Vaping and tobacco harm reduction
10 February 2021
Clive Bates
Counterfactual
www.clivebates.com
Webinar
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Well research toll of harm from smoking…
Smoking prematurely
kills around 96,000
annually in the UK
…more than obesity,
alcohol, road
accidents, drug
misuse and HIV
combined
2

Median smoker loses 10 years between 73-83…
3

Levelling up – deprived areas
NHS CCG - Adult smoking prevalence %
1 Corby 27.5
2 Blackpool 23.4
3 Great Yarmouth and Waveney 22.5
4 Hull 22.2
5 North East Lincolnshire 22.2
6 Thanet 21.0
7 Nottingham City 20.9
8 West Lancashire 19.2
9 Doncaster 19.1
10 Salford 19.1
11 Durham Dales, Easington and Sedgefield 19.0
12 Mansfield and Ashfield 18.9
13 Barnsley 18.3
14 Bradford City 18.3
15 Stoke on Trent 18.3
16 Barking and Dagenham 18.1
17 Manchester 18.0
18 Bradford Districts 17.9
19 Oldham 17.9
20 North Lincolnshire 17.8
England 13.9
4

Levelling up – Employment gradient
0%
10%
20%
30%
40%
Unemployed Employed
Smoking - Employment status
ONS, Adult Smoking habits in the UK: 2019. July 2020 5

Levelling up – Socioeconomic gradient
0%
10%
20%
30%
40%
Manual Managerial
Smoking - Socioeconomic status
ONS, Adult Smoking habits in the UK: 2019. July 2020 6

Levelling up – Education gradient
0%
10%
20%
30%
40%
No qualifications Degree
Smoking - Eduction status
ONS, Adult Smoking habits in the UK: 2019. July 2020 7

Levelling up – Mental health gradient
0%
10%
20%
30%
40%
Serious mental illness Adults 2014
Smoking - Mental health status
ONS, Adult Smoking habits in the UK: 2019. July 2020 8

Very high prevalence in some sub-populations
40%
depression
62%
psychosis
88%
substance
use
disorder
57-82%
Homeless
80%
Prisons
• Dawkins L, Ford A, Bauld L, Balaban S, Tyler A, Cox S. A cross sectional survey of smoking
characteristics and quitting behaviour from a sample of homeless adults in Great Britain.
Addict Behav. 2019;
• Public Health England Reducing Reducing Smoking in Prisons, 2015
• Cookson C, Strang J, Ratschen E, Sutherland G, Finch E, McNeill A. Smoking and its
treatment in addiction services: Clients’ and staff behaviour and attitudes. BMC
Health Serv Res. 2014 Jul 14;14(1):1–8.
• Royal College of Physicians, Royal College of Psychiatrists Smoking and mental
health London (2013)
• L Szatkowski, A McNeill Diverging trends in smoking behaviours according to
mental health status Nicotine Tob Res, 3 (2015), pp. 356-360
With thanks to Sharon Cox & Debbie Robson 9

Levelling up - eye-watering cost of being a smoker
79% tax
Pack a day =
£3,760 per year
10

“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
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Smokeless tobacco
Tobacco based
Pure nicotine based
Heated
aerosol
Unheated
Reduced-risk consumer nicotine market
Vaping products Heated tobacco products
“Heat-not-burn”
Items are not shown to scale
Oral nicotine products
12

“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”.
US Annual Review of Public Health
13

Snus: proof of concept
14

European Union smoking prevalence 2017
15

European Union smoking prevalence 2017 - Sweden
Sweden
16

Smoking Disease
17

The public health mechanism
18

Smoking and vaping 2019 – Great Britain (ONS)
ONS, E-cigarette use in Great Britain in 2019, July 2020
~3m vapers
~8m smokers
19

Smoking and vaping – “making smoking products obsolete”
ONS, E-cigarette use in Great Britain in 2019, July 2020
5% prevalence
Two-thirds cut
20

Last 10 years – about a one-third cut in smoking
0
5
10
15
20
25
30
%
cigarette
smokers
(3
month
moving
average)
Smoking prevalence trend - last ten years - England
~One-third cut
21

Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
The strongest evidence for reduced harm is reduced exposure
22

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".
23

Risk perceptions are far out of line with expert judgement and getting worse
ASH / YouGov surveys 2013-2020 24

