2024 Thursday 5th December Seminars

Around a decade on from the EU Tobacco Products Directive entering into force, the nicotine landscape in England and in many countries around the world has changed – for example, vaping products and their user profile look very different. As a result, the UK government is introducing new primary legislation around smoking and vaping to improve the population’s health. This year’s summit will provide a forum to discuss, respectfully, these developments and the latest science and evidence around vaping, and smoking.

Peter will discuss the conceptual framework of total community harm reduction that involves the dynamic balance between products, practices, and policies that affect the availability and consumption of tobacco products. He will then describe project VECTOR (Vaping and Electronic Cigarette Toxicity Overview and Recommendations)  where his team used systematic and umbrella reviews and a consensus-driven approach with a panel of 30 international academics and individuals with lived experience. They voted on recommendations related to four key health outcomes: cancer, cardiovascular disease, respiratory health, and dependence. The consensus resulted in 14 recommendations, each assessed for evidence quality and strength. Four accompanying knowledge products were developed to support decision-making.  He will describe the recommendations and considerations for people who currently use or are thinking of using e-cigarettes, and discuss how these recommendations can be applied in clinical practice and population-level health considerations to balance absolute versus relative risk in a time of evolving evidence.

The Tobacco and Vapes Bill will be a landmark step towards achieving a smoke-free UK. It will deliver on the government’s manifesto commitment to ensure that the next generation will never legally be sold tobacco products and that vapes will be banned from being branded and advertised to appeal to children. The Bill will be the biggest public health intervention in a generation and will deliver on the government’s mission to improve healthy life expectancy and reduce the number of lives lost to the biggest killers, including cancer and cardiovascular diseases.

The presentation will (i) set out the context and evidence underpinning the Bill, (ii) outline the provisions that will be included on the face of the Bill as well as regulation-making powers requiring subsequent secondary legislation, and (iii) discuss the main challenges ahead for success, including where further consultation and engagement will be needed.

In this session, Jamie will provide an update on emerging trends in smoking and cessation in England in 2024 from the Smoking Toolkit Study. This long-term population study involves a monthly survey of a new sample of approximately 1,700 adults each month in England asking detailed questions on smoking, cessation and vaping. It has been running since 2006 and has collected data from over 400,000 adults across 215 monthly waves. A lot has changed in smoking, cessation and vaping profiles and trends, especially in the last 5 years. Jamie will synthesise emerging trends on topics including daily and non-daily smoking, non-cigarette smoking, menthol and hand-rolled smoking, overall use of inhaled nicotine, the use of smoking cessation aids - including newer products such as nicotine pouches and heated tobacco - and inequalities in smoking. He will conclude by reflecting on the possible implications of these findings for e-cigarette research and policy.

Nicola will describe the most up-to-date evidence from the Cochrane systematic review of e-cigarettes for smoking cessation. What do we know? What do we still need to know? What is the current status of this living review of the evidence? Nicola will also discuss a new Cochrane systematic review investigating methods of quitting vaping, initial observations, and what comes next.

Cigarette smoking is a major cause of morbidity and mortality in those who smoke. Helping smokers quit benefits public health. Ideally, smokers would just stop smoking, but this is not easily achieved due to the addictive nature of nicotine. An alternative would be to switch to a less harmful product, and e-cigarettes can fill this role. However, the harm reduction resulting from smokers switching needs to be balanced against any adverse effects in those who take up e-cigarettes but who would not otherwise have smoked. This is of particular concern in young people. A major consideration regarding e-cigarette policy is their potential toxicological impact. Some argue that the toxicity of many of the constituents of e-cigarettes is unknown, or such that significant harm might result in users. This is particularly true of flavourings. However, objective evidence is against this. The most commonly used flavourings do not appear to be markedly toxic, either directly or following thermal transformation in e-cigarettes. Suggesting otherwise would be a strong argument for people to avoid e-cigarettes. While this might help reduce uptake by non-users, it would also deter smokers from switching. In addition, exaggerating the harm could lead to lack of confidence in public health messaging regarding e-cigarettes. Hence, policy needs to be based on sound scientific evidence, and whilst the possible adverse health effects of flavourings should not be ignored, addressing behavioural aspects, such as appeal to young people versus adults, may be more important in developing an effective public health strategy.

