1. The Endgame Revisited
US E-cigarette Summit 2021
Clive Bates
Counterfactual
26 May 2021
(Virtual)

2. The Tobacco Endgame – the official version

3. The endgame revisited
1. The recreational drug perspective

4. 1. The recreational drug perspective

5. 1. The recreational drug perspective
“People smoke for the nicotine
but die from the tar”.
Professor Michael Russell 1932-2009
Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer
smoking. BMJ 1976;1:1430–3

6. 1. The recreational drug perspective

7. 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”
1. The recreational drug perspective: the future technologies

8. 1. The recreational drug perspective: the fundamental innovation
Battery Energy Density

10. The endgame revisited
1. The recreational drug perspective
2. The weirdness of harm

11. The weirdness of harm: the lifeblood of tobacco control

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

13. 2. Weirdness of harm: driver of abstinence
Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.

14. 2. Weirdness of harm: addiction
Addiction is marked by a change in behavior caused
by the biochemical changes in the brain after
continued substance abuse. Substance use becomes
the main priority of the addict, regardless of the harm
they may cause to themselves or others.
Addiction Center
A compulsive, chronic, physiological or
psychological need for a habit-forming substance,
behavior, or activity having harmful physical,
psychological, or social effects
Meriam Webster Dictionary
Addiction is a complex condition, a brain disease
that is manifested by compulsive substance use
despite harmful consequence. People with
addiction (severe substance use disorder) have an
intense focus on using a certain substance(s),
such as alcohol or drugs, to the point that it takes
over their life.
American Psychiatric Association
Addiction is defined as a chronic, relapsing
disorder characterized by compulsive drug
seeking and use despite adverse
consequences.
National Institute on Drug Abuse (NIDA)

15. 2. Weirdness of harm: addiction
Addiction is marked by a change in behavior caused
by the biochemical changes in the brain after
continued substance abuse. Substance use becomes
the main priority of the addict, regardless of the harm
they may cause to themselves or others.
Addiction Center
A compulsive, chronic, physiological or
psychological need for a habit-forming substance,
behavior, or activity having harmful physical,
psychological, or social effects
Meriam Webster Dictionary
Addiction is a complex condition, a brain disease
that is manifested by compulsive substance use
despite harmful consequence. People with
addiction (severe substance use disorder) have an
intense focus on using a certain substance(s),
such as alcohol or drugs, to the point that it takes
over their life.
American Psychiatric Association
Addiction is defined as a chronic, relapsing
disorder characterized by compulsive drug
seeking and use despite adverse
consequences.
National Institute on Drug Abuse (NIDA)

16. The endgame revisited
1. The recreational drug perspective
2. The weirdness of harm
3. The smoking epidemic is over

17. 3. The smoking epidemic is over
20
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Years’ observations on male British
doctors. BMJ 2004

18. 3. The smoking epidemic is over
21
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Years’ observations on male British
doctors. BMJ 2004

19. 3. The smoking epidemic is over
22

20. 3. The smoking epidemic is over
23

21. 0
5
10
15
20
25
30
35
40
45
1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025
Percent
Past-30 day and daily cigarette smoking prevalence (percent) 1975-2019
United States 12th grade students - Source: Monitoring the Future 2016 and 2019
Smoked in last 30 days
(pre-2010)
Smoked daily
(pre-2010)
Smoked in last 30 days
(post-2010)
Smoked daily
(post-2010)
Daily smoking
Any smoking in past 30
days
@clive_bates (2020)
3. The smoking epidemic is over
24
Rate of decline post-
2010 is 4 times
greater than 1975-
2010
3 times

22. 0
5
10
15
20
25
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Norway: daily tobacco use
women age 16-24 - per cent
3. The smoking epidemic is over
1 percent
17 percent

24. Youth risk behaviors in context – United States 2017
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
E-cigarette Smoking any
combusible
tobacco
Marijuana Alcohol Binge
drinking
Drink driver
riding as
passenger
Carried a
weapon
Texting while
driving
Percentage
of
high
school
students
Past 30 day prevalence – high school students NYTS and YRBS
2019
2018
2017
2020
Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ 2018;67(No. SS-8):1–114.
* Refers to driver or passengers riding in vehicles where the driver had been drinking.

25. The endgame revisited
1. The recreational drug perspective
2. The weirdness of harm
3. The smoking epidemic is over
4. The anti-nicotine propaganda complex

26. 4. A formidable opposition: giant coalitions

27. 5. A formidable opposition: big money
Since 2007, Bloomberg
Philanthropies has committed
> US$1 billion to tobacco control
Since 2008, the Bill and Melinda
Gates Foundation has also invested
$210m in global tobacco control
Source: Framework Convention Alliance : A Global Strategy to Accelerate FCTC Implementation, 2018

28. 4. A formidable opposition: a hostile international treaty

29. 4. A formidable opposition: interventionist regulators

30. 4. Formidable opposition: fighting dirty

31. 4. Formidable opposition: weaponising teenagers

32. 4. A formidable opposition: anti-nicotine propaganda complex
Politics
Regulator
Funder Academics Press offices
Activists Media
Journals & peer
review
Press releases
Conferences
Societies and
networks
Power Influence Communications

33. The endgame revisited
1. The recreational drug perspective
2. The weirdness of harm
3. The smoking epidemic is over
4. The anti-nicotine propaganda complex
5. The irreconcilable conflict principle

34. 5. The irreconcilable conflict principle
Principle 1. There is a fundamental and
irreconcilable conflict between the tobacco
industry’s interests and public health policy
interests.
Article 5.3. In setting and implementing their
public health policies with respect to tobacco
control, Parties shall act to protect these policies
from commercial and other vested interests of
the tobacco industry in accordance with national
law.

35. 5. The irreconcilable conflict principle: world’s lowest smoking rate

36. 5. The irreconcilable conflict principle: world’s lowest smoking rate
Sweden

37. 5. The irreconcilable conflict principle: cannibalising cigarette sales
Total - steady decline
Cigs – rapid decline
Heated Tobacco – sharp rise
Phillip Morris International Data

38. 5. The irreconcilable conflict principle: the problem of wrongness
• Oppose harm reduction
• Contrived explanations and bad science
• Rejecting innovation
• Distorted goals
• Flawed policymaking
• Echo chambers

39. 5. The irreconcilable conflict principle: a technology transition

40. 5. The irreconcilable conflict principle: a technology transition

41. 5. The irreconcilable conflict principle: a final word…
“Claims about the promise of new technology are at times greeted with
skepticism, vilification or outright opposition—often dominated by slander,
innuendo, scare tactics, conspiracy theories and misinformation.
“The assumption that new technologies carry unknown risks guides much of
the debate. This is often amplified to levels that overshadow the dangers of
known risks.”
Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.

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