Tobacco use disorder - Towards achieving a Smoke Free goal.pptx

How Malaysia can achieve its smokefree goal.
My presentation at the International Society for Addiction Meeting, Kuala Lumpar
12 September 2024

1. ISAM Regional Meeting 2024 Tobacco use disorder: Towards achieving a Smoke-Free goal 12 September 2024 Dr Colin Mendelsohn. Founding Chairman, Australian Tobacco Harm Reduction Association

2. I have never received payments from electronic cigarette or tobacco companies Unpaid Board member of the Australian Tobacco Harm Reduction Association (ATHRA), a registered health promotion charity, October 2017 - January 2021. ATHRA accepted Unconditional seed funding from the vape retail industry. Ceased March 2019 A donation from KAC Communications in March 2018, sourced from a surplus arising from the Global Forum on Nicotine conference in May 2017 Invited speaker at World Vape Show Conference 2022 (Dubai). Travel expenses paid Author of Stop Smoking Start Vaping Disclosure 2

3. Smoking in Malaysia People who use drugs Quitting smoking Tobacco harm reduction Vaping nicotine Safety Effectiveness Myths Outline 3

4. Smoking in Malaysia

5. Adults 15+ 1 19% currently smoke 35.7% of men 1.5% of women 1. Global Adult Tobacco Survey (GATS) Malaysia, 2023 2. 2023 Adolescents Health Survey. National Health and Morbidity Survey 2022 3. World Bank 2020 data Smoking rates 5 Youth 13-17 2 9% currently smoke tobacco Males 14.5% Female 3.6%

6. Leading preventable cause of death and illness in Malaysia > 27,200 deaths annually 1 20.2% of all deaths attributed to smoking 2 23.1% of all male deaths 10.5% of all female deaths 1. National Health and Morbidity Survey, NIH, Ministry of Health, Malaysia 2019 2. Tobacco atlas (2016) Mortality 6

7. People who use drugs

8. Very high smoking rate (65-87%) 2 Smoke more heavily More nicotine dependent Lower quit rates Psychiatric comorbidity Higher use of vapes than people without SUD 3 1 Mendelsohn CP, Wodak A. Smoking cessation in people with alcohol and other drug problems Aust Fam Physician 2016 2. Guydish . NRT 2011 3. Erinoso O. Addict Behav 2024 People who use drugs 1 8

9. People who use drugs 1. Richter KP. Subst Abuse Treat Prev Policy 2006 2. Prochaska JJ. J Consult Clin Psychol 2004 3. Baca C. J Subs Abuse Treat 2009 4. Tsoh JY. Drug Alc Depend 2011 5. Hurt RD. JAMA 1996 9 They are not motivated to quit Smoking cessation will jeopardise recovery from other drugs Treat the primary addiction first and smoking later smoking is a low priority in SUDS 40-80% of drug users are interested in quitting smoking 1 Smoking cessation improves recovery from alcohol, other drugs 2-4 Concurrent treatment: 25% increase in abstinence from illicit drugs 12m after quitting 2 More likely to die from a tobacco-related illness than from their primary drug use 5

10. Rees V. Toward a Comprehensive Measure of Drug-Attributable Harm. JAMA 2024 Disease and mortality burden 10

11. Smoking cessation Abstinence is the preferred choice

12. The preferred goal is always abstinence But quitting is difficult Smoking (nicotine dependence) is a chronic medical disorder with multiple stages of relapse and remission Relapse is a normal part of the quitting journey Many smokers take 30 or more quit attempts before being successful 3 1. Chaiton M. BMJ Open 2016 Quitting is ideal but difficult 12

13. The most popular method: 70% 1 The least effective method 3-5% abstinent at 6-12 months 2 1. Friezen P. Tobacco Induced Diseases 2022 2. Hughes J. Addiction 2004 Unassisted quitting (“cold turkey”) 13

14. Australia 1 16% NRT 4% smoking cessation pills Malaysia 2 10% pharma meds 1. AIHW. National Drug Strategy Household Survey. 2022-23 2. Global Adult Tobacco Survey Malaysia 2023 Low use of medications 14

15. 1. Lindson N. Pharmacological and e-cigarette interventions for smoking cessation in adults - network meta-analysis. Cochrane 2023 Low quit rates from medication at 6m (RCTs) 15

16. 62 RCTs of NRT, varenicline and bupropion (Rosen L. Addiction 2018) 12 RCTs of NRT ( Etter J.-F. Tob Control 2006) Low long-term success 16 94% smoking after 4 years in RCTs Even more under real-world conditions