The debate on the role of e-cigarettes in the UK and across the world has continued to evolve as trend data on vaping and smoking accumulates. Participants on all sides of the debate feel strongly about the lens they look through. Bringing people together toward a consensus view and proportionate regulation requires the use of the best current evidence available. The RCP report “ E-cigarettes: An Evidence Review’ published in 2024, examines the literature on numerous complex issues related to vaping including safety, efficacy, industry and regulation to make over 50 recommendations on how best to use e-cigarettes to treat tobacco dependency and discourage use amongst people who do not smoke, especially young people.

Balancing regulatory responsibilities to improve public health

Across the UK and globally government and public health bodies are focused on exploring effective measures to discourage youth vaping.  However, evidence of unintended consequences of potential vaping policies remains a concern. In this session, Jasmine and Martin will share fresh data on the “Policy Decision Making Aid” that will explore foreseeable unintended consequences and potential ideas to minimise them. Key policies to discuss include:

• Reducing affordability (tax, minimum pack size)
• Restricting appeal (flavours, packaging)
• Reducing accessibility (Age of sale, licensing)

Vaping is emerging as a key method of administering drugs beyond nicotine. For example, in legal cannabis markets, cannabis vaping products have emerged as highly popular. Vaping drugs such as cannabis could offer valuable opportunities for reducing the harms of smoked administration. This is particularly important given that cannabis is widely co-administered with tobacco. On the other hand, vaping products for drugs such as cannabis may not always be less harmful and could carry greater risks. For example, they might contain drugs different to those expected by the consumer, such as synthetic cannabinoids – highly harmful synthetic drugs that are implicated in half of all prison deaths. Inspired by media reports of vaping-related serious adverse events in schools, we tested the contents of vapes collected from 27 schools in England, seized from pupils during normal school operation. We found the presence of synthetic cannabinoids in 17.5% of all samples and in 78% of all sampled schools. We found THC (the active drug in cannabis) in only 1.6% of samples. Informed by discussions with young people, we believe that pupils are being mis-sold synthetic cannabinoids as ‘cannabis’ in vapes, and are unaware that they are being sold a considerably more harmful drug. These findings raise significant concerns for the health of young people using these vapes.

Smoking among people experiencing homelessness is extremely high, and as smoking rates come down, it leads to a widening of health and social inequalities. Project SCeTCH is a nationwide cluster randomised controlled trial for people accessing homeless services delivered by people who work within the services. Over the 3-year trial, 477 people accessing 32 homeless services were randomised to receive either an e-cigarette starter pack (intervention) or a referral to the stop smoking service (usual care). This talk will present the study findings, including findings from our qualitative process evaluation and consider broader implications of reducing smoking in line with national treatment and policy agendas, such as Swap to Stop and the Smokefree Future.

An increasing proportion of youth and adults are inaccurately perceiving vaping as equally or more harmful than smoking. In this session, Dr Katie East will provide an update on what we currently know about harm perceptions of vaping among youth and adults, including their relationship with vaping and smoking behaviours as well as interventions to correct misperceptions. Findings from an online experiment evaluating the impact of brief vaping facts films (designed for social media) on correcting vaping misperceptions among young adults in the UK will also be presented. Dr East will also discuss gaps in the evidence around vaping perceptions, particularly in the UK, and how these could be filled.

Package design and elements are powerful tools for the marketing and promotion of tobacco and nicotine products. In 2024, the UK Government has proposed powers to regulate nicotine product packaging and flavours; however, to date, these have not been outlined.

Dr Eve Taylor will discuss her work on standardising the packaging, flavour descriptors and nicotine descriptors of e-cigarettes, nicotine pouches and heated tobacco products and how this may effect the appeal and harm perception of adults and youth.

The regulatory context around tobacco and vapes is reactive and fast-moving. This session will reflect on Cancer Research UK’s role in commissioning timely research that helps inform key outstanding evidence gaps and policy questions on vaping policy.

Identifying effective interventions to minimise unintended consequences

As the Tobacco and Vapes Bill is set to bring forward further regulations on both tobacco, vaping and other nicotine products this presentation will explore what the role will be for vaping as progress is made towards a smokefree country, how our legislative and policy approaches may need to evolve and what questions we should be considering as the UK moves closer to making smoking obsolete.

