Welcome from the Chair
Recent UK developments
- Professor Ann McNeill Professor of Tobacco Addiction - UK Centre for Tobacco and Alcohol Studies (UKCTAS), Kings College London
Recent UK developments
Electronic cigarettes are controversial. This new technology in the smoking field has been welcomed by some, severely criticised by others. Do e-cigarettes potentially reduce the harm from smoking by diverting smokers down a safer route – or do they amplify harm and also recruit new smokers? Evidence on these points has been produced but has been treated differently in different national contexts.
This paper will present ideas and themes arising from a pilot cross national study funded by the Wellcome Trust involving the UK and Australia. We argue that these divergent national responses relate to many issues which have little to do with ‘evidence’ as a value free construct. The presentation will compare these different national policies and histories. We argue that ‘evidence’ is global. But unless we understand how evidence fits into national histories, structures and contexts we will not understand the divergences in policy towards e cigarettes.
This session will look at the different policy and tobacco control environments that LMIC countries are working in, and the influence this has on attitudes to tobacco harm reduction, and presents the concerns and issues that this raises.
The UK’s experience and attitude to harm reduction is almost unique, even within Europe. What is often overlooked is that the UK’s approach is underpinned by some of the strictest tobacco control environments in the world. This session will explore how a successful and sensible Harm reduction strategy must be viewed in context and supported by a strong tobacco control strategy.
It is difficult for us in tobacco control to realize that snus, e-cigarettes and heat-not-burn products may have greater potential to make smoking obsolete than the regulations we have spent a lifetime fighting for.
Still, evidence from Norway and Sweden - where snus has been available for decades - suggest that snus has reduced smoking initiation among youth, increased smoking cessation among established smokers and halved smoking intensity among dual users.
The combined numbers who have i) quit smoking for snus, ii) reduced smoking intensity by snus, iii) picked up snus instead of cigarettes, have outnumbered iv) snus users who otherwise would have been tobacco-free.
It is time for us in tobacco control to accept that health gains from smoking cessation, smoking reduction and smoking substitution produced by snus, have more than out-weighed the marginal health loss in the fraction of never-smokers taking up snus.
Canada’s new regulatory regime for e-cigarettes and other vaping products was established with the creation of the Tobacco and Vaping Products Act in May of 2018. The Act balances objectives of protecting young persons from nicotine addiction and tobacco use while allowing adult smokers access to vaping products as a less harmful alternative to smoking. Mr. Van Loon will provide an overview of the Canadian approach and look ahead to key issues and challenges.
Tobacco harm reduction is a scientific field with many unknowns (and perhaps some unknown unknowns), which is to be expected given how new many of the products are. This presentation will explore the limitations and opportunities in scientific research and discuss how science is influencing the regulatory environment. In light of these unknowns, what decisions do regulators need to make and what would the appropriate approach to harm reduction be?
This talk will cover latest published and unpublished data from the Smoking Toolkit Study, the National Youth Tobacco Survey and other international population surveys to evaluate the association of e-cigarette use with cigarette smoking in adolescents and young adults. It will use a variety of methodological and analytical approaches to triangulate findings in an effort to balance findings from small scale longitudinal studies with large scale epidemiological trends
There is less high quality evidence on the effectiveness of e-cigarettes as a smoking cessation aid than there is for prescription medications and licensed nicotine products. Therefore it seems logical to recommend to smokers that they try those first and only try e-cigarettes as a last resort. This talk argues that this logic is the wrong way around and that every single smoker should be recommended immediately to switch to an e-cigarette if they can because this will immediately radically reduce the harm they are experiencing. Those who cannot make the switch and those who make the switch and then wish to reduce their risk further should be recommended to use the range of products and services available to achieve this.
Large numbers of smokers report to have stopped smoking with the help of EC, but claims are also being made that there are data showing that EC prevent quitting. This presentation will summarise existing evidence and look more closely at relevant studies from the past two years. Studies will be reviewed that examine effects of EC on smoking cessation when provided pro-actively by health professionals to smokers seeking help; and also when bought by smokers as a consumer product.
The much anticipated NASEM report published earlier this year, highlighted that the public health impact of e-cigarettes will depend on the balance of 3 factors i) The ability to help current smokers quit ii) The potential to increase adolescents' use of combustible cigarettes iii) Any inherent toxicity of e-cigarettes themselves. This session will discuss from a clinician’s perspective how the “JUUL phenomenon” being reported in the US might change the calculations.
The recent WHO COP8 meeting in Geneva and the FDA's announced enforcement actions and threatening of further restrictions in the US has signalled a toughening of tobacco harm reduction regulation globally. Meanwhile many countries around the world are regulating these new products for the first time. But how many countries still ban THR products around the world? What impact do restrictive laws have on consumers and the market? And how are the various parts of the market affected both large international companies, and smaller independents, to the variation in regulation globally?
