1. Global Tobacco Control: What to do about e-cigarettes
Deborah Arnott Chief Executive Action on Smoking & Health
AAAS 13th February 2015

2. 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

3. 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

4. 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

5. What’s the evidence so far?

6. Uptake since 2010
E-cigarette use among British smokers,

7. Sustained use among adults confined to smokers & ex-smokers
E-cigarette use in Britain, 2014 (All adults)

8. Most users motivated by quitting or preventing relapse

9. Aids used in quit attempts
N=9783 adults who smoke and tried to stop or who stopped in the past year

10. 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

11. 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).

12. 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.

13. Summary of the evidence: a view from Britain
Regular e-cig use tripled between 2012 to 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

14. Adult and youth smoking in England%
E-cig marketing
starts taking off

15. 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 = High school = 14-17

16. What’s the global policy position?

17. 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.

18. BUT tweet less nuanced….

19. 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

20. 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…

21. 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

22. 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.

23. 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

24. Thank you deborah.arnott@ash.org.uk
Public Health England
Evidence papers. Policy position in favour of regulation of electronic cigarettes as medicines.
NICE guidance on tobacco harm reduction
Prioritises quitting but supports harm reduction approaches for smokers currently unable or unwilling to quit.
NCSCT briefing
Summarises evidence with helpful advice for stop smoking advisers
MHRA regulatory approach
ASH briefings and research
Smoking in England toolkit data