Challenges in Regulation: Craig will examine the changing vaping market in the UK over the past 12 months, the effects of the single-use plastics ban, the rise of novel vaping products under the current legislation, and the close collaboration between regulatory agencies. What are the pros and cons of these products? Are they legal? Are they safer? Are they the way forward?

Challenges of Enforcement:  The UK Government is planning to introduce further legislation to reduce the attractiveness and availability of vaping products to children and protect the environment. Critics say there is no point in considering new regulations when the current ones are not enforced. Kate will discuss the challenges faced by the authorities in enforcing the current regulations and how new legislation may help or hinder attempts to prevent children from using vapes while maintaining their availability and attractiveness for smoking cessation.

New Zealand is one year from the 2025 government deadline to reduce adult daily smoking to 5%. Until 2020, achieving this goal was looking unlikely, but in the last 4 years, adult smoking rates have dropped by 40%, correlating with a rapid increase in vaping and putting New Zealand on a trajectory to achieve 5% by 2025.

The unprecedented fall in smoking rates has gone largely uncelebrated. Concerns about the significant rise in youth vaping are dominating the public debate, with increased public perception that vaping is simply replacing smoking as the next public health disaster.

Tensions have been heightened by the repeal of the previous government’s smoking endgame laws that would have de-nicotinised cigarettes, reduced cigarette outlets by 90% and a smokefree generation policy.

This talk will update on progress towards Smokefree 2025 and how vaping has not just disrupted smoking, but also the way New Zealand thinks about tobacco control and addiction.

Is the noise about vaping distracting us from the real public health problem of smoking, and what this might mean for tobacco policy, harm reduction, and becoming a smokefree nation?

In this session, Prof Coral Gartner will provide a brief history and timelines of the major regulatory changes in Australia and examine the implementation and outcomes of the "Prescription model approach" where the defined objective was "to prevent adolescents and young adults from taking up nicotine vaping products while allowing current smokers to access these products for smoking cessation with appropriate medical advice".  Prof Gartner will discuss the challenges of the prescription model and reference patterns of vaping use, looking at age and motivation and how well the prescription model was used for smoking cessation.  Finally, Prof Gartner will discuss the most recent regulatory change that allows vape products to be sold by pharmacies without a prescription.  In conclusion, Prof Gartner will summarise the challenge of reaching a compromise that allows for wider access to vaping products while retaining health professional oversight while different groups argue for the continuation of the prescription model or introduction of a consumer model.

The near disappearance of youth smoking in the U.S. is one of the great public health triumphs of the present century. Yet, it is rarely mentioned. Shouldn’t we be shouting it from the mountaintops? Why aren’t we? This presentation explores factors responsible for the silence that has greeted this remarkable accomplishment. One is the public’s (and professionals’) failure to distinguish the risks associated with smoking from those produced by other tobacco and nicotine products. Another, closely related, is the erroneous perception that nicotine causes the disease and death associated with smoking. The rise in the popularity of e-cigarettes has supplanted consideration of the disappearance of smoking, despite the ironic fact that youth smoking has fallen at its fastest rate ever during vaping’s ascendancy. As a result of the demise of youth smoking, the current generation will live longer, healthier lives than their parents and grandparents.

Flavours other than tobacco in vapes and nicotine pouch products are very common, and are generally regarded as pivotal to a users' experience. This presentation will show how the vast majority of products on the market in Europe and around the world are currently non-tobacco flavours, and consumers report that such flavours are important to their experience. However, flavours have been blamed by many as the driver of youth usage, and, other than in the case of menthol cigarettes, have historically been removed from the market for combustible tobacco products in many countries around the world.

The European Union's Tobacco Product Directive is already over 10 years old, in need of an update to reflect the changing consumer market for tobacco products, and in particular to encompass new products which were not prevalent a decade ago such as nicotine pouches. Will non-tobacco flavours be banned from the vape and nicotine pouch segments in the same way as for combustible cigarettes and heated tobacco, or will regulatory bodies recognise the role of flavours in the uptake of these products by smokers, and continue to allow them?  What are the consequences of restricting flavours to consumer behaviour and the development of illicit markets? And if the EU continues to allow flavours in these categories, what are EU Member States likely to do to further regulate the products themselves given the public concern over youth usage?