17. Every year of smoking after age 35 years shortens life expectancy by 3 months 1,2 “It is vital for smokers to stop at the earliest possible opportunity , and for every quit attempt to have the best possible chance of success ” 3 1. Thun MJ NEJM 2013 2. Jha P. NEJM 2013 3. West R. Addiction 2010 Quitting is urgent 17

18. How do we help the vast majority of smokers who are unable or unwilling to remain abstinent? Dilemma 18

19. Tobacco harm reduction A complementary tobacco control strategy

20. Tobacco Harm Reduction Switching to a less harmful, smokeless nicotine substitute No tobacco, combustion or smoke Focus is to reduce harm (not eliminate) for smokers unable or unwilling to quit tobacco or nicotine 1,2,3 Harm reduction widely used in public health and medical practice Methadone or buprenorphine for heroin users, needle and syringe exchange programs, condom promotion, car seat belts, motorcycle helmets 20 1. Harm Reduction International 2. UK Royal College of Physicians 2016 3. Hatsukami D. Prev Med 2020 20

21. Almost all the harm from smoking is from the 7,000 chemicals and toxins in smoke from burning tobacco DHHS, Surgeon General report 2010 21

22. Nicotine causes dependence but is relatively benign Nicotine use per se represents minimal risk of serious harm to physical health 1,2,3,4 Nicotine Does not cause cancer 5,6 Does not cause respiratory disease 5 Is not a major cause of cardiovascular disease 7 22 1. Public Health England 2018 2. UK Royal Society for Public Health 3. NZ Ministry of Health 4. National Health Service, UK 5. US Surgeon General 2014 6. International Agency for Research on Cancer 7. Benowitz NL. Trends Cardiovasc Med 2016 22

23. Abrams DB. Managing Nicotine Without Smoke to Save Lives Now. Evidence for Harm Minimization. Prev Med 2018 The continuum of risk for nicotine products 23

24. Reduced-risk nicotine products 24 Nicotine pouches Snus Nicotine vaping devices Heated tobacco products

25. Vaping nicotine

26. Coil Battery e-liquid What is vaping? 26 Used as 1) short-term quitting aid, or 2) long-term less harmful alternative Addresses both aspects of the addiction Nicotine (like a cigarette) Behavioural, sensory and social 26 26

27. Adult vaping Refs Malaysia: 1. Global Adult Tobacco Survey Malaysia 2023 2. National Health and Morbidity Survey (NHMS) 2022 Current vaping in Malaysia (past 30d) 27 Youth vaping

28. 1. Global Adult Tobacco Survey Malaysia 2023 2. AIHW. National Drug Strategy Household Survey 2022-23 The most popular quitting aid 28 The commonest aid for quitting or reducing smoking in Malaysia and globally Malaysia 1 14% ecigs Australia 2 32% ecigs Faster nicotine delivery Replicates hand-to-mouth action, sensations, social aspects Nicotine enjoyment and benefits

29. 29 Prof Michael Russell “People smoke for nicotine but die from the tar” 1 1977 Hon Lik First commercial e-cigarette 2003 First tobacco industry activity Lorillard purchases blu ecigs 2012 Royal College of Physicians Report: Nicotine without smoke. Tobacco Harm Reduction 2016 Tobacco industry Controls 26% of global vaping market (Euromonitor) 2023 National Academy of Sciences Report: Clearing the smoke. Tobacco harm reduction Royal College of Physicians Report: Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit Public Health England Report: E-cigarettes: an evidence update US FDA Comprehensive plan for tobacco and nicotine regulation 2001 2007 2015 2017 Is vaping a tobacco industry plot? Russell M. Low-tar medium-nicotine cigarettes – a new approach to safer smoking. BMJ 1997

30. Relative safety

31. 1. Hartmann-Boyce J. Addiction 2023 2. McNeill A. OHID 2022 3. Polosa R. Discov Med. 2016 4. Polosa R. Ther Adv Chronic Dis. 2020 5. Polosa R. Int J Environ Res Public Health. 2016 6. Farsalinos K. Intern Emerg Med. 2016 8. Polosa R. Ther Adv Chronic Dis. 2021 9. Miler J. J Add Res Ther. 2016 10. Cibella F. Clin Sci. 2016 11. Lucchiari C. Addict Behav . 2020 12. Hajek P. N Engl J Med. 2019 13. George J. J Am Coll Cardiol . 2019 14. Berlowitz JB, Circulation 2022 15. Yang I. Crit Rev Toxicol . 2020 16. Stephens W. Tob Control 2017 17. Murkett R. F1000Research 2022 18. Public Health England. Evidence Review 2018 Not risk-free but far less harmful than smoking 31 Substantially reduced biomarkers (toxicants measured in urine and blood) 1,2 Clinical improvements Asthma 3 , COPD 4 , blood pressure 5,6 , muco-ciliary clearance 8 , respiratory infections 9 , lung function 10 , respiratory symptoms 11,12 , cardiovascular markers 13,14 , gum disease 15 Cancer risk Modelling studies predict a lifetime cancer risk <0.5% that of smoking 16,17 No evidence so far of harm from second-hand vapour 18

