The extended version of my presentation to the UK E-cigarette summit 16 November 2023. We look at the following: 1. End of harm or end of nicotine 2. The demand for nicotine 3. The future market for nicotine 4. False risk perceptions 5. Who is to blame

1. The end of what?
Clive Bates
Counterfactual
E-cigarette Summit UK
London
16 November 2023

2. 1. The end of harm or nicotine?

3. 0
1
2
3
4
5
6
7
8
9
10
Youth (ASH) Adults (ONS)
Million
British
people
Smoking and vaping in 2022
Millions of Brits
Source: Youth: ASH and YouGov (ASH) 2022 data age 11-17. Adult: Office for National Statistics(NHIS) 2022
data, age 16 or over. (Note the age ranges overlap for age 16 & 17)
The stock and flow problem

4. 0
1
2
3
4
5
6
7
8
9
10
Youth (ASH) Adults (ONS)
Million
British
people
Smoking and vaping in 2022
Millions of Brits
Source: Youth: ASH and YouGov (ASH) 2022 data age 11-17. Adult: Office for National Statistics(NHIS) 2022
data, age 16 or over. (Note the age ranges overlap for age 16 & 17)
The stock and flow problem
Smoking
Vaping
only
Dual use

5. 0
1
2
3
4
5
6
7
8
9
10
Youth (ASH) Adults (ONS)
Million
British
people
Smoking and vaping in 2022
Millions of Brits
Source: Youth: ASH and YouGov (ASH) 2022 data age 11-17. Adult: Office for National Statistics(NHIS) 2022
data, age 16 or over. (Note the age ranges overlap for age 16 & 17)
The stock and flow problem
Smoking
Vaping
only
Dual use
16 x

6. 0
1
2
3
4
5
6
7
8
9
10
Youth (ASH) Adults (ONS)
Million
British
people
Smoking and vaping- youth and adults
Millions of Brits
Source: Youth: ASH and YouGov (ASH) 2022 data age 11-17. Adult: Office for National Statistics(NHIS) 2022
data, age 16 or over. (Note the age ranges overlap for age 16 & 17)
Public health needs to focus on the stock of adult smokers
Smoking
Vaping
only
Dual use
The public health
problem is here
Nearly all the
attention goes
here

7. Similar in the United States
0
5
10
15
20
25
30
35
40
Youth (NYTS) Adults (NHIS)
Million
Americans
Smoking and vaping in 2021
Millions of Americans
Source: National Youth Tobacco Survey (NYTS) 2021 data, National Health Interview Survey (NHIS) 2021
data. Graphic by Clive Bates. With thanks to Brad Rodu for data extraction and cross-tabulations.
Smoking
Vaping
only
Dual use
Millions
Youth
(NYTS)
Adults
(NHIS)
Vaping 1.53 7.8
Dual use 0.52 3.3
Smoking only 0.37 25.0
All smoking 0.89 28.3
15 x

8. Ending harm means addressing risks to the stock of
adult smokers
But the flow of new users dominates the policy
discourse

9. The flow of new nicotine users (United States, age 18-24)
Data extraction and graphics:
Brad Rodu, Professor of Medicine,
University of Louisville, U.S.

10. The flow of new nicotine users (age 18-24)
Smoking & vaping prevalence (%) Americans aged 18-24.
National Health Interview Survey, 2014-2022
Did not smoke before vaping
Vaping former smokers
Smoking & vaping
Smoking only
>70% reduction in smoking, >80%
reduction in exclusive smoking
Over time, the demand for
nicotine is far more robust
and resilient than any
particular way of taking it.
Data extraction and graphics:
Brad Rodu, Professor of Medicine,
University of Louisville, U.S.
Annotations: Clive Bates

11. The flow of new nicotine users (age 18-24)
Smoking & vaping prevalence (%) Americans aged 18-24.
National Health Interview Survey, 2014-2022
Data extraction and graphics:
Brad Rodu, Professor of Medicine,
University of Louisville, U.S.
Annotations: Clive Bates
Is this big green bar a
success or a failure?

12. Similar effect in Britain
Source: ASH(UK) and YouGov 2013-2023
Rising vape uptake
among never-users

13. The problem of fad-induced moral panics
0
5
10
15
20
25
30
35
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Per
cent
Past 30-day e-cigarette & any combustible use
US high school students
National Youth Tobacco Survey 2011-23
E-cigarettes
Fad? Are we prone to overreacting to
transient trends and then
implementing de facto
irreversible bad policies?

14. Yet overall a very positive trend for public health
0
5
10
15
20
25
30
35
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Per
cent
Past 30-day e-cigarette & any combustible use
US high school students
National Youth Tobacco Survey 2011-23
Any combustible
Cigarettes
E-cigarettes

15. And even an overall declining trend in US adolescent nicotine use
0
5
10
15
20
25
30
35
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Per
cent
Past 30-day any tobacco / nicotine use
US high school students
National Youth Tobacco Survey 2011-23
Any tobacco / nicotine

16. The concern about youth
vaping is grounded in beliefs
about the end of nicotine use

17. Chief Medical Officer – plausible, compelling …and wrong
“If you smoke, vaping is much safer;
If you don't smoke, don't vape;
Marketing vapes to children is utterly
unacceptable.”
Chris Witty: The Times, 30 May 2023
The challenge for real-world public
health is to engage with the world as
it is, not as you would like it to be.

18. 2. The demand for nicotine

20. Nicotine acts on
nicotinic cholinergic
receptors, triggering
the release of
dopamine, producing
rewarding psychoactive
effects.

