To e-cig or not to e-cig? Hertfordshire Tobacco Control Alliance Conference, 21 st January 2016 Prof. Jim McManus, CPsychol, Csci, AFBPsS, FFPH Director of Public Health for Hertfordshire Winners 2015

Changing World for tobacco control Footfall for traditional smoking cessation plummeting nationally Segmentation of the population – a long tail market? –E cigs- Roll ups –Shisha- Illicit tobacco –Young people still initiating smoking National campaigns Legislation, Regulation and Licensing changes

Where we are A crowded and confused market of products and users which is becoming increasingly differentiated and fragmented while the prevalence of tobacco use and burden of disease, disability and death is still highest in –Routine and manual workers –Pregnant women – People with long term conditions including HIV –People with mental health problems –Some BME communities

What this requires Some clear thinking about what our aims and objectives are The use of new tools for a new social situation

Continued loss of healthy life References: 1. ASH Factsheet, Smoking Statistics: illness & death, October 2011 ( NB area represents value Obesity: 34,100 Smoking: 81,400 Alcohol: 6,541 Suicide: 5,377 Drug misuse: 1,738 HIV: 529 Traffic: 2,502 Each year smoking causes the greatest number of preventable deaths

Tobacco – A driver of Inequalities Smokers from the highest social class have a lower life expectancy than non-smokers in the lowest social class I+IIIV+V Social Class Relative mortality Male non-smokersMale smokers HighestLowest The life expectancy between rich and poor smokers is similar Richer smokers have a lower life expectancy than poorer non- smokers

Driver of inequalities

Herts Ambitions Reduce Adult smoking prevalence by 1% per year from 15.5% baseline* in Routine and Manual workers by 2% per year from the 25.7% baseline* Reduce Young People uptake continuous reduction in REGULAR and OCCASIONAL smoking in 15 year olds to 5% by 2017 (from a baseline of 10% in 2014 ) Reduce Smoking in Pregnancy smoking prevalence at the time of delivery (SATOD) is less than: –5% for women registered with HVCCG (from a baseline of 6.6% in14/15) and to –7% for women registered with ENHCCG (from a baseline of 9.2% in 14/15).

Traditional methods are not going to be enough in the new social circumstances Tobacco control has showed itself to be innovative. It’s time to do that again What does that mean in 2016?

“The Big 4” issues going forward 1.Continue to control tobacco and its effects 2.Keep going with nuanced strategy – segment populations 3.Getting people into quitting by targeting and segmentating audiences 1.Harm reduction 2.Ecigs 3.Stoptober, Our Services New technologies, new solutions, new markets, and new allies?

The fundamental question.... What form do e-cigarettes play in a comprehensive local tobacco control framework? Aims: –Less tobacco, fewer deaths, less disability –Stop people from taking up tobacco

My contention.... After more debate and reading bad and good science than I care to remember E cigarettes have a fundamental part to play in a coherent whole system approach to tobacco control We need to become friendly to their use and their distribution The science supports this Much, much, safer than tobacco No convincing evidence of gateway or renormalisation

Where this leaves us For me I have fundamentally changed my mind on e-cigarettes. I am convinced if we do not seize their benefits, we will see stop smoking services cuts drastically across England Demographics have changed Over 2.4m people have used ecigs to quit tobacco according to UK figures

Key questions 1.The end game for tobacco is still what we want, yes? Denormalising tobacco 2.Our current strategy is reducing in return 3.Quitting is NOT something some people will or can do. Nice recognised this on Harm guidance 4.The remaining core of tobacco smokers won’t or cant give up tobacco as things stand 5.Time to rethink our offer.....

Mental health as an example Allowing people with mental health problems to just keep smoking perpetuates the myth that it’s a kindness and the fact that 64% of tobacco use, and associated disease and death, falls on this population. Early deaths are a sign of our failure. Making people with mental health problems go cold turkey is inhuman Offering enough real alternatives for people to find an easy way out of tobacco is the challenge. For people with MH issues who quite tobacco, major health benefits accrue Including the ability to reduce doses of many medicines

My reading of that context... Hertfordshire should follow the lead of Leicestershire and others and become as e-cigarette friendly as we can be, in the recognition that the public health gains from e-cigarettes significantly outweigh the risks. We will keep this under regular review

The Big Wins E cigarettes as part of the tobacco control repertoire Reduce deaths, disease and disabillity An acceptable route for people with mental health issues Normalising e-cigarette use does NOT mean renormalising smoking Save some money in austerity climate Help people to help themselves 1 Am J Public Health.Am J Public Health Oct;105(10): doi: /AJPH Epub 2015 Aug 13. Smoking Norms and the Regulation of E-Cigarettes. 1

How..... Working with ecig users in our services taking their choice of tool (an ecig) seriously Publicity about ecigs as a valid option for quitting Looking at how and whether we can give ecig starter kits especially in MH facilities Accrediting safe and knowledgeable retailers Helping review vaping policies in workplaces and elsewhere

Safe Retailers are important, we should support them Can we tell consumers that there are vendors they can trust to be of good quality and safety?

Could we go even further, what if..?? In Hertfordshire trusted e cig vendors operated under explicit endorsement from us? “come here and quit tobacco” – directing would be quitters to knowledgeable and helpful vape vendors? Even a badge or quality mark? Endorsed by Hertfordshire Public Health Service Give up Tobacco Here! Ecigs – helping people quit tobaco in Herts Benefits to Taxpayers? Benefits to Quitters? Benefits to Vendors?

Thank you Winners 2015