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Tobacco Harm Reduction - an introduction

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Tobacco Harm Reduction - an introduction

  1. 1. Tobacco Harm Reduction – an introduction Clive Bates Counterfactual United Kingdom September 2018
  2. 2. Declaration Clive Bates has no competing interests with respect to tobacco, e-cigarette or pharmaceutical industries He is former Director of Action on Smoking and Health ASH (UK) and a former UK and UN civil servant. He currently runs an advocacy and consultancy practice “The Counterfactual”
  3. 3. “People smoke for the nicotine but die from the tar” (1976) Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3 Professor Michael Russell 1932-2009 The central insight in smoking and health
  4. 4. Unheated nicotine products Smokeless tobacco Vaping products Tobacco basedPure nicotine based HeatedaerosolUnheated Items are not shown to scale Reduced-risk consumer nicotine market Directly-heated tobacco products “Heat-not-burn” Indirectly-heated tobacco products
  5. 5. Snus ban: worst EU policy of all time?
  6. 6. Royal College of Physicians – on relative risk This report lays to rest almost all of the concerns over these products, and concludes that, with sensible regulation, electronic cigarettes have the potential to make a major contribution towards preventing the premature death, disease and social inequalities in health that smoking currently causes in the UK. ".
  7. 7. U.S Annual Review of Public Health “A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes”. “ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke”.
  8. 8. Royal College of Physicians – on relative risk "Although it is not possible to precisely quantify the long- term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure".
  9. 9. American Cancer Society Based on the most recent studies, e- cigarettes are, in general, substantially less harmful than smoking cigarettes. But long-term health effects are still unclear. American Cancer Society, What do we know about e-cigarettes? 6 March 2018 U.S. National Academy of Sciences While e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes. National Academies of Science, Engineering and Medicine (US). The Public Health Consequences of E-cigarettes. Washington DC. January 2018. Many organisations now making statements on risk
  10. 10. More statements
  11. 11. Royal College of Physicians – on population effects “There are concerns that e-cigarettes will increase tobacco smoking by renormalising the act of smoking, acting as a gateway to smoking in young people, and being used for temporary, not permanent, abstinence from smoking. To date, there is no evidence that any of these processes is occurring to any significant degree in the UK. Rather, the available evidence to date indicates that e- cigarettes are: • being used almost exclusively as safer alternatives to smoked tobacco • by confirmed smokers • who are trying to reduce harm to themselves or others from smoking • or to quit smoking completely.
  12. 12. 2004-10 little progress 2010-17 rapid progress Adult smoking prevalence (age 18 and over) United States 1997 – June 2017
  13. 13. The long view on youth smoking: United States
  14. 14. Royal College of Physicians – quitting smoking as consumer choice " E-cigarettes are marketed as consumer products and are proving much more popular than NRT as a substitute and competitor for tobacco cigarettes. E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking.”
  15. 15. Some research on quitting Zhu S-H, Zhuang Y-L, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. Bmj. 2017;358:j3262. [link] The substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level. Self-reports from a representative sample of 27,460 EU citizens: Extrapolating to the whole EU population, an estimated 6.1 million Europeans have quit smoking with the use of e-cigarettes, while a further 9.2 million have reduced their smoking consumption’ Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries. Addiction. 2016;111(11):2032-40
  16. 16. UK: “Highest proportion of quitters in over 40 years”
  17. 17. Royal College of Physicians – on quitting smoking " […]in the interests of public health it is important to promote the use of e- cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK ".
  18. 18. Royal College of Physicians – policy and unintended consequences “A risk-averse, precautionary approach to e-cigarette regulation can be proposed as a means of minimising the risk of avoidable harm […] “However, if this approach also makes e-cigarettes • less easily accessible • less palatable or acceptable • more expensive • less consumer friendly • pharmacologically less effective • inhibits innovation and development of new and improved products …then it causes harm by perpetuating smoking. Getting this balance right is difficult
  19. 19. E-cigarettes present an opportunity to significantly accelerate already declining smoking rates, and thereby tackle one of the largest causes of death in the UK today. […] Recent report from UK parliament There should be a shift to a more risk- proportionate regulatory environment; where regulations, advertising rules and tax duties reflect the evidence of the relative harms of the various e-cigarette and tobacco products available.
  20. 20. 1. Taxes: reflect risk and incentivise switching
  21. 21. 2. Standards for devices Mechanical risks Thermal risks Chemical risks Information
  22. 22. 2. Standards for liquids Liquid standards Containers Information Testing protocol
  23. 23. 2. Flavours: critical part of appeal to smokers
  24. 24. 3. E-cig marketing is anti-smoking marketing  Don’t be socially irresponsible  Don’t target or feature children  Don’t confuse e-cigarettes with tobacco products  Don’t make health or safety claims  Don’t make smoking cessation claims  Don’t mislead about product ingredients  Don’t mislead about where products may be use Commercial freedom Constrained by guidelines
  25. 25. 4. Warning labels: intimidating or informing consumers? This product contains nicotine which is a highly addictive substance. It is not recommended for use by non-smokers Intimidating
  26. 26. Scares people away
  27. 27. 4. Warning labels: intimidating or informing consumers? This product contains nicotine which is a highly addictive substance. It is not recommended for use by non-smokers Intimidating No product is completely safe but using this product is substantially safer than smoking cigarettes Informing
  28. 28. 5. Where you can vape? Owner / manager decides Government / law decides
  29. 29. 6. Communicate honestly with the public
  30. 30. 7. Age restrictions – obviously. But… Politically popular Friedman AS. How does Electronic Cigarette Access affect Adolescent Smoking? J Health Econ Published Online First: October 2015. Pesko MF, Hughes JM, Faisal FS. The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use. Prev Med (Baltim), February 2016 … but may increase smoking
  31. 31. WHO Framework Convention on Tobacco Control Article 1 (d) “tobacco control” means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke; (emphasis added)
  32. 32. Thankyou! Counterfactual www.clivebates.com @clive_bates

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