Nicotine without smoke Nicotine Tobacco harm reduction Tobacco Nicotine without smoke Tobacco harm reduction A report by the Tobacco Advisory Group of the Royal College of Physicians Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk April 2016 HRR Prelims C:Layout 1 07/04/2016 15:14 Page iii Acknowledgements The Tobacco Advisory Group acknowledges the help of the UK Centre for Tobacco and Alcohol Studies (www.ukctas.net), which is funded by the UK Clinical Research Collaboration, in writing this report; and thanks Natalie Wilder, Claire Daley, Jane Sugarman and James Partridge in the Royal College of Physicians Publications Department for their work in producing the report. The Royal College of Physicians The Royal College of Physicians (RCP) plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing 32,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare. Citation for this document Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP, 2016. Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Copyright © Royal College of Physicians 2016 ISBN 978-1-86016-600-6 eISBN 978-1-86016-601-3 Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk Registered charity no 210508 Typeset by Cambrian Typesetters, Camberley, Surrey Printed and bound in Great Britain by The Lavenham Press, Suffolk HRR Prelims C:Layout 1 07/04/2016 15:14 Page i Contents Contributors vii Declaration of contributors’ interests ix Members of the Tobacco Advisory Group of the Royal College of Physicians x Foreword xi Abbreviations xiii 1 Introduction 1 1.1 The harm of smoking 3 1.2 Principles of tobacco harm reduction 5 1.3 Role of harm reduction in tobacco control policy 6 1.4 Developments since the publication of the 2007 RCP report and the need for this update 7 1.5 Summary 8 2 Smoking in Britain 12 2.1 Recent trends and current prevalence of smoking in the UK 12 2.2 Smoking and disadvantage 15 2.3 Trends in the uptake and progression of smoking in the UK 19 2.4 Current and expected future mortality and morbidity from smoking 21 2.5 Summary 22 3 Effectiveness of current and future tobacco control policy 25 3.1 Background 25 3.2 Tobacco control policy effectiveness and implementation in the UK 27 3.3 Cumulative impact of conventional tobacco control policies and future challenges 40 3.4 Developing a more effective tobacco control policy approach 42 3.5 Summary 43 © Royal College of Physicians 2016 iii HRR Prelims C:Layout 1 07/04/2016 15:14 Page ii Tobacco harm reduction 4 Nicotine pharmacology and pathophysiology 52 4.1 Nicotine chemistry and absorption 52 4.2 Nicotine metabolism 54 4.3 Systemic and central nervous system effects 56 4.4 Toxicity and potential hazards 57 4.5 Development of addiction 59 4.6 Smoke constituents influencing the addictive potential of cigarette smoke 61 4.7 Impact of cigarette design characteristics on nicotine delivery 62 4.8 Lessons from cigarette design for harm-reduction product development 63 4.9 Summary 64 5 Non-tobacco nicotine products 69 5.1 Introduction 69 5.2 NRT products 70 5.3 E-cigarettes 74 5.4 Products in development 85 5.5 Summary 86 6 Quitting smoking 95 6.1 Introduction 95 6.2 Quit attempts and quit success 95 6.3 Methods used to quit 99 6.4 What motivates smokers to try to quit and what are the obstacles? 103 6.5 Why do more smokers not try to quit and how could the numbers be increased? 104 6.6 How could changes in the availability of nicotine products influence quitting behaviour? 106 6.7 Summary 106 7 Trends in use of non-tobacco nicotine in Britain 110 7.1 Sources of data 110 7.2 Trends in the use of non-tobacco nicotine products among adults 110 7.3 Trends in the use of non-tobacco nicotine products among children 116 7.4 Summary 119 8 Harm reduction and population health 121 8.1 The need for harm reduction 121 8.2 Potential hazards of harm reduction 122 8.3 Harm to health and wellbeing of self and others from smoking at different stages of life 124 iv © Royal College of Physicians 2016 HRR Prelims C:Layout 1 07/04/2016 15:14 Page iii Contents 8.4 Harm reduction with conventional NRT products 125 8.5 Substitution with e-cigarettes 127 8.6 Summary 130 9 E-cigarettes, harm reduction and the tobacco industry 135 9.1 Introduction 135 9.2 The tobacco industry and e-cigarettes 136 9.3 E-cigarette marketing 137 9.4 Undermining tobacco control 140 9.5 E-cigarettes and the future of the tobacco industry 143 9.6 Summary 145 10 Regulating nicotine products in the UK 151 10.1 What does nicotine product regulation need to achieve? 