The presentation gives my take on the conflict raging in tobacco control. It looks at where things are going wrong in science, risk communication, policy, and youth politics. It then looks at causes: institutional and cultural inertia. And finally, finds hope in the basic processes of innovation.

1. The new tobacco wars
E-cigarette Summit 2021
Clive Bates
Counterfactual
7 December 2021
(Virtual)

2. 1. Science

3. Toxicology explained

6. From correlation to causation
• […] cross-sectional nature of our study
design limits our ability to make causal
inferences between e-cigarettes and fragility
fractures.
• […] the effect estimates we observed may be
subject to residual confounding.
• […] duration of vaping were not
systematically available to allow for such
sub-group analyses.
• […] for some individuals, e-cigarette use may
have started after fracture occurrence and
diagnosis.
Limitations

7. 2. Risk Communication

8. “Vape Facts”

11. Tobacco firms promote
[snus] as “safer” than
smoking, but whether
you jump from the tenth
storey of a building or
the 20th, the effect is
the same.

13. Localised supply chain contamination
13
US Centers for Disease Control and Prevention

14. “EVALI” E-cigarette and Vaping Product
Associated Lung Injury
14

15. It’s working
ASH / YouGov surveys 2013-2020 15

16. The Big Lie
“These products are falsely marketed as
safer and more sustainable options to
deadly cigarettes, misleading consumers,
media and international institutions.”

17. The Big Lie
“…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.”

18. 3. Policymaking

19. Prohibition for 800 million smokers

20. Awards for prohibition
“Dr Harsh Vardhan received the
award for spearheading the
Government of India’s legislation
to ban e-cigarettes and heated
tobacco products in 2019.”

21. Prohibition - Bhutan
21
Today, the country is faced with a
greater challenge, that of illegal
traffic in tobacco and its products.
So long as the demand within the
country persists, it will continue to
fuel the illicit market that has
expanded since the ban of its sale in
early 2000.
Unfortunately, as studies indicate,
Bhutanese youth are at the centre
of this growing illegal trade in
tobacco and its products.
WHO Office Bhutan: The Big Ban: Bhutan’s journey towards a tobacco-free society, 2019

23. Banning e-liquid flavours
23

24. Perverse consequences for adults?
Tobacco
Fruit
Dessert
or pastry
Choc,
sweets
Russell et al. vaping
flavour preferences
Russell C, et al. 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 24

25. Compliant youth?
25
• The intended outcome: abstinence from nicotine, vaping, smoking and any other vice
• Using tobacco flavoured vape products instead of other flavoured products
• Accessing flavoured vapes via an illicit supply chain (a black market)
• Relapsing back from vaping to smoking – both teenagers and adults
• Not switching from smoking to vaping and continuing to smoke
• 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
• 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
• Initiating smoking instead of initiating vaping
• Adopting another risk behaviour that may be worse

26. Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San
Francisco, California. JAMA Pediatrics. 2021
Perverse consequences: banning e-liquid
Teenage smoking
increased following an
e-cigarette flavours ban
in San Francisco
Past-30-Day Smoking Trends Among High School Students Younger Than 18
Years

27. Taxing vapes

28. US Federal E-cig tax
• Reduce teen e-cigarette use by 2.7 percentage
points, but that 2 in 3 teens who do not use e-
cigarettes due to the tax would smoke
cigarettes instead.
• ….approximately a half million extra teenage
smokers overall.
• … raise the number of daily adult cigarette
smokers by 2.5 million nationally and reduce
adult e-cigarette users by a similar number.
• For every e-cigarette pod eliminated by an e-
cigarette tax, more than 5.5 extra packs of
cigarettes are sold instead
Congress: raise e-cigarette taxes to a level
comparable to cigarette taxes…

29. 4. ‘Kids’

30. The US “Youth Vaping Epidemic”

31. Still the US “Youth Vaping Epidemic?

33. 5. Reasons for opposition?

34. Reasons for opposition (1)
Cultural
inertia
Statist
Warrior
code
Coercive
&
punitive
Moral
instincts
Visceral
disgust

35. A Coercive Playbook

36. A useful nemesis

37. Reasons for opposition (2)
Institutional
inertia
Money
&
support
Leader-
ship
Brand
Set
Modus
operandi
Prestige

38. Research infrastructure

44. Reason for opposition
Institutional
inertia
Money
&
support
Leader-
ship
Brand
Set
Modus
operandi
Prestige
Cultural
inertia
Statist
Warrior
code
Coercive
&
punitive
Moral
instincts
Visceral
disgust

46. 6. Innovation

47. Fundamental technology driver
Battery Energy Density

51. A technology transition - music
51
Digital Storage density Bandwidth
Analogue

52. 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”
Opportunity or threat?

53. Innovation and its enemies…
“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.

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