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Prohibition or profit motive: competing visions for the endgame
This document discusses competing visions for reducing tobacco-related harm and cigarette consumption globally by 2040. It summarizes the view that prohibition of cigarettes is unlikely to succeed and may backfire, while introducing reduced-risk nicotine products could displace smoking if regulated appropriately. Charts show global cigarette consumption trends and hypothetical scenarios where safer nicotine products capture market share from cigarettes. The argument is made for an approach that balances public health, individual rights, and business interests to maximize harm reduction opportunities.
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Prohibition or profit motive: competing visions for the endgame
- 1. Prohibition or profitmotive? Competing visions for the endgame Global Forum on Nicotine 6th June 2015 Clive Bates Counterfactual www.clivebates.com
- 2. Global cigarette consumption- still rising Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 Billionpieces Global cigarette consumption 1980-2012 Total cigarette consumption
- 3. Global cigarette consumption- still rising Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 Billionpieces Global cigarette consumption 1980-2012 Developing countries Developed countries
- 4.
- 5. The Lancet –March 2015
- 6. 2040 ‘endgame’ –the story so far Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012 - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 Billionpieces Global cigarette consumption - phase out by 2040
- 7. 2040 ‘endgame’ –eliminating tobacco Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012 - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 Billionpieces Global cigarette consumption - phase out by 2040
- 8. 2040 ‘endgame’ –reducing to 5 percent adults Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012 - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 Billionpieces Global cigarette consumption - phase out by 2040
- 9. The standard kitbag (FCTC)
- 10.
- 11. Endgame: How tobaccocontrol sees it…
- 12.
- 13. Prohibitions • No qualitystandards • No consumer protection • Limited or bad consumer info • No ‘marketing’ controls • No tax revenue • Enforcement costs • Police credibility / compliance • Disproportionate penalties • Corruption in law enforcement • Users harmed by criminalisation • Ultimately regulated by violence • Criminal supply chain diversifies • Gateway?
- 14. 2. Smoke freegeneration
- 15. It may beprohibited but is definitely not gone 15.7 23.4 0 5 10 15 20 25 Cigarettes Marijuana Percent Marijuana and cigarettes US high school prevalence 2013 Source: CDC MMWR Youth Risk Behavior Surveillance — United States, 2013 Current use: used at least once in last 30 days Approximately age 14-18 – grade 9-12
- 16. 3. Sinking lid Q0 P0 P1 Q1Quantity Price Lid Tax
- 17. 4. Reduce nicotinein cigarettes
- 18.
- 19. Big Tobacco: halfa trillion dollars 0 20 40 60 80 100 120 140 PMI Altria BAT JTI ITC (India) Imperial Reynolds Lorillard Market capitalisation – April 2015 (billion US dollars) Total = $550 billion
- 20. Charter of FundamentalRights of the European Union Everyone has the right to own, use, dispose of and bequeath his or her lawfully acquired possessions. No one may be deprived of his or her possessions, except in the public interest and in the cases and under the conditions provided for by law, subject to fair compensation being paid in good time for their loss. The use of property may be regulated by law in so far as is necessary for the general interest. Fifth Amendment: Takings or Just Compensation Clause …nor shall private property be taken for public use without just compensation.
- 21. What’s the rightthing to do? Right thing to do? • Legitimate objective • Appropriate relationship between citizen and state • Respect for rights, property, liberty • Harm principle Right way to do it? • Unintended consequences • Proportionate • Non-discriminatory • Evidence based
- 22.
- 23. Much safer recreationalnicotine delivery Vapour products ‘Heat not burn’ tobacco Smokeless tobacco Novel nicotine products ‘Crossover’ NRT Inhalers + 25 years innovation to come
- 24. Multi-criteria estimate ofnicotine product harms…. Nutt DJ et al Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach – European Addiction Research March 2014
- 25. Harm reduction categories– risk continuum? 0 20 40 60 80 100 120 Cigarettes Smokeless E-cigs NRT Crudeestimateofrisk–Cigs=100 From analysis of the constituents of e-cigarette vapour, e-cigarette use from popular brands can be expected to be at least 20 times safer (and probably considerably more so) than smoking tobacco cigarettes in terms of long-term health risks Professor Robert West Professor Ann McNeill Professor Peter Hajek Dr Jamie Brown Ms Deborah Arnott
- 26. Value proposition: asmoker’s cost-benefit analysis 1. Keep smoking Benefit: nicotine, sensory, taste, ritual, brand- related Cost: illness, money, stigma, addiction 2. Quit smoking Benefit: avoid smoking harm, take control, cash savings Cost: withdrawal, craving, sustained willpower, lost smoking benefits 3. Switch to e-cigs Benefit: most smoking benefits*, no/minor smoking harms, personalisation, buzz, cash saving Cost: addiction? * Full benefits – subject to continued innovation “Quit or die”
- 27. Global cigarette consumption- still rising Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 1980 1985 1990 1995 2000 2005 2010 Billionpieces Global cigarette consumption 1980-2012 Total cigarette consumption
- 28. Global cigarette consumption– trend to 2030 Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. y = -1.4623x2 + 86.419x + 4888.9 R² = 0.9932 - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 Billionpieces Global cigarette consumption and trends – parabolic trend Global
- 29. Cigarette consumption continueson trend Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 2010 2015 2020 2025 2030 Billionpieces Extrapolation of trend (parabolic curve) Global cigarette consumption
- 30. Hypothetical introduction ofnew nicotine products Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 2010 2015 2020 2025 2030 Billionpieces New non-combustible nicotine with high initial but declining growth Low risk nicotine consumption Global cigarette consumption
- 31. Hypothetical introduction ofnew nicotine products Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 2010 2015 2020 2025 2030 Billionpieces New non-combustible nicotine with high initial but declining growth This boundary is harder to move. This boundary is easier to move.