“EVALI” E-cigarette and Vaping Product Associated Lung Injury
25

“EVALI” E-cigarette and Vaping Product Associated Lung Injury
26

“EVALI” looks exactly like localised supply chain contamination
27

Randomised controlled trial – e-cigs versus NRT
886 smokers
1 year quit status
18% E-cigarette
9.9% NRT
Hajek et al., 2019. A randomized trial of e-cigarettes versus nicotine
replacement therapy . New England Journal of Medicine. 28

Cochrane review – October 2020
More people probably stop
smoking for at least six months
using nicotine e-cigarettes than
using nicotine replacement
therapy (3 studies; 1498 people),
or nicotine-free e-cigarettes (3
studies; 802 people).
Nicotine e-cigarettes may help
more people to stop smoking
than no support or behavioural
support only (4 studies; 2312
people).
29

The public health mechanism is not “smoking cessation medication”
Harm reduction = Reduced risk x Number who switch
Product toxicity &
other risks
Proportion who succeed
Who tries and how
many
Harm reduction equation (crude)
Appeal and
user choice
30

The public health mechanism: “value propositions” – the 7 Ps
Value
Price
Promotion
Place
Product
Positioning
People
Packaging
31

The public health mechanism: rival “value propositions”
Tobacco control
Smoking
Price
Promotion
Place
Product
Positioning
People
Packaging
Degrade the value
Tobacco harm reduction
Vaping
Price
Promotion
Place
Product
Positioning
People
Packaging
Enhance the value to smokers
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2. The public health mechanism: rival “value propositions”
Tobacco control
Smoking
Price
Promotion
Place
Product
Positioning
People
Packaging
Degrade the value
Tobacco control
Vaping
Price
Promotion
Place
Product
Positioning
People
Packaging
Degrade the value to everyone
33

Evidence for beneficial population effect ‘triangulates’
• Also, user testimony
• And… it is what you would expect!!
34

Royal College of Physicians – unintended consequences
35

…if a risk-averse, precautionary approach
makes e-cigarettes:
• less easily accessible
• less palatable or acceptable
• more expensive
• less consumer friendly
• pharmacologically less effective
• inhibits innovation …
…then it causes harm by perpetuating
smoking.
Royal College of Physicians – unintended consequences
36

3. Perverse consequences: warnings
This product contains
nicotine which is a highly
addictive substance. It is not
recommended for use by
non-smokers
37

3. Perverse consequences: warnings
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
I do not want to substitute one addiction for another
I am not addicted to smoking and don't need help to quit
I do not know enough about them
I do not want to quit smoking
I do not think they would help me to quit or cut down
I am concerned they are not safe enough
Haven't got around to it yet
They cost too much
Other
I would be embarrassed to use them in public
I do not like the way they look
There are too many products to choose from
I’m using other things to help me quit smoking
They are too difficult to get hold of
Main reason for not trying an e-cigarette among smokers (2019)
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3. Perverse consequences: warnings
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
I do not want to substitute one addiction for another
I am not addicted to smoking and don't need help to quit
I do not know enough about them
I do not want to quit smoking
I do not think they would help me to quit or cut down
I am concerned they are not safe enough
Haven't got around to it yet
They cost too much
Other
I would be embarrassed to use them in public
I do not like the way they look
There are too many products to choose from
I’m using other things to help me quit smoking
They are too difficult to get hold of
Main reason for not trying an e-cigarette among smokers (2019)
39

Perverse consequences: warnings
“[Our findings] suggest that the
TPD nicotine addiction e-cigarette
health warning may reduce
smokers' willingness to use, and
likelihood of purchasing an e-
cigarette.”
40

This product is likely to
be at least 95% safer
than smoking cigarettes
No product is completely
safe, but use of this
product is much less
harmful than smoking
Perverse consequences: better warnings
41

E-cigarettes were the most
commonly cited tobacco
product currently used by
27.5% of high school
students (4.1 million)
The US “youth vaping epidemic”
42

Drill down into the 2019 NYTS headline
27.5%
Percentage of high school students who used e-cigarettes in past 30 days
HEADLINE
more than one
in five high
school
students is
vaping
43

We can distinguish between frequent and infrequent use
Frequent use
≥20 days per
month
Infrequent use
≤ 19 days per
month
9.4%
18.1%
Most teen
vapers (66%)
are not
frequent users
Percentage of high school students who used e-cigarettes in past 30 days
44

We can distinguish between prior tobacco users and never-users
8.8% 18.7%
Most teen
vapers (68%)
are prior
tobacco users
Percentage of high school students who used e-cigarettes in past 30 days
Prior tobacco use
Never used tobacco
45

