk/files/documents/ASH_715.pdf Will you permit or prohibit electronic cigarette use on your premises? http://www.ash.org.uk/files/documents/ASH_900.pdf NCSCT briefing paper- Electronic cigarettes http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf The economics of tobacco http://www.ash.org.uk/files/documents/ASH_121.pdf