1. The e-cigarette: opportunity or threat? SSA Annual Symposium 2015 Deborah Arnott Chief Executive Action on Smoking and Health

2. What we’re going to cover Tobacco use: the context Harm reduction: the obvious next step Why e-cigs challenge the consensus What’s the evidence Building support for an evidence-based approach Lessons learnt

3. UK: world leader in TC

4. BUT: significant and widening gap between rich and poor

5. Harm reduction: obvious next step “People smoke for nicotine but they die from the tar” Russell MAH. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ1976;1:1430–3

6. Key principles of THR Smoke not nicotine primary cause of death and disease Quitting completely best option Smokers switching to alternative nicotine sources can substantially reduce harm Need to minimise risks of uptake by youth and never smokers

7. Solid foundations in England: Building support for harm reduction policy MHRA remit to protect public health – liberalises NRT regulation from 2005 on RCP harm reduction report 2007 Beyond Smoking Kills 2008 – harm reduction principles endorsed by over 100 health orgs DH tobacco strategy endorses harm reduction 2010 and 2011

8. Principles into practice: e-cigarettes – a disruptive technology % of smokers who have tried and are using 2010 - 2015

9. Principles into practice: e-cigarettes % of ex-smokers and never smokers who have tried and are using 2010 - 2015

10. Aids used in most recent quit attempt 10 N=10078 adults who smoke and tried to stop or who stopped in the past year E-cigarette use for quitting is still increasing somewhat

11. Aids used in most recent quit attempt 11 N=9783 adults who smoke and tried to stop or who stopped in the past year; 2009 is Jul to Dec E-cigarettes have grown the use of moderately effective aids to cessation from 24% to 35%; use of most effective methods has decreased from 4% to 3% At stable quit attempt rate of 37% this contributed 0.05% to the decreased prevalence (~20,000 additional ex-smokers) Approx odds of success relative to nothing and NRT-OTC: 1.5 Moderately effective 3.0 Most effective Least effective Moderately effective Most effective

12. Courtesy of Prof John Britton, Nottingham

13. Cigarette smoked Study conclusion: “e-cigarettes used under real- conditions emit toxicants, including PM2.5” E-cigarette puff

14. Children who have never smoked rarely use electronic cigarettes 14

15. Youth smoking in England 15

16. Yet controversy abounds

17. Why the controversy? Historic goals of tobacco control are to eliminate: Harm caused by tobacco Nicotine addiction Tobacco industry

18. Answer: ecigs threaten the consensus Historic goals of tobacco control are to eliminate: Harm caused by tobacco Nicotine addiction Tobacco industry

19. Harm reduction policy in England: Building on our foundations While ecigs banned in many jurisdictions not in UK: DH tobacco strategy endorses harm reduction 2010 and 2011 NICE guidance Tobacco Harm Reduction 2013 PHE report and position statement 2015 Prisons going smokefree allow ecig use October 2015 UK pursuing twin track regulatory approach – opt in for medicines regulation If not regulated as medicines then will come under the EU Tobacco Products Directive from 2016

20. Twin track regulatory approach from 2016 20 Tobacco Products Directive regulation of electronic cigarettes MHRA licenced Nicotine Containing Products (NCPs) including e-cigs Products not available on prescriptionProducts available on prescription 20% VAT5% 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 endorsement or free samples and must be targeted at adult smokers etc. Products widely availableProducts available on general sale (GSL) Can’t make health claimsCan 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.

21. Lessons learnt Harm reduction has great potential to reduce the death and disease caused by smoking Electronic cigarettes have a role to play Highly controversial so: Building and disseminating evidence base essential if sensible policies are to prevail It’s working in England to date… question is how do we ensure this continues in the new regulatory environment?

22. And finally…. www.ash.org.ukwww.ash.org.uk deborah.arnott@ash.org.uk

23. And finally…. www.ash.org.ukwww.ash.org.uk deborah.arnott@ash.org.uk