We can segment by both frequency and prior tobacco use
Prior tobacco use
Never used tobacco
Frequent use
≥20 days per
month
Infrequent use
≤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
Percentage of high school students who used e-cigarettes in past 30 days
46

We can segment by both frequency and prior tobacco use
Prior tobacco use
Never used tobacco
Frequent use
≥20 days per
month
Infrequent use
≤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
Few teen
vapers (5%) are
both tobacco
naïve and
frequent users
Percentage of high school students who used e-cigarettes in past 30 days
47

We can identify a significant group who may benefit
Frequent use
≥20 days per
month
Infrequent use
≤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
Most of the
teen frequent
vapers (85%)
are prior
tobacco users
– vaping may
be helping
them
Percentage of high school students who used e-cigarettes in past 30 days
Prior tobacco use
Never used tobacco
48

49

Perverse consequences: flavour bans
Tobacco
Fruit
Dessert
or pastry
Choc,
sweets
Russell et al. vaping
flavour preferences
Russell C, McKeganey N, Dickson T, Nides M. Changing patterns of first e-cigarette flavor used
and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J.
BioMed Central; 2018 Jun 28;15(1):33
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Possible consequences – a flavour ban
• The intended outcome - abstinence from nicotine and not adopting any other risk behaviour
• Using tobacco flavoured vape products instead of other flavoured products
• Accessing flavoured vapes via an illicit supply chain (a black market)
• Buying from foreign suppliers in person or via the internet and importing for personal use
• Buying from foreign suppliers to resell to others through informal networks
• Making and mixing their own flavours at home or buying or selling home-mixed flavours
• Using vapes that are made to look tobacco flavoured but have other flavours
• Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids
• Using flavours made for vaping but ostensibly marketed for another purpose
• Switching to cannabinoid (THC or CBD) vapes
• Relapsing back from vaping to smoking – both teenagers and adults
• Not switching from smoking to vaping and continuing to smoke
• Initiating smoking instead of initiating vaping
• Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping
• Using other tobacco or nicotine products – hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches
• Adopting another risk behaviour that may be worse
51

CDC, Tobacco Product Use and Associated Factors Among Middle and
High School Students — United States, 2019, Table 6 (simplified)
Reasons for e-cigarette use among middle and high
school students who reported using e-cigarettes and
other tobacco products during the past 30 days
Reason given for vaping
Use e-cigarettes
only
Use e-
cigarettes and
other tobacco
products
I was curious about them 56.1% 38.4 %
Friend or family member used them 23.9% 22.2%
They are available in flavors, such as
mint, candy, fruit, or chocolate
22.3% 26.6 %
I can use them to do tricks 22.0% 29.0%
They are less harmful than other
forms of tobacco, such as cigarettes
17.2% 19.1%
Adolescents are curious
52

Heated tobacco products
53

Heated tobacco product (iQOS) versus smoking abstinence – exposure biomarkers
…a measurable and substantial
reduction in morbidity or
mortality among individual
tobacco users is reasonably likely
in subsequent studies, and
issuance of an order is expected
to benefit the health of the
population as a whole taking into
account both users of tobacco
products and persons who do not
currently use tobacco products.
FDA modified risk order
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Risk-Proportionate Regulation
Measure Cigarettes, hand-rolling tobacco and other
combustibles
Vaping, heated tobacco smokeless and oral
nicotine
Taxation Relatively high taxes Low or zero tax (sales tax only)
Illicit trade Track and trace (FCTC protocol) Complaint-driven
Advertising Prohibit other than within trade Control themes and placement
Warnings Graphic warnings depicting disease Messages encouraging switching
Public places Legally mandated controls Up to the discretion of the owner
Plain packaging Yes No
Ingredients Control reward-enhancing additives Blacklist material health hazards
Flavours Prohibit Allow, subject to health hazards
Flavour descriptors Not applicable if flavours banned Control appeal to youth/trademarks
Age restrictions No sales to under-21s No sales to under-18s
Internet sales Banned Permitted with age controls
Product standards Control risks and reduce appeal Control risks
55

Summary
1. Smoking remains a major burden
2. Now low risk alternatives
3. Good evidence for reduced harm
4. Good evidence for population benefits
5. Long term nicotine market
6. Risk proportionate regulation
7. New front in the war on drugs
Thank you!
Clive Bates
Counterfactual
clivedbates@gmail.com
www.clivebates.com
@clive_bates
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