Respect Vapers Ireland - webinar on tobacco harm reduction
1. 1
Vaping and tobacco harm reduction
6 things you need to know
Clive Bates
29 March 2021
2. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2
3. Well researched toll of harm from smokingā¦
Smoking prematurely kills
around 5