32. “ vaping is not risk-free but poses only a small fraction of the risks of smoking ” “ the at least 95% less harmful estimate remains broadly accurate, at least over short-term and medium-term periods ” Nicotine vaping in England: an evidence update including health risks and perceptions, A report commissioned by the Office for Health Improvement and Disparities. September 2022 Quantifying the relative risk compared to smoking APPROXIMATELY 32

33. 1. US DHHS 2010 2. Heywood J. J App Tox 2024 3. Margham J. Chem Res Toxicol 2016 4. Nicol J. Chem Res Toxicol 2020 Constituents of smoke and vapour Tobacco smoke >7,000 chemicals 1 Combustion of tobacco, 900 C ➡️solid particles, gases, liquids Vapour 100-150 chemicals 2,3,4 Heating liquid, 250 C ➡️liquid aerosol 33

34. “the level of toxins , rather than their presence, is the most important determinant of how harmful a product is to humans” 1 “mostly at levels much below 5% of smoking doses ( mostly below 1% ) and far below safety limits for occupational exposure” 2,3 1. Royal College of Physicians 2016 2. Public Health England 2015 3. Heywood J. J Appl Toxicol 2024 “The dose makes the poison” 34

35. Professor of Tobacco Addiction in the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience ( IoPPN ), King’s College London. Lead Author of Public Health England reports on vaping Long-term safety 35 “levels of exposure to cancer-causing and other toxicants are drastically lower in people who vape compared with those who smoke, which indicates that any risks to health are likely to be a fraction of those posed by smoking” Professor Ann McNeill, 2023 Professor Ann McNeill King’s College London

36. 36 Organisation Statement RCP, UK 1 Vaping is at least 95% less risky than smoking Public Health England 2 Vaping is at least 95% less risky than smoking UK Office for Health Improvement and Disparities 3 ‘vaping is not risk-free but poses only a small fraction of the risks of smoking’ NASEM (US) 4 Vaping is ‘likely to be far less harmful ’ than smoking NZ Ministry of Health 5 Vaping is ‘not harmless, but it is much less harmful than smoking’ Health Canada 6 ‘Vaping is less harmful than smoking’ Committee on Toxicity, UK 7 ‘the relative risk … expected to be substantially lower ’ 1. RCP, Nicotine without smoke: Tobacco harm reduction 2016 2. Public Health England. Evidence review of e-cigarettes and heated tobacco products 2018 3 UK Office for Health Improvement and Disparities. Sept 2022 4. National Academies of Sciences Engineering and Medicine 2018 5. New Zealand Ministry of Health. Vaping Facts 2020 6. Health Canada. Vaping and quitting smoking 2021 7. Committee on Toxicity. UK 2020

37. Effectiveness

38. RCTs: compared to NRT 38 Lindson N. Electronic cigarettes for smoking cessation (Review). Cochrane Jan 2024 38

39. Head-to-head with varenicline 3 Equally effective (RCT) UK National Institute for Health Research 1 363 RCTs (network meta-analysis) The most effective monotherapy Cochrane review 2 332 RCTs (network meta-analysis) Nicotine vapes and varenicline were the two most effective treatments 1. Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis. National Institute for Health Research 2021 2. Lindson N. Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses (Cochrane Review) 2023 3. Tuisku A. JAMA Int Med 2024 RCTs: compared to varenicline 39 At least as effective as varenicline

40. Observational studies 1-3 Population studies 4-5 Declines in national smoking rates 6-7 Accidental quitting 8-9 Naturalistic RCT 10 1. Goldenson NI. Am J Health Behav 2021 2. Adriaens K. Harm Reduc J 2021 3. Kotz M. Dtsch Arztebl Int 2022 4. Chambers MS. Addiction 2022 5. Zhu SH, BMJ 2017 6. Office of National Statistics, UK 2022 7. NHIS, US 2022 8. Kasza KA. JAMA Netw Open 2021 8. Foulds J. Nicotine Tob Res 2022 10. Carpenter MJ. Lancet 2023 Triangulation with real world studies 40

