Tobacco harm reduction and new nicotine products – an end to smoking?

1. Tobacco harm reduction and new nicotine products – an end to smoking? 31st May 2012

2. Professor Gerry Stimson Knowledge Action Change Chair

3. Dr Karl Fagerström Smokers’ Information Centre, Sweden Can we extinguish the use of tobacco and nicotine - if not what should we do?

4. CAN WE EXTINGUISH TOBACCO/NICOTINE? IF NOT, WHAT SHOULD WE DO? Karl Fagerstrom PhD Fagerstrom Consulting karl.fagerstrom@swipnet.se

5. That humanity at large will ever be able to dispense with Artificial Paradises seems very unlikely. Most men and women lead lives at the worst so painful, at the best so monotonous, poor and limited that the urge to escape, the longing to transcend themselves if only for a few moments, is and has always been one of the principal appetites of the soul. Aldous Huxley

6. CULTURAL DRUGS • ALCOHOL, BEER, WINE, HARD LIQUER • CAFFEINE, SODA, TEA, COFFEE • NICOTINE, CLEAN NIC., SMOKEFREE, CIGARETTES Semi-cultural • THC, marijuana etc

7. Examples of problems that probably cannot be solved or eliminated • Prostitution • Drug use, incl. cultural drugs • Sexually transmitted infections

8. What is our purpose? What are we against? • Addiction • Tobacco industry • Smoking related diseases • Smokers

9. If ingestion of caffeine by inhalation was common and we knew it could be safer taken brewed what would we do?

10. Nicotine/tobacco is an ideal area for harm reduction Used largely because of nicotine Pure nicotine, and even unburned tobacco, is not a big part of the problem: the health consequences.

11. CONTINUUM OF HARM Modified cigarettes, no burning NRT Smoklesstobacco, e.g. India Traditional cigarettes Snus LOW HIGH

12. Success in Stopping Using Different Tobacco/Nicotine Products When Treated With Different Placebo Products Cigarette cessation Success rate (%) (Cochrane, 2011) with placebo gum 11.2 patch 9.8 varenicline 10.0 bupropion 10.2 Smokeless tobacco Cessation (Cohrane,2011) gum26.6 patch 25.5 lozenge 21.1 varenicline 33.0 bupropion 19.1 Cessation of long-term use of nicotine replacement therapy (Tonnesen & Mikkelsen, 2012) varenicline 36.0 M=10 % M=25% M= 36% Fagerstrom & Eissenberg 2012

13. CONTINUUM OF DEPENDENCE Traditional cigarettes Smokeless tobacco NRT HIGH LOW Gum Patch

14. Tob Contr 2010

15. Finally! Should future´s children interested in rebellious and adult behaviour just have cigarettes available – the most harmful form – and when hooked helped to less harmful alternatives? Can society offer a better solution?

16. Thank you!

17. Deborah Arnott Action on Smoking and Health Why regulating nicotine effectively is the only way to end smoking

18. Why regulating nicotine effectively will bring an end to smoking Deborah Arnott Chief executive ASH KAC dialogues 31 May 2012

19. “People smoke for nicotine but they die from the tar” • Professor Michael Russell BMJ 1976 • Revolutionised our understanding of smoking

20. 35 years on where are we now? • Clean nicotine only widely available as a tool for quitting • …… despite deadly nature of smoking cigarettes still primary source of nicotine • ….smoking still major cause of preventable, premature death killing than the next six causes put together.

21. Growth in inequalities

22. Poorer smokers more addicted

23. Tobacco Control crusade • To end all death and disease caused by tobacco; • To end nicotine addiction; and, last but not least • To destroy the tobacco industry

24. Harm reduction upsets the equilibrium • Meets first objective: to reduce the death and disease caused by smoking • But at the expense of the second and third objectives • Nicotine addiction sustained • TI potentially benefits from HR

25. Hostility to Big Tobacco • TI documents reveal industry lied about the deadly and addictive nature of its product • TC community believes industry cannot ever be trusted • TC community believes industry doesn’t deserve to survive • Annual global sales $500 bn – profits $35 bn