- 32. In the longterm it may displace smoking Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92. - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 2010 2015 2020 2025 2030 2035 2040 Billionpieces New non-combustible nicotine with high initial but declining growth Global cigarette consumption Low risk nicotine consumption
- 33.
- 35. Diminishing and negativereturns to regulation Net health Net harm Valuetosociety Regulatory costs, burdens and restrictions Builds confidence Destroys viable firms and products Compromises design & consumer appeal Sweet Spot
- 36. Morgan Stanley onFDA deeming regulations The greater barriers to entry (slower approval process, higher costs, higher product standards), will ultimately take a toll on the number of available products and rationalize the category. This could result in the larger tobacco companies dominating the category in the future, given the burden it would place on smaller manufacturers.
- 37. Opportunity not threat Regulator ConsumersPublic health Business Government Find that sweet spot Big vision, win big Tell the truth, focus on disease Fight for your interests and spread the word Innovative, competitive not predatory
- 38.
Editor's Notes
- #3 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +36 billion per year
- #4 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +36 billion per year
- #7 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +37 billion per year
- #8 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +37 billion per year
- #9 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +37 billion per year
- #12 In April 2013 the journal Tobacco Control published a special supplement on the ‘end game’ for tobacco: http://tobaccocontrol.bmj.com/content/22/suppl_1.toc In this supplement, some of the world’s most brilliant tobacco control scholars, strategists and activists, including those who originated the principal endgame concepts, offer a wide range of observations pertinent to contemplating the endgame. These are some of the main ideas: Lowering nicotine content: the idea of federal regulation of the nicotine content of cigarettes such that the nicotine content of cigarettes would be reduced over time, resulting in lower intake of nicotine and a lower level of nicotine dependence. When nicotine levels get very low, cigarettes would be much less addictive. As a result, fewer young people who experiment with cigarettes would become addicted adult smokers and previously addicted smokers would find it easier to quit smoking when they attempt to do so. Main issue: people more or less seek a desired nicotine intake – as nicotine concentrations go down, exposure to harmful toxins would go up causing more harm. No regulator could do this. Loose tobacco, RYO, black market… Sinking lid: seeks to end tobacco use through the imposition of progressive limits on the amount of commercial tobacco released for legal sale, and the use of auction to license suppliers for the remaining portion. Using a biannual reduction of 5% of the initial volume, the authors foresee a phasing out of commercial tobacco within two decades. Main issue: same effect and challenges as raising taxes only vastly more complicated. Note equivalence of emissions trading and carbon taxes in climate policy. Tobacco free generation. The tobacco-free generation proposal advocates legislation precluding the sale and supply of tobacco to individuals born after a certain year. The legal age limit goes up by 1 year each year. Main issues: Vastly overstates role and effectiveness of age limitations and retail controls. Creates dividing line in adult consumers – 42 year olds allowed to buy, but not 41 year olds. Policy reductio ad absurdum Nationalisation: establishment of a ‘non-profit enterprise with public health mandate’ (NPE), which would remove profit-making from the entire tobacco supply system and replace duty to shareholders with an unencumbered responsibility to meet the public health goal of phasing out smoking. Regulated market model: a harm reduction model where the marketing is under the control of a non-profit entity (a regulated market) is required to curtail the incredible power of for-profit marketing and to allow tobacco marketing to be done in ways that further the goal of minimising tobacco-related harm. Implausible seizure of shareholder property rights (nb companies owned by pension funds etc). Performance based regulation: rests on the simple proposition that the tobacco companies themselves should be required to achieve sharply improved public health outcomes’. He suggests that this can be done through the imposition of legal requirements on tobacco companies to reduce the number of people who smoke their products and to impose effective financial penalties on those who fail to do so. Main issue: cannot be translated into a plausible business model for a tobacco company – what would the employees do at work? Note different to schemes where energy companies save energy and recover costs through tariffs. Abolition: Robert Proctor's appeal for ‘Abolition’ of commercial tobacco. He proposes to ban the sale and manufacture of cigarettes, and to permit the smokers to grow their own tobacco. Instead of seeking to better regulate the market, transform it or impose performance requirements on it, Proctor seeks to collapse the organised supply. Politically infeasible due to the one-two billion users.
- #16 http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6304a1.htm?s_cid=ss6304a1_w
- #25 Article: http://www.karger.com/Article/FullText/360220
- #26 This si my own conceptualisation of the risks – it my be a few points different in reality but there are two characteristics: A very low risk elative to cigarettes A residual risk that is not very large and probably within the normal range of things we accept without huge regulatory oversight (eg. Bacon, BBQs, cheese, coffee etc)
- #27 This looks at the choices faced by smokers – the first two represent the ‘quit or die’ proposition. The third is a new value proposition in which smokers can switch and get almost all of the benefits (and some new ones like personalisation) and almost none of the costs. This value proposition will get stronger with advancing innovation, as recreational experience matches that of smoking. But it does need regulators to enable this.
- #28 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000 On a linear basis over 30 years Developed –16 billion per year Developing +53 billion per year Global +36 billion per year
- #29 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
- #30 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
- #31 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
- #32 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
- #33 Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960 Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
- #37 This comment from David Adelman of Morgan Stanley July 2014 reflects the reality of heavy regulation – it plays to the advantages of companies with strong balance sheets able to support their vapour subsidiaries through regulatory approvals, while killing off the competition. Just about everything called for by the public health community plays into this dynamic – bans, meds regulation, massive amounts of testing etc