41. Concerns about vaping

42. Prevalence Malaysia 69% 1 Australia 33% 2 Great Britain 39% 3 USA 35-39% 4 Often a temporary, transition phase for vaping and NRT 5 More dependent smokers 6 Most reduce cigarette consumption substantially 5 ➡️ Lower levels of toxins 7 1. Malaysian Vape Industry Study. MVCC 2023 2. AIHW. NDSHS 2023 3. ASH UK 2024 4. Mattingly D. IJERPH 2021 5. Selya A. AmJHB 2021 6. McNeill A. Addiction 2019 7. Hartmann-Boyce J. Addiction 2023 Dual use 42 Dual use decreases over time (ASH UK 2024 )

43. Young people should not vape, smoke, drink or use drugs Most vaping by never-smokers is infrequent, experimental and temporary Serious harms are very rare Nicotine dependence is uncommon in never-smokers. It is unpleasant but not serious Vaping is one of the least risky risk-taking behaviours in adolescence Regulation needs to balance the small harms to youth with the substantial benefits to adult smokers Youth vaping 43

44. Young people who vape are also more likely to smoke, drink alcohol, use drugs, but no good evidence of causation More likely to be common liability (shared risk factors) 2 Youth smoking declines as vaping increases 3-5 Vaping is diverting young people away from smoking overall 6-8 13.8% in 2017, 6.2% in 2022 (NHMS) Restrictions on vaping increase smoking 9-11 Regular use by never-smokers is rare (2-5%) 12-13 and some would have smoked instead 1. Selya A. HRJ 2024 2 Vanyukov M. Drug Alc Depend 2012 3. Delnevo C. IJERPH 2023 4. Levy D. BMJ Open 2019 5. Meza R. JAMA Open 2020 6. Foxon F. Addictin 2020 7. Selya A Addiction 2021 8. Sokol N. Nic Tob Res 2021 9. Friedman A. J Health Econ 2015 10. Abouk R. J Health Econ 2023 11. Pesko M. Prev Med 2023 Gateway 44

45. Harmful effects found in rodent studies Extrapolation to humans is speculative 1 No evidence of harm in adults who smoked when young 2 Smokers have no difference in IQ 3 , educational achievement 4 or cognitive function 5 in adulthood 1. Balfour D. Am J Public Health 2021 2. DHHS, Surgeonn General 2004 3. Wennerstad K. Soc Sci Med 2010 4. Treur J. Bio Psych 2015 5. Corley J. J Psychosom Res 2012 Adolescent brain 45

46. The place of vaping

47. “It is now time for the medical community to acknowledge this progress and add e-cigarettes to the smoking-cessation toolkit” Professor Nancy Rigotti, New England Journal of Medicine 2024 Harvard University, US Rigotti N. editorial. Electronic Cigarettes for Smoking Cessation — Have We Reached a Tipping Point. NEJM 2024 Expert advice 47 Professor Nancy Rigotti Harvard University

48. Progress is slow with abstinence-only treatment Low uptake Low effectiveness Complementary role for THR for smokers who are unable or unwilling to quit tobacco or nicotine Focus on public health: reducing death, cancer, heart, lung disease Trade-off is some ongoing use of nicotine products, some use by young people For patients with SUDS “Utilize harm reduction principles to reduce harms associated with tobacco use” 1 Integrating Tobacco Use Disorder Interventions in Addiction Treatment. American Society of Addiction Medicine 2024 Integrating THR into smoking cessation treatment 48

49. Beaglehole R et al. Nicotine without smoke fighting the tobacco epidemic with harm reduction. Lancet 2019 Public health impact 49 “The potential of vaping is that it combines high efficacy with widespread uptake” “Vaping and other smoke-free products have the potential to reduce the enormous harm of smoked tobacco products” Professor Robert Beaglehole, The Lancet 2019 Former Director of the Department of Chronic Disease and Health Promotion, World Health Organisation Prof Robert Beaglehole University of Auckland

50. “Accelerated access to THR products would prevent 280,000 premature deaths in Malaysia” Lives Saved Report. August 2024. Yach D, Puteh S, Sharipov A, Human D, Polosa R, Fagerstrom K, Glover M et al. Projected lives saved 2020-2060 50

51. People who use drugs are more likely to die from smoking Quitting is urgent but difficult The evidence supports the use of vaping for smokers who are unable or unwilling to quit Effective and the most popular quitting aid Not risk-free but is far less harmful than smoking Nicotine causes dependence but is relatively benign Vaping has substantial potential for improving public health in Malaysia Summary 51