Worst fears & optimal outcomes

Dr Alexandria Andrayas will present evidence from the Avon Longitudinal Study of Parents and Children (ALSPAC), exploring how smoking behaviours evolve from adolescence into early adulthood. Her talk will also delve into the transitions young adults take from smoking to quitting with or without e-cigarettes or to dual use of both cigarettes and e-cigarettes. Dr Andrayas will give insights into how sociodemographic, psychological, lifestyle, and substance use factors shape these smoking patterns and vaping transitions and will engage with the broader literature on youth vaping, highlighting shared influences and discussing the implications of these in the context of health inequalities. Such research has important implications for informing more tailored interventions and enhancing harm reduction strategies for both youth and adults.

Has the nicotine market become ungovernable? When regulatory superpowers like the United States and Australia have over 90% of the e-cigarette market supplied through unauthorised channels, what’s going on, and what can we learn? Is there a guiding principle we can draw for regulation? Everyone wants to square the circle between preventing youth uptake and promoting smoking cessation, but are they missing the point, doomed to fail, and what is the cost of getting it wrong?

The US Pre-Market Tobacco Application (PMTA) is a complex and expensive application process overseen by the FDA, designed to provide a path to market for reduced-harm products.  Rigorous FDA review of company PMTAs was intended to ensure that authorized products were safer for the individual user and did not present an initiation risk among the nicotine naïve – under a standard called "appropriate for the protection of public health." More than four years after the filing of the first PMTAs and more than three years since the first authorizations, the US vaping marketplace is increasingly chaotic and there is little evidence that PMTA authorizations have had the impact that had been expected or hoped for them.  In significant part, this is attributable to influential advocacy groups and health bodies that had previously supported the PMTA review framework (and indeed had a strong hand in designing it), but that have in recent years taken a stridently anti-harm reduction position – both based on youth initiation concerns and out of hostility to industry.  Their advocacy has influenced public opinion and has placed significant political pressure on the FDA to limit authorizations, particularly of flavours.  Concurrently, the gap between perception and reality regarding the comparative harm of vaping and smoking continues to grow throughout the world – in the UK as well as in the US.  Where did the US go wrong?  And what is the path forward?  It is a time for new solutions, and an evidence-based implementation of THR will be central to that process.

Jeff Weiss is a former senior executive with NJOY, which was one of the first vaping companies to secure PMTA authorizations for vaping products and, to this point, the only one with authorizations for a non-tobacco flavour.

The WHO voluntary target of a 30% reduction in adult tobacco use by 2030 from a 2010 baseline will be reached, notably by women. However, the prevalence rate of tobacco use in men will still be 30% in 2030. The target does not acknowledge the vast differences in prevalence by country, gender, or type of tobacco used (smoked, smokeless), and its achievement will not significantly impact noncommunicable disease (NCD) mortality rates, the focus of Sustainable Development Goal 3.4.

More than half of the 130 countries with reliable trend data are on track to reach the tobacco target by 2030. Another third have declining tobacco use prevalence rates but will not reach the 30% reduction target by 2030. The prevalence of tobacco use has increased or remained unchanged since 2010 in the remaining countries.

The FCTC was initially associated with the rapid implementation of many measures, but progress in implementing key policies has slowed over the last ten years. Much more ambitious tobacco targets and a modernised FCTC are required to ensure reductions in NCD mortality.

The wide range of much less harmful, alternative nicotine delivery products now available since WHO set the global target has led to a rapid acceleration in the rate of decline in smoking in a few countries. Unfortunately, these innovations remain contested, including by WHO. Over the next two years, we must ensure that WHO aligns with the full range of evidence-based smoking reduction policies so that all countries contribute to accelerating the end of smoking.

This session will reflect on the cultural norms experienced in the North East of England and how, two decades since the launch of Fresh and a collaborative approach to focus on tobacco smoking, rates have dropped 62%, the largest in England. Despite this significant progress, smoking is still killing too many loved ones each day, and there is still much to be done, with rates much higher within some groups. At the core are real people living in real communities whose stories need to be told and heard. With a clear regional vision for a smokefree future, free from the death and disease of tobacco, this presentation will explore whether we are doing enough to make this a reality.

Is smoking still the main problem?