New Zealand has almost no controls or regulations on vape products, sales, or use. Government has taken a light touch approach and allowed a thriving vape industry to spring up in response to increasing demand from smokers for less harmful alternates. The New Zealand experience has been largely positive with local entrepreneurs and independent vape stores being a leading source of support for people quitting traditional cigarettes. Concerns about youth vaping have been largely unfounded with recent large scale youth surveys indicating youth vaping is largely confined to smokers. This presentation will focus on what happens when the market, not public health drives change and how policymakers are now scrambling to catch up.
'Alternative nicotine delivery systems' are disruptive. Snus is well advanced in the creative destruction of smoking in Scandinavia. But the big prize is to generalise this experience through vaping and heated tobacco products. The key disruptor is an energy technology - the battery. The critical distinction in public health and consumer policy is not tobacco versus non-tobacco, nor is it novel versus established technologies. It is combustion versus non-combustion. As with all disruptions, many interests and incumbents are threatened - and the enemies of innovation are rich, ruthless and on the offensive.
Smokers are extremely diverse and product / flavour diversity is essential to meet their varying needs when they are looking to switch to vaping. Smokers walking into a vape shop for the first time do not consider themselves ill or needing treatment – they want an enjoyable alternative to cigarettes. And yet there would be benefits for having some medicinally regulated products – for GPs, NHS Stop Smoking Services and in hospitals. There are many lessons here to be learned from the NRT experience in the UK. There are obvious challenges inherent to the medicinal regulatory route, but there are also some less obvious challenges. Furthermore, the UK regulatory framework is unique in ways that mean the model here is not transferable to other countries.
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. They are substantially less harmful—by around 95%—than conventional cigarettes. In August 2018 the House of Commons Science and Technology Committee published its Report on e-cigarettes. The Committee concluded that there was no public health rationale for treating e-cigarettes and conventional cigarettes as one and the same. In his address Normal Lamb MP will talk about what the Committee heard and its key recommendations, including the Committee’s call for:
Although Public Health professionals and bodies in the UK are generally more optimistic about the role of e-cigarettes than in other parts of the world, reasonable professionals still have concerns. Between them, Martin Dockrell and Tim Macylo have been key in shaping PHE’s thinking on e-cigarettes and tobacco harm reduction, Martin as a harm reductionist and Tim as a toxicologist. In this session Martin will try to switch from “transmit” to “receive” and discuss with Tim why so many in UK public health continue to be concerned about initiating nicotine addiction, evidence of harm and the influence of the tobacco industry.
Over 10 weeks at the beginning of 2018, Salford City Council, funded by the Greater Manchester Health and Social Care Partnership, provided 1,000 free e-cigarettes to support smokers with their quit attempt. The pilot was delivered through community stop smoking services and pharmacies, targeting some of the most deprived areas of the city and the country. This session discusses the delivery and evaluation of this innovative pilot.
There have always been moral panics about young people’s substance use but ultimately most of us turn into our parents, reproducing socio-economic disparities in smoking. This means that middle-class young people may resist their parents’ values temporarily by experimenting with cigarettes (or JUULING?), but most later revert to type. For working-class young people from smoking families and communities however, smoking can be a marker of belonging – a fact that the tobacco industry has long understood – and quitting can be experienced as a betrayal. As public health practitioners and researchers, we need to recognise that the influence of family and community on young people is much stronger than our own. The real public health gains will happen when we stop making young people our primary focus and instead work harder with older generations and whole communities to change smoking norms for their children and grandchildren.
The most harmful misperception about vaping is the inaccuracy of public, including smokers, understanding of the potential risks of vaping compared to the known risks of smoking. The fact that this and many other issues have been allowed and even encouraged to propagate has created a battleground which threatens to undermine the public trust in public health. Any legislator will tell you that the best laws and regulations are those which the public support because they believe it will improve their lives. But what happens when public health policy appears designed to harm, obfuscate or mislead them? In the digital age people are more equipped than ever before to scrutinise the actions of public health authorities and disseminate alternative views. “Because we’re experts and we said so” is no longer an acceptable or sustainable argument.
There are estimates that up to 90% of homeless adults’ smoke, more than any other minority group, around 80% of adults dependent on illicit substances also smoke, up to 70% of those dependent on alcohol will die from a tobacco related disease. Desire to quit is no different in these groups, quit attempts are also high but success is low, with most lasting less than 24 hours. Cessation is often unplanned and unsupported, and worryingly often discouraged by professionals. When we look at why success is so low, stress is cited as a key reason for relapse. But what do we mean by that?
Drawing on her experience of working with alcohol and tobacco use in vulnerable and marginalised groups Sharon discusses how the field looks unequal both in terms of who is doing the research and who is being researched, and explains why it’s not a coincidence.