Global Tobacco Control:What to do about e-cigarettes

Deborah ArnottChief Executive

Action on Smoking & HealthAAAS 13th February 2015

What is ASH (UK)?

• NGO using evidence-based advocacy to reduce the harm caused by tobacco

• Anti-smoking not anti-smoker• Set up 1971 by Royal College of Physicians • Core funding from British Heart Foundation and Cancer

Research UK• No commercial funding

Ending the EpidemicDo e-cigarettes have a role?Harm reductionists – YES•To eliminate tobacco use alternative needed•E-cigs ‘disruptive technology’ could help end the epidemic

Traditionalists – NO•Triple goals - eliminate tobacco use, addiction and the tobacco industry•Harm reduction undermines 2nd and 3rd objectives

ASH (UK) positionWhat to do about e-cigarettes?

Maximise benefit

•Encourage switching

•Support quitting

•Discourage relapse

Minimise risk

•Discourage uptake amongst youth

•Discourage uptake amongst never smokers

What’s the evidence so far?

Uptake since 2010E-cigarette use among British smokers, 2010-14

Sustained use among adults confined to smokers & ex-smokers

E-cigarette use in Britain, 2014(All adults)

Most users motivated by quitting or preventing relapse

Aids used in quit attempts

N=9783 adults who smoke and tried to stop or who stopped in the past yearwww.smokinginengland.info/latest-statistics

Gateway hypothesisArguments on both sides

Renormalise

•Mimics smoking behaviour

•Socially attractive, pleasurable, cool

•Celebrity endorsement, sport sponsorship

•Social media, price promotions

Denormalise

•Promotes vaping not smoking

•Promotes switching to safer alternative

•Promotes idea smoking not cool

10

Increase in e-cigarette use (from 4.9% to 8.5%) is in regular smokers

2013

2014

Of those who didn’t want to disclose their smoking status 84% in 2014 had never used them and 9% had used them once or twice

Vast majority of young people who have never smoked or vaped have no intention to

Summary of the evidence:a view from Britain

• Regular e-cig use tripled between 2012 to 2014 from 700K to over 2 million

• 2/3 smokers and 1/3 ex-smokers

• For every 3 who try only 1 carries on using

• Almost no never smokers use e-cigarettes

• Growing experimentation amongst youth but almost entirely among smokers

Adult and youth smoking in England

% E-cig marketing starts taking off

US data: similar pattern to Britain

US Centers for Disease Control and Prevention data from National Youth Tobacco Survey 2011, 2012 and 2013Percentage of young people using in last 30 daysMiddle school = 11-13 High school = 14-17

What’s the global policy position?

WHO positionPaper to WHO FCTC COP 6

• Sets out regulatory objectives and specific regulatory options

• “the subject of a public health dispute among bona fide tobacco-control advocates.”

• “represent an evolving frontier, filled with promise and threat for tobacco control.”

• COP invited to note report and provide further guidance.

BUT tweet less nuanced….

WHO FCTC COP 6 Decision

• 180 Parties (>80% world population but not the US)

• Global guidelines not yet feasible• Parties invited to consider prohibiting or

regulating e-cigarettes to protect human health• Such regulation could be as tobacco, medicinal,

consumer or other • Further WHO report to COP 7 in late 2016

Global policy responses

No level playing field•US will regulate as tobacco product•Europe twin track approach – from 2016 either consumer product or medicine•Australia – nicotine classified as a poison unless in tobacco or NRT •Canada personal consumption legal – sales banned•South Korea legal but heavily taxed•Legal in China, banned in Hong Kong•Ban under consideration in India•Banned in Argentina, Brazil, Malaysia, Turkey, UAE…

UK regulatory framework

• UK pragmatic, evidence-based approach to harm reduction

• Government commitment to make medicines regulation work

• Opt in model so proof will be whether manufacturers opt in or not

• UK already licenced Voke – a novel nicotine inhaler• Still to see whether licenced products popular or not• Twin track approach gives producers and consumers

choice about which market they’re in

Future regulatory framework in Europe – twin track

Tobacco Products Directive regulation of electronic cigarettes

MHRA licenced Nicotine Containing Products (NCPs) including e-cigs

Products not available on prescription Products available on prescription

20% VAT 5% VAT

Cross border advertising banned by 2016; up to Member States to decide on domestic advertising (billboards, Point of Sale, buses etc.)

Advertising allowed – under OTC rules so no celebrity or health professional endorsement; or free samples; and must be targeted at adult smokers etc.

Products widely available Products available on general sale (GSL)

Can’t make health claims Can make health claims

Upper limits for nicotine content will be set and likely to be in force by 2017.

MHRA regulation is flexible; there are no upper limits.

30% health warning on packs about nicotine on front and back of packs

No health warnings on packs

Member States retain powers e.g. on flavours, domestic advertising.

Flavours require a marketing authorisation

Children and Families Bill allows for age of sale of 18 for nicotine products.

Age of sale 12 but can be varied by product so could be higher for electronic cigarettes.

ASH (UK) position

• Policy should be evidence-based• Regulatory framework should be consistent; and:

– Support quitting completely as the best outcome

– Ensure easy access for smokers

– Restrict marketing to adult smokers only

– Facilitate communication of accurate information on relative risks

– Encourage improvements in quality, safety and efficacy

– Support innovation

– Requires market surveillance

• The UK can and should set the standard for effective regulation, in Europe and worldwide

Thank youdeborah.arnott@ash.org.uk

• 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/