151 10.2 Current regulation of tobacco, and licensed and unlicensed nicotine products 152 10.3 The 2014 EU TPD 156 10.4 Advantages and disadvantages of medicines and TPD regulation of non-tobacco nicotine 158 10.5 The future of nicotine regulation 160 10.6 If e-cigarettes are removed from the TPD, what are the alternatives? 162 10.7 Providing consistency in messages to smokers 163 10.8 Taxation and price 163 10.9 Summary 164 11 Harm reduction and e-cigarettes: an international perspective 168 11.1 Harm reduction and tobacco control policy implementation in the UK 168 11.2 Approaches to regulation of e-cigarettes in other countries 168 11.3 Awareness and use of e-cigarettes in different countries 170 11.4 Patterns of use across countries with different regulatory regimens 173 11.5 Harm reduction and the WHO Framework Convention on Tobacco Control 174 11.6 Summary 176 12 Ethics and conclusions 180 12.1 Moral and ethical considerations of harm-reduction strategies 180 12.2 Smoking and public health 182 12.3 The effect of conventional tobacco control approaches 182 12.4 Priorities for conventional tobacco control policy implementation 183 12.5 Nicotine addiction and its effects 183 12.6 Non-tobacco nicotine products 184 © Royal College of Physicians 2016 v HRR Prelims C:Layout 1 07/04/2016 15:14 Page iv Tobacco harm reduction 12.7 How smokers in the UK try to quit, and their chances of success 185 12.8 Use of e-cigarettes by smokers and non-smokers 186 12.9 Harm reduction and population health 186 12.10 Regulation and harm reduction 187 12.11 The tobacco industry and e-cigarettes 188 12.12 Conclusions 188 12.13 Summary 189 vi © Royal College of Physicians 2016 HRR Prelims C:Layout 1 07/04/2016 15:14 Page v Contributors Amanda Amos Professor of health promotion, University of Edinburgh Deborah Arnott Chief executive, Action on Smoking and Health (UK) Richard Ashcroft Professor of bioethics, Queen Mary University of London Paul Aveyard Professor of behavioural medicine, University of Oxford Linda Bauld Professor of health policy, University of Stirling and CRUK/BUPA chair in behavioural research for cancer prevention, Cancer Research UK Ilze Bogdanovica Research fellow, University of Nottingham John Britton Professor of epidemiology, University of Nottingham Meghan Chenoweth Postdoctoral fellow, University of Toronto, Canada Jeff Collin Professor of global health policy, University of Edinburgh Martin Dockrell Head of tobacco control, Public Health England Peter Hajek Professor of clinical psychology, Queen Mary University of London Nick Hopkinson Reader in respiratory medicine and honorary consultant physician, National Heart and Lung Institute, Imperial College London Tessa Langley Assistant professor in health economics, University of Nottingham Sarah Lewis Professor of medical statistics, University of Nottingham Ann McNeill Professor of tobacco addiction, King’s College London © Royal College of Physicians 2016 vii HRR Prelims C:Layout 1 07/04/2016 15:14 Page vi Tobacco harm reduction Hayden McRobbie Professor of public health interventions, Queen Mary University of London Marcus Munafò Professor of biological psychology, University of Bristol Magdalena Opazo Breton Research statistician, University of Nottingham Rachel F Tyndale Professor of pharmacology and toxicology, and psychiatry, Centre for Addiction and Mental Health, University of Toronto Jennifer Ware Research fellow, University of Bristol Robert West Professor of health psychology, University College London viii © Royal College of Physicians 2016 HRR Prelims C:Layout 1 07/04/2016 15:14 Page vii Declaration of contributors’ interests Paul Aveyard is the chief investigator of a trial of nicotine preloading in which NRT is donated by GlaxoSmithKline to the NHS. Peter Hajek has received research funding from and provided consultancy to Pfizer, Johnson & Johnson, Novartis and GlaxoSmithKline. Hayden McRobbie has received honoraria for speaking at smoking cessation educational and advisory group meetings, which have been organised by Johnson & Johnson and Pfizer; he has received funding for investigator-led research from Pfizer and was an investigator on a 2008 study of e-cigarettes sponsored by manufacturer Ruyan Group and conducted independently at the University of Auckland.