1 Tobacco risks and new nicotine productsDr Ross Morgan MD FRCPI FCCP Consultant Respiratory Physician, Beaumont Hospital March 26th 2015

2 The Tobacco Century WHO, European Lung Foundation & others 2010

3 Outline Burden of disease from smoking5,200 people die from smoking related disease in Ireland each year 1 -2 billion euro is spent annually on treating the effects of smoking Burden of lung disease from smoking 2 common conditions; COPD and lung Cancer Smoking prevalence and tobacco control Impact of Quitting Nicotine Replacement – Electronic Cigarette

4 Ireland needs Healthier Airways and Lung – The EvidenceT O’Connor et al, INHALE II report 2008

5 1 in 5 people in Ireland die from respiratory diseaseT O’Connor et al, INHALE II report 2008

6 Ireland has the highest death rate from respiratory disease in western Europe -- x 2 EU average.T O’Connor et al, INHALE II report 2008

7 T O’Connor et al, INHALE II report 2008

8 Economic Burden -EU 50 % of the economic burden of lung disease is due to smoking European Lung Foundation, White Book 2014

9 Chronic Obstructive Pulmonary Disease COPD – on the riseChange in age-adjusted death rates for COPD and cardiovascular disease in the USA 1965–98. Pauwels and Rabe, Lancet 2004 9 9

10 Chronic Obstructive Lung Disease - COPDWorld Health Organization (W.H.O.) 2010: COPD is 4th leading cause of death On course to be no.3 by 2020 In 2010 in the U.S. 8 million doctors’ visits 1.5 million emergency department visits 726,000 hospitalisations (13% of total hospital admissions) Second most common reason for payment of social security disability benefits

11 COPD and Multi-morbiditySmoking related chronic disease L Vanfleteren, April 2013, AJRCCM

12 Lung Cancer 1.6 million cases worldwide a year65% presents with locally advanced or metastatic disease RISKS for Lung Cancer Smoking (90%) Radon gas exposure Asbestos exposure Other exposures:heavy metals/Cadmium Irelands Biggest cancer killer

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14 Number of Lung Cancers Diagnosed in Ireland 200 400 600 800 1000 1200 1400 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Number females males This slide shows the number of lung cancers that were diagnosed in Ireland between There are more lung cancers in men than women but over the past 15 years the gap has narrowed. In 1994 there were 1065 male lung cancers diagnosed and this steadily increased to 1280 by 2010 (20.2% increase) In women there were 510 lung cancers diagnosed in 1994 and the number increased at a much higher rate than for men to 942 in 2010 (an overall increase of 85%). Cancer in Ireland 2013, report of National Cancer Registry

15 Years of Life lost to cancerCancer in Ireland 2013, report of National Cancer Registry

16 Survival with cancer – Ireland Lung Cancer: - 20% of all cancer deaths - In 2013 became the most common cause of cancer death in women National Cancer Registry, 2013

17 What do we expect? LUNG FEMALE BREAST CancerCancer in Ireland 2013, report of National Cancer Registry

18 Lung Cancer Screening

19 LUNG CANCER Ex- smokers tooEffect of smoking cessation on lung cancer risk Cigarettes smoked/day Risk of developing lung cancer* Risk after 16 years of smoking cessation* fold 1.6-fold  fold 4.0-fold 4. Lung Cancer: Impact of Smoking on Risk The risk of developing lung cancer increases with the number of cigarettes smoked and decreases in proportion to the number of years after smoking cessation. Other factors that impact smoking-related risk include age that smoking begins, years of smoking duration, extent of smoke inhalation, tar and nicotine content of the cigarettes, and use of unfiltered cigarettes. *Data in women; risk compared to nonsmokers. Humphrey EW, et al. The American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;

20 Benefits of Stopping Smoking on Lung Cancer RiskThe Million Women Study New Engl J Med. Jan 2, 2014

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22 Health Consequences of smokingU.S. Surgeon General 2014

25 Health Effects of Second Hand Smoke on ChildrenSudden Infant Death Syndrome Low birth weight Lower respiratory illness Asthma Middle Ear Infections Preterm Birth Childhood cancers, leukaemia, lymphoma Congenital Malformations Premature atherosclerosis Pregnant women and children particularly vulnerable US surgeon generals report 2014 Gall S. Eur Heart Journal. March 2014

26 Ireland Work Place Smoke Ban 2004 Evaluation of impactChange in Indoor Air Quality Health Benefits For Bar workers (lung function) Health Benefits for All In the first year of the ban, hospital admissions for acute coronary events fell by 12% 32% fall in stroke admissions 38% reduction in COPD admissions Impact on Preterm deliveries and low birth weight 3, 726 fewer smoking related deaths than would have been expected Compliance 98% Stalling-Smith S et al, PLOS One 2013 Cronin EM, Clin Cardiol. 2012;35:205–209. Kabir Z, BJOG. 2009;116

27 Ireland –consumption of Tobacco

28 Ireland – Fewer people smokingOffice of Tobacco Control Omnibus Tracker Survey % Office of Tobacco Control Omnibus Tracker Survey % Source:

29 Policy Document launched by the Minister for Health October 2013Tobacco Free Ireland 2025 Policy Document launched by the Minister for Health October 2013 “In Ireland a tobacco free society will mean the achievement of a smoking prevalence rate of less than 5% of the Irish population by 2025” Denormalisation of tobacco at every level of society

30 Ireland Smoking Prevalence 10 – 17 year olds

32 Playground Initiative 201475% of County Councils and 60% of City Councils in Ireland have adopted smoke free playgrounds on a voluntary basis Malahide Castle, Dublin 2014

34 Tobacco Dependence

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36 Significant impact on survival from stopping smoking at ANY age

37 Getting people to Quit – Massachusetts Health

38 Getting people to Quit II – ‘Plain’ packagingLess attractive (pack attributes); smokers less sociable/stylish and poorer quality and less satisfying when smoked (800 smokers) 38

39 Components of cigarette – “ a dirty syringe”Nicotine = the component that causes addiction

40 Electronic Cigarettes - Electronic Nicotine Delivery Systems (ENDS)Promise or Public Threat? Tobacco product? Medicine? Electronic device? WHO 2013: 7% of EU citizens (doubled in 4 yrs) In U.K million e-cigarette users compared with 9 million tobacco smokers 40

41 E Cigs : Are they a smoking cessation Aid? Do they Reduce Harm?

42 Smoking Cessation Aid? Bullen C et al. Lancet 2013;

43 Evidence based - Pharmacotherapy for Cessation

44 Electronic Cigarettes ? renormalising smokingRather than reducing or even replacing traditional smoking, e-cigarettes could increase smoking rates by attracting new recruits and reducing quit attempts.

46 Conclusions In Ireland, Tobacco Use is the biggest cause of preventable Premature Death (5,200/year) Inequality There is no risk-free level of tobacco smoke exposure Benefits of Quitting will be seen at any age Effective Cessation therapies exist Nicotine/E-Cigs have their own health risks; though they are small compared to tobacco smoking