Challenges ahead for tobacco policies Ann McNeill, Professor of Tobacco Addiction Institute of Psychiatry, Psychology & Neuroscience, King’s College London

Competing interests No tobacco industry, electronic cigarette company or pharma funding My funding comes from the public and voluntary sectors

Contents Job done?! Understanding nicotine Implementing what we know works, including harm reduction Tobacco industry

JOB DONE?!

Projected Deaths Caused by Tobacco Use During the 21st Century Total: 1 Billion Tobacco use is the single most preventable cause of disease, disability, and death in the world. Tobacco use causes an estimated 5 million deaths worldwide each year. (Mathers CD, et al., 2006) http://www.tobaccoatlas.org/

4 Stages of the Cigarette Smoking Epidemic Adapted from Lopez et al. A descriptive model of the cigarette epidemic in developed countries. Tobacco Control 1994, 3 242-247

http://www.tobaccoatlas.org/

Eurobarometer (2017)

The International Tobacco Control Policy Evaluation Project (the ITC Project) Canada United States Australia United Kingdom Greece Ireland Thailand Malaysia South Korea Hungary China Uruguay Mexico New Zealand Poland France Germany Netherlands Bangladesh Romania We put all of those principles into place in 2002, when we created the International Tobacco Control Policy Evaluation Project--the ITC Project. Starting first with 4 countries, we have now expanded so that we are conducting the only international evaluation system across 20 countries. Brazil Mauritius Bhutan India Spain Zambia Kenya Abu Dhabi 9 9 9 9 9

Belief that society disapproves of smoking (preliminary data) † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Belief that society disapproves of smoking † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Belief that society disapproves of smoking † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Cigarette smoking prevalence England Base: All adults Graph shows prevalence estimate and upper and lower 95% confidence intervals

Smoking prevalence 88% 62% 32% 18.0% Substance use4 Psychosis3 Depression & Anxiety2 General population1 www.smokinginengland.info 2016 data 2. McManus et al (2010) NCSR. 3. Wu C-Y et al. (2013). PLoS ONE 8(9): e74262. 4. Cookson C, et al (2014) BMC Health Services Research 2014, 14:304  

Smoking & longstanding mental disorders over time (Szatkowski & McNeill, 2014; Royal College of Physicians, 2016)

understanding nicotine

Separate the nicotine from the tobacco smoke “Smokers smoke for the nicotine, but die from the tar” Professor Mike Russell, Maudsley Smokers Clinic, 1979

Perceived proportion of the harms of smoking caused by nicotine (ASH surveys, GB)

Perceptions of harms of electronic cigarettes relative to tobacco cigarettes (ASH surveys, GB)

Belief that e-cigarettes are less harmful (preliminary data) † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Belief that e-cigarettes are less harmful † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Belief that e-cigarettes are less harmful † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

NNS= nicotine nasal spray; inset = nicotine transdermal patch Absorption kinetics of cigarettes, NRT and electronic cigarettes (RCP Nicotine without smoke report, 2016) NNS= nicotine nasal spray; inset = nicotine transdermal patch Electronic cigarettes

Can we deliver the policies we know are effective?

Comprehensive tobacco control strategy Taxation Smoke-free Product Mass media Cessation support Promotion ban

Joossens & Raw, 2017

Hiscock et al, Tobacco Control, Oct, 2017

can we successfully add tobacco harm reduction?

Harm reduction is additional and complementary to other tobacco control strategies such as cessation and prevention

The best thing to do if you are a smoker is to stop using tobacco completely and as soon as possible However not every smoker wants to quit or if they do, not everyone succeeds

Tried to stop smoking in past year (West & Brown, Smoking Toolkit Survey) Base: Adults who smoked in the past year Graph shows prevalence estimate and upper and lower 95% confidence intervals

Of 100 smokers, 31 tried to stop last year (2016) 69 did not want /try to quit

Success rate for stopping in those who tried (West & Brown, Smoking Toolkit Survey) Base: Smokers who tried to stop n the past year Graph shows prevalence estimate and upper and lower 95% confidence intervals

Of the 31 who tried to stop last year, how many quit? The majority of these smokers who are left behind, come from the most disadvantaged groups

Nicotine harm continuum Heat not burn Waterpipes Tobacco chewing gum Cigars Hand-rolled cigarettes Nicotine replacement therapies Pipes Snus Chewing tobacco Cigarettes E-cigarettes Combustible tobacco products Non- combustible tobacco products Non- combustible nicotine (non-tobacco) products Most Dangerous Least Dangerous

E-cigarette report 2015 Emphasised relative health risks Smokers who have tried other methods of quitting without success could be encouraged to try e-cigarettes to stop smoking Stop smoking services should support smokers using e-cigarettes to quit by offering them behavioural support Encouraging smokers who cannot or do not want to stop smoking to switch to e-cigarettes could help reduce smoking related disease, death and health inequalities Continued vigilance and research in this area are needed.

CONSENSUS

ASH Great Britain Surveys

Ever tried e-cigarettes (preliminary data) † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Ever tried e-cigarettes † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Ever tried e-cigarettes † Results are for cigarette smokers in all countries except Bangladesh and Zambia, where results also include other smoked tobacco product users (ie. bidis). * Note: The data for Australia and England are preliminary and unweighted. The data for England are adjusted for oversampling of 18-24 year olds; there was no such oversampling in Australia.  In all other countries, the results are adjusted by sex, age, smoking status, and time in sample.

Tobacco industry

Players ? ACADEMICS GOVERNMENT/PHE/NICE TOBACCO INDUSTRY HPs/ADVOCATES/NGOs CONSUMERS

Foundation for a Smoke-Free World Launched 13th Sept 2017 Initial funding of ~ US$80 million/year for 12 years, from 2018, from Philip Morris International (PMI) Derek Yach founder and president-designate (formerly led WHO Framework Convention on Tobacco Control) PMI/other tobacco industry not allowed to be involved in governance, or influence over funding decisions, strategy, or activities Foundation will have an independent research agenda, ownership of its data, freedom to publish, and strict protections against conflict of interest

Initial activities to focus on Support research into smoking harm reduction and build research capacity through academic centers of excellence Collaboratively build consensus around which interventions can best reduce harm and deaths from smoking and increase smoking cessation Measure and report on global progress towards smoking harm reduction Identify alternative crops and livelihoods for tobacco farmers as the global demand for tobacco declines

Summary A long way to go, particularly to reduce smoking globally and in high risk groups such as substance users We need your help in nicotine awareness Need to implement evidence-based policies, without loopholes, and harm reduction, proactively Should tobacco industry be part of the solution as well as the problem? Can we make cigarettes obsolete in our lifetime?

Acknowledgements Debbie Robson, Robert West, Jamie Brown, Geoffrey Fong, Leonie Brose, Linda Bauld, EUREST Plus and ITC Questions? ann.mcneill@kcl.ac.uk