21. Demand for
nicotine
Hedonistic
Dopamine
release
Sensory
Ritual & social
Functional
Cognitive
enhancement
Control stress
& anxiety
Weight &
appetite
Therapeutic
Neuro-
protection
Anti-
inflammatory
ADHD

22. Why might people use nicotine?
Demand for
nicotine
Hedonistic
Dopamine
release
Sensory
Ritual & social
Functional
Cognitive
enhancement
Control stress
& anxiety
Weight &
appetite
Therapeutic
Neuro-
protection
Anti-
inflammatory
Regulating
(e.g. ADHD)
Consumer
value
Self-
medication

23. If nicotine has functional
benefits and hedonistic appeal
for some people, it will always
be in demand

25. Why do people quit?
Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.

26. People quit to avoid harm
Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.

27. Main justification for tobacco control policies is to address harm
… but what if there is minimal harm?

28. If the harm is minimal, the main
deterrents are no longer
applicable and the demand for
nicotine may rise

29. Nicotine as a recreational drug
There is no compelling objection to the
recreational and even addictive use of
nicotine provided it is not shown to be
physically, psychologically, or socially
harmful to the user or to others.
The Lancet, 1991
Professor Michael Russell 1932-2009
Russell, M. A. H. (1991). Nicotine use after the year 2000. The Lancet,
337(8751), 1191–1192.

30. 3. The future nicotine market

31. Socially acceptable psychoactive substances

32. Cigarettes will go the way of
vinyl records… overtaken by
better technologies, but
remaining a niche interest for
some

33. Smokeless tobacco
Tobacco based
Pure nicotine based
Heated
aerosol
Unheated
Items are not shown to scale
Oral nicotine products
Vaping products Heated tobacco products
“Heat-not-burn”

34. When delivered with minimal
harm, shouldn’t nicotine just be
classed as a socially acceptable
recreational stimulant?

35. Harm reduction in the 1980s – Skoal Bandits

36. 1989 – UK bans Skoal Bandits “to protect youth”

37. Finland – the prohibitionists should be paying attention
EU snus ban
Sweden diverges
from Finland
Sweden
Finland
Maki J. The incentives created by a harm reduction approach to smoking cessation: Snus and smoking in Sweden and Finland. Int J
Drug Policy. Netherlands; 17 June 2014;26(6):569–74

38. Finland – the prohibitionists should be paying attention
EU snus ban
Norway converges
with Finland
Finland
Norway
Maki J. The incentives created by a harm reduction approach to smoking cessation: Snus and smoking in Sweden and Finland. Int J
Drug Policy. Netherlands; 17 June 2014;26(6):569–74

39. The end of tobacco or the end of combustion?
0
20
40
60
80
100
120
140
160
180
200
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
sales
volume
(bn)
50% reduction Cigarettes and cigarillos

40. The end of tobacco or the end of combustion
0
20
40
60
80
100
120
140
160
180
200
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
sales
volume
(bn)
Cigarettes and cigarillos
Heated tobacco
…the accelerated decline in cigarette-only
sales in Japan since 2016 corresponds to
the introduction and growth in the sales of
HTPs.

41. The risk-based distinction for policy is
between combustion and non-combustion
… not tobacco and non-tobacco

42. 4. False risk perceptions drive bad policy

43. Terrible risk perceptions (1) – vaping compared to smoking
0 5 10 15 20 25 30 35 40
Much less harmful
Less harmful
Just as harmful
More harmful
Much more harmful
Don't know
Missing
Compared to smoking cigarettes, would you say that electronic cigarettes
are…
( % US adults 2020 )
43
Rare rightness– 2.6%
Vast wrongness – 62%
Confusion – 24%

44. Terrible risk perceptions (2) – is nicotine causing cancer
0 5 10 15 20 25 30 35
Strongly agree
Agree
Disagree
Strongly disagree
Don't know
Missing
How much do you agree or disagree that the nicotine in cigarettes is
the substance that causes most of the cancer caused by smoking?
( % US adults in 2019 )
44
56% severe
wrongness
Confusion – 19%

45. British risk perceptions not much better
Big wrongness – 43%
Confusion – 21%

46. False risk perceptions reduce the focus
on the stock of smokers…
… increase the focus on the flow of new
nicotine users

47. 5. Who is to blame?

51. The tobacco control establishment is threatened
Three strategies are evident
1. Disinformation about harm
2. Shifting focus to nicotine
3. Non-health objectives

52. 1. Fake news about health impacts
“These products are falsely marketed as
safer and more sustainable options to
deadly cigarettes, misleading consumers,
media and international institutions.”

53. 1. Fake news about health impacts
“…over 40 organizations and professors from all
continents”.
10 November 2021
“These products are falsely marketed as
safer and more sustainable options to
deadly cigarettes, misleading consumers,
media and international institutions.”

54. 1. Fake news about health impacts

55. 1. Merchants of bad advice
“…try breathing
through a straw”
Official U.S. federal
government advice

56. 2. WHO bad advice – anything but “try a vape”

57. National healthcare provider endorsement (with due caution)

58. 2. Shifting goals to nicotine

59. 3. Emphasis on non-health objectives

60. 3. Better harm to 1 million people than profit to tobacco or vape industry

61. The tobacco control community finds
it…
“…difficult to accept that availability
of snus may have greater impacts in
reducing smoking than the regulations
we have spent a lifetime fighting for.”
Karl Erik Lund

62. Is tobacco control the new Big Tobacco?
Click the link to explore this question. It may surprise you. It should shock you.
Misinformation protects the cigarette trade, keeps people smoking, abuses trust,
violates autonomy, and prolongs the epidemic of disease and death
https://clivebates.com/is-tobacco-control-the-new-big-tobacco/

64. Thankyou!
Counterfactual
clivedbates@gmail.com
www.clivebates.com
@clive_bates