Global Tobacco Control: What to do about e-cigarettes Deborah Arnott Chief Executive Action on Smoking & Health AAAS 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 Epidemic Do 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) position What 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 2010 E-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 year www.smokinginengland.info/latest-statistics

Gateway hypothesis Arguments 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

Increase in e-cigarette use (from 4.9% to 8.5%) is in regular smokers 2013 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 2014 NB. Those who have never smoked appear to be heavily protected from e-cig experimentation (98.5% in 2013 had never used an e-cig, compared with 97.8% in 2014).

Vast majority of young people who have never smoked or vaped have no intention to NB: The proportion of individuals who have no intention to vape has fallen significantly between 2013 and 2014.

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 2013 Percentage of young people using in last 30 days Middle school = 11-13 High school = 14-17

What’s the global policy position?

WHO position Paper 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 you deborah.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/