Generic presentation on tobacco harm reduction - please download the slides as use as you wish

1. Tobacco Harm Reduction – an introduction
Clive Bates
Counterfactual
United Kingdom
September 2018

2. Declaration
Clive Bates has no competing interests with respect to
tobacco, e-cigarette or pharmaceutical industries
He is former Director of Action on Smoking and Health
ASH (UK) and a former UK and UN civil servant.
He currently runs an advocacy and consultancy practice
“The Counterfactual”

3. “People smoke for
the nicotine but
die from the tar”
(1976)
Russell MJ. Low-tar medium nicotine cigarettes:
a new approach to safer smoking. BMJ
1976;1:1430–3
Professor Michael Russell 1932-2009
The central insight in smoking and health

4. Unheated nicotine products Smokeless tobacco
Vaping products
Tobacco basedPure nicotine based
HeatedaerosolUnheated
Items are not shown to scale
Reduced-risk consumer nicotine market
Directly-heated tobacco products
“Heat-not-burn”
Indirectly-heated
tobacco products

7. Snus ban: worst EU policy of all time?

8. Royal College of Physicians – on relative risk
This report lays to rest almost
all of the concerns over these
products, and concludes that,
with sensible regulation,
electronic cigarettes have the
potential to make a major
contribution towards
preventing the premature
death, disease and social
inequalities in health that
smoking currently causes in
the UK. ".

9. U.S Annual Review of Public Health
“A diverse class of alternative nicotine
delivery systems (ANDS) has recently
been developed that do not combust
tobacco and are substantially less
harmful than cigarettes”.
“ANDS have the potential to disrupt
the 120-year dominance of the
cigarette and challenge the field on
how the tobacco pandemic could be
reversed if nicotine is decoupled from
lethal inhaled smoke”.

10. Royal College of Physicians – on relative risk
"Although it is not possible to
precisely quantify the long-
term health risks associated
with e-cigarettes, the
available data suggest that
they are unlikely to exceed
5% of those associated with
smoked tobacco products,
and may well be substantially
lower than this figure".

11. American Cancer Society
Based on the most recent studies, e-
cigarettes are, in general, substantially
less harmful than smoking cigarettes.
But long-term health effects are still
unclear.
American Cancer Society, What do we know about e-cigarettes? 6
March 2018
U.S. National Academy of Sciences
While e-cigarettes are not without
health risks, they are likely to be far
less harmful than combustible tobacco
cigarettes.
National Academies of Science, Engineering and Medicine
(US). The Public Health Consequences of E-cigarettes.
Washington DC. January 2018.
Many organisations now making statements on risk

12. More statements

13. Royal College of Physicians – on population effects
“There are concerns that e-cigarettes will
increase tobacco smoking by renormalising
the act of smoking, acting as a gateway to
smoking in young people, and being used
for temporary, not permanent, abstinence
from smoking.
To date, there is no evidence that any of
these processes is occurring to any
significant degree in the UK. Rather, the
available evidence to date indicates that e-
cigarettes are:
• being used almost exclusively as safer
alternatives to smoked tobacco
• by confirmed smokers
• who are trying to reduce harm to
themselves or others from smoking
• or to quit smoking completely.

14. 2004-10
little progress
2010-17
rapid progress
Adult smoking prevalence (age 18 and over) United States
1997 – June 2017

15. The long view on youth smoking: United States

16. Royal College of Physicians – quitting smoking as consumer choice
" E-cigarettes are marketed as
consumer products and are
proving much more popular
than NRT as a substitute and
competitor for tobacco
cigarettes.
E-cigarettes appear to be
effective when used by
smokers as an aid to quitting
smoking.”

17. Some research on quitting
Zhu S-H, Zhuang Y-L, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation:
evidence from US current population surveys. Bmj. 2017;358:j3262. [link]
The substantial increase in e-cigarette use among US adult smokers was
associated with a statistically significant increase in the smoking cessation
rate at the population level.
Self-reports from a representative sample of 27,460 EU citizens: Extrapolating
to the whole EU population, an estimated 6.1 million Europeans have quit
smoking with the use of e-cigarettes, while a further 9.2 million have reduced
their smoking consumption’
Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union: analysis of a representative
sample of 27 460 Europeans from 28 countries. Addiction. 2016;111(11):2032-40

18. UK: “Highest proportion of quitters in over 40 years”

19. Royal College of Physicians – on quitting smoking
" […]in the interests of public
health it is important to
promote the use of e-
cigarettes, NRT and other
non-tobacco nicotine
products as widely as possible
as a substitute for smoking in
the UK ".

21. Royal College of Physicians – policy and unintended consequences
“A risk-averse, precautionary approach
to e-cigarette regulation can be
proposed as a means of minimising the
risk of avoidable harm […]
“However, if this approach also makes
e-cigarettes
• less easily accessible
• less palatable or acceptable
• more expensive
• less consumer friendly
• pharmacologically less effective
• inhibits innovation and development
of new and improved products
…then it causes harm by perpetuating
smoking. Getting this balance right is
difficult

23. E-cigarettes present an opportunity to
significantly accelerate already declining
smoking rates, and thereby tackle one of the
largest causes of death in the UK today. […]
Recent report from UK parliament
There should be a shift to a more risk-
proportionate regulatory environment; where
regulations, advertising rules and tax duties
reflect the evidence of the relative harms of
the various e-cigarette and tobacco products
available.

24. 1. Taxes: reflect risk and incentivise switching

25. 2. Standards for devices
Mechanical risks
Thermal risks
Chemical risks
Information

26. 2. Standards for liquids
Liquid standards
Containers
Information
Testing protocol

27. 2. Flavours: critical part of appeal to smokers

28. 3. E-cig marketing is anti-smoking marketing
 Don’t be socially irresponsible
 Don’t target or feature children
 Don’t confuse e-cigarettes with tobacco
products
 Don’t make health or safety claims
 Don’t make smoking cessation claims
 Don’t mislead about product ingredients
 Don’t mislead about where products may be
use
Commercial freedom Constrained by guidelines

29. 4. Warning labels: intimidating or informing consumers?
This product contains
nicotine which is a highly
addictive substance. It is
not recommended for use
by non-smokers
Intimidating

30. Scares people away

31. 4. Warning labels: intimidating or informing consumers?
This product contains
nicotine which is a highly
addictive substance. It is
not recommended for use
by non-smokers
Intimidating
No product is completely
safe but using this
product is substantially
safer than smoking
cigarettes
Informing

32. 5. Where you can vape?
Owner / manager decides Government / law decides

33. 6. Communicate honestly with the public

34. 7. Age restrictions – obviously. But…
Politically popular
Friedman AS. How does Electronic Cigarette
Access affect Adolescent Smoking? J Health
Econ Published Online First: October 2015.
Pesko MF, Hughes JM, Faisal FS. The influence
of electronic cigarette age purchasing
restrictions on adolescent tobacco and
marijuana use. Prev Med (Baltim), February
2016
… but may increase smoking

35. WHO Framework Convention on Tobacco Control
Article 1
(d) “tobacco control” means a range
of supply, demand and harm
reduction strategies that aim to
improve the health of a population
by eliminating or reducing their
consumption of tobacco products
and exposure to tobacco smoke;
(emphasis added)

36. Thankyou!
Counterfactual
www.clivebates.com
@clive_bates