How rapid is the impact of quitting?

1. Sex, Drugs and Roll ups:‘Risky behaviour’ and public healthSmokingProfessor Eugene MilneDirector for Adult Health & WellbeingEmail: eugene.milne@phe.gov.ukTwitter: @EugeneMilne

2. How rapid is the impact of quitting? • Initial fall in heart attacks • Early fall in asthma admissions

3. How rapid is the impact of quitting? • Impact on cancer in decades • Major impact on CVD in years

4. Dilemma 1: Standardised packaging

8. Sir Richard DollEpidemiologist1912 - 2005 [In 2002] … on the BBC radio programme Desert Island Discs, Doll said he had formulated a strategy towards health education: "Find out what the tobacco industry supports and don't do it, and find out what they object to and do it." The Guardian May 2005

9. Statement by Alison Cooper, CEO of Imperial Tobacco, made in relation to their half-year 2013 results:"I should also mention Australia, we've had the first six months of the plain pack environment in Australia. We've seen the market decline roughly 2% to 3%, so maybe not as bad as we might have anticipated. But I think moreimportantly, it's our portfolio that has been really successful. The initiatives we've taken in this environment such as our share in both cigarette and fine cut is growing in the market. So, some good initial signs from a plain pack environment and how we're handling that within Imperial in the first half."

10. Assessing Standardised Packaging: • It will be difficult or impossible to provide a specific attribution of impact upon prevalence to SP in the face of: • continuing campaigns to reduce smoking, • statistical noise in measurement of prevalence, and • impact of specific additional national measures that will also act upon prevalence. • Among the latter are, notably, changes to the duty free allowances during 2012 and substantial tax rises that will be effected progressively from March 2014. • prevalence also affected by prominence and vigour of public debate. The huge publicity that preceded and accompanied SP introduction in Australia is likely, in itself, to have had an impact - it will not be possible to derive a separate attribution of impact for this factor, distinct from the direct effect of SP.

11. Standardised packaging • Curtailment of individual choice? • Bullying? • Justified to protect vulnerable groups? • How much evidence is sufficient?

12. Dilemma 2: Prevalence reduction or treatment?

13. ASH Briefing: UK Tobacco Control Policy and Expenditure Updated October 2012

15. LA responsibilities • tobacco control; • alcohol and drug misuse services; • obesity and community nutrition initiatives • increasing levels of physical activity in the local population • assessment and lifestyle interventions as part of the NHS Health Check Programme; • public mental health services; • dental public health services; • accidental injury prevention; • population level interventions to reduce and prevent birth defects; • behavioural and lifestyle campaigns to prevent cancer and long term conditions; • local initiatives on workplace health; • supporting, reviewing and challenging delivery of key public health funded and NHS delivered services such as immunisation programmes; • comprehensive sexual health services • local initiatives to reduce excess deaths as a result of seasonal mortality; • role in dealing with health protection incidents and emergencies • promotion of community safety, violence prevention and response • local initiatives to tackle social exclusion • [Commissioning advice, NCMP, Aspects of healthy child programme]

16. PHOF targets: • 2.01 - Low birth weight of term babies • 2.03 - Smoking status at time of delivery • 2.14 - Smoking Prevalence - adults (> 18) • 4.03 - Mortality rate from causes considered preventable • 4.04i - Under 75 mortality rate from all cardiovascular diseases • 4.04ii - Under 75 mortality rate from cardiovascular diseases considered preventable • 4.05i - Under 75 mortality rate from cancer • 4.05ii - Under 75 mortality rate from cancer considered preventable • 4.07i - Under 75 mortality rate from respiratory disease • 4.07ii - Under 75 mortality rate from respiratory disease considered preventable • 4.12i - Preventable sight loss - age related macular degeneration

17. Some NNTs • Statins (primary prevention) per death or MI = 95 • Statins (secondary prevention) = 12-34 • HPV testing plus Pap smear every 2 years: • detecting invasive cervical cancer = 472 • preventing death from cervical cancer = 1367 • Smoking cessation per additional quitter: • Brief advice (<5 mins) = Between 35 and 140 • NRT = 20 • Buproprion = 15 • Varenicline = 8

20. Smoking in mental ill-health • Around twice as common, and more so in those with more severe disease • A third of all cigarettes smoked in England • Has changed little over the past 20 years • As likely to want to quit as those without, but • more likely to be heavily addicted to smoking • anticipate difficulty quitting smoking • much less likely to succeed in any quit attempt • Over the course of a year: • Are more likely to receive advice from their GP to quit smoking • be prescribed cessation medications • only a minority receive cessation pharmacotherapy • Quitting may improve mental health • Treatments used are as effective as in the general population

23. Tobacco Control or Cessation? Non-specific, population-based reduction in risk? versus Individual, highly cost-effective, therapeutic intervention?

24. Dilemma 3: E-cigarettes & denormalisation

27. Tried to stop smoking in past year Base: Adults who smoked in the past year Graph shows prevalence estimate and upper and lower 95% confidence intervals

28. Success rate for stopping in those who tried Base: Smokers who tried to stop n the past year Graph shows prevalence estimate and upper and lower 95% confidence intervals

29. Decrease in smoking prevalence Base: All adults

31. e-cigarettes • No more effective than NRT • Untested long-term safety • Might perpetuate addiction • May reintroduce advertising • Tobacco companies likely to dominate market • Risk re-normalising smoking behaviours • BUT: • May increase numbers of quitters • May reduce overall tobacco consumption • Are much safer than tobacco • Could provide a rapid route to removal of all tobacco from e.g. prisons

32. Thank you for listening