26. Skoal Banditsa cautionary tale • 1985 US Tobacco opened Scottish factory to make smokeless • Marketing youth oriented • Dramatic increase in youth sales since 1970s in US • Massive public health campaign • 1989 total ban on sales of oral snuff (snus) in UK • Subsequently extended to EU (except Sweden), Australia and Israel

27. Nicotine harms and misperceptions Nicotine is highly addictive which is why few smokers are able to quit Addiction does enable the industry to charge high prices BUT Nicotine wrongly believed to be harmful- by public and professionals

28. Potential risks of THR • Massive business opportunity for tobacco companies to profit from addiction • Undermines quit message causing extra harm to those who might otherwise have quit completely • Potential for young people to start with the harm reduction option then move to smoking (‘gateway’ theory) • Potential for ex-smokers to relapse to the harm reduction option – then to smoking. • Population level nicotine addiction will stop declining/start growing again

29. Potential benefits of THR • Significantly reduces population level harm caused by smoking: • Reduced harm to people that would have otherwise carried on smoking • Reduced harm arising from passive smoking. • Possible ‘halfway house’ to cessation • Creates a market incentive for ever-better products to replace cigarettes • Could lead to smoked tobacco becoming obsolete

30. Tobacco Harm ReductionEnglish art of compromise • Government led HR strategy to: • minimise risks and maximise opportunities • Publicly launch plan to public, HCPs and smokers • Target campaigns to address misperceptions about nicotine amongst public, HCPs and smokers • Light touch medicines regulation for NCPs to ensure • products coming to the market place are safe and effective • regulation appropriate to the level of addictiveness of the product • marketing is regulated to prevent promotion to non smokers/youth • Impact properly evaluated • Regulated products on market to meet smokers’ needs

31. Public Health community in support Royal College of Physicians BMA Public health community at large

32. Where are we now? • DH tobacco plan 2011 committed to ‘develop new approaches to encourage tobacco users who cannot quit to switch to safer sources of nicotine’ • Working in collaboration with the public health community • NICE and MHRA playing key roles – May 2013 key date

33. NICE public health guidanceharm reduction approaches to smoking • Aimed at professionals and public • THR means reducing the illnesses and deaths caused by smoking tobacco – among people who smoke and those around them. • People who smoke can do this by: • stopping smoking altogether • cutting down prior to quitting • smoking less • abstaining from smoking temporarily

34. NICE public health guidanceharm reduction approaches to smoking • Includes completely or partially substituting the nicotine from smoking with nicotine from less hazardous non-tobacco sources such as pharmaceutical nicotine and ‘electronic cigarettes’ either temporarily or indefinitely. • Products containing tobacco not included • Covers people of all ages with the exclusion of pregnant women. • Particular focus on groups who are more likely to smoke

35. MHRA • Public health remit • 2010 licenced NRT for long-term use on basis that “it has become widely accepted that there are no circumstances in which it is safer to smoke than to use NRT” • Launched consultation on how to regulate e-cigarettes and other non-tobacco NCPs

36. MHRAconsultation result • Clear support for regulation; but • not for immediate removal of e-cigarettes from market • Risk to do so would stifle innovation and lead to potentially useful products being removed from the market • Further work underway • Final decision on regulation to be announced May 2013

37. One in five smokers tried Up from one in ten in 2010 BUT only a third carry on using Of those 8 in 10 dual users 2 in 10 switch completely E-cigarettesproof of demand

38. Electronic cigarettes Potential pitfalls • MHRA didn’t ban them as recognised risk e-cig users would revert to smoking BUT • Still marginal, underdeveloped and undermarketed • Concerns about lack of safety and efficacy

39. Toxic sofas

40. Regulation needed

41. Wider regulatory contextfor e-cigarettes • Already banned in Australia, Brazil, Canada, Panama, Singapore, Saudi Arabia and Thailand • EU considering banning them too under review of Tobacco Products Directive • Likely decision will only be legal in EU if come under medicines regulation

42. Tobacco Industry moving in

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50. Tobacco industry already moving in