Tobacco harm reduction and new
nicotine products – an end to
smoking?
31st May 2012
Professor Gerry Stimson
Knowledge Action Change
Chair
Dr Karl Fagerström
Smokers’ Information Centre, Sweden
Can we extinguish the use of tobacco and
nicotine - if not what should we do?
CAN WE EXTINGUISH
TOBACCO/NICOTINE? IF NOT, WHAT
SHOULD WE DO?
Karl Fagerstrom PhD
Fagerstrom Consulting
karl.fagerstrom@swipnet.se
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
CULTURAL DRUGS
• ALCOHOL, BEER, WINE, HARD LIQUER
• CAFFEINE, SODA, TEA, COFFEE
• NICOTINE, CLEAN NIC., SMOKEFREE,
CIGARETTES
Semi-cultural
• THC, marijuana etc
Examples of problems that probably
cannot be solved or eliminated
• Prostitution
• Drug use, incl. cultural drugs
• Sexually transmitted infections
What is our purpose? What are we
against?
• Addiction
• Tobacco industry
• Smoking related diseases
• Smokers
If ingestion of caffeine by inhalation was
common and we knew it could be safer
taken brewed what would we do?
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.
HIGH
NRT
Snus
Smokless tobacco, e.g.
India
Modified cigarettes, no burning
Traditional cigarettes
CONTINUUM OF HARM
LOW
Success in Stopping Using Different Tobacco/Nicotine Products
When Treated With Different Placebo Products
Cigarette cessation
(Cochrane, 2011)
Smokeless tobacco Cessation
(Cohrane,2011)
Success rate (%)
with placebo
gum
patch
varenicline
bupropion
11.2
9.8
10.0
10.2
M=10 %
gum
patch
lozenge
varenicline
bupropion
26.6
25.5
21.1
33.0
19.1
M=25%
varenicline
36.0
Cessation of long-term use of
nicotine replacement therapy
(Tonnesen & Mikkelsen, 2012)
M= 36%
Fagerstrom & Eissenberg 2012
CONTINUUM OF DEPENDENCE
Traditional
cigarettes
HIGH
Smokeless
tobacco
NRT
Gum
LOW
Patch
Tob Contr 2010
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?
Thank you!
Deborah Arnott
Action on Smoking and Health
Why regulating nicotine effectively is the only
way to end smoking
Why regulating nicotine effectively
will bring an end to smoking
Deborah Arnott
Chief executive ASH
KAC dialogues
31 May 2012
“People smoke for nicotine but
they die from the tar”
• Professor Michael Russell BMJ 1976
• Revolutionised our understanding of
smoking
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.
Growth in inequalities
Poorer smokers more
addicted
Sa liv a c otinine (ng/m l)
Sa liv a c otinine by de priv a tion
in a dult s m ok e rs : HSE 1 9 9 8 -2 0 0 4
350
300
cr ude
250
200
adj ust ed f or
ci gs/ day
0
1
2
3
4
DEPRI VATI O N SCO RE
d
e
p
r
e
v
.
t
c
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
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
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
Skoal Bandits
a 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
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
7
Nicotine causes most cancer
Canada
Aust.
U.K.
U.S.
41%
45%
49%
44%
46%
52%
57%
51%
37%
33%
25%
33%
(% answering “true”)
Nicotine causes most cancer
(% answering “true”) LOW INCOME
NRT might harm health
(% agree strongly + somewhat)
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
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
Tobacco Harm Reduction
English 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
Public Health community in
support
• Royal College of
Physicians
• BMA
• Public health
community at large
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
NICE public health guidance
harm 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
NICE public health guidance
harm 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
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
MHRA
consultation 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
E-cigarettes
proof of demand
• 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
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
Toxic sofas
Regulation needed
Wider regulatory context
for 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
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco Industry moving in
Tobacco industry already
moving in
The lesson of the electric car
• Does the industry
really want
alternatives to
succeed?
• Without regulation no
incentive to change
• Once regulatory
environment changed
GM trashed its
electric cars
Regulation the key
• Need to provide appropriate and effective
regulatory environment to encourage
innovation and investment
• At same time keep up the regulatory
pressure to reduce smoking – making it
less attractive and less affordable to the
consumer and less profitable for the
manufacturers
Conclusions
• 100,000 die in UK
• 1 in 5 still smoke
• Many more in
disadvantaged
communities
• Is it realistic to talk of
the end game?
• …Not unless smokers
given an alternative…
Dr Delon Human
Health Diplomats
Respondent
in association with
Present
A major international conference on public health and health
behaviours to be held in the City of London’s Historic Guildhall
For more details please visit the conference website
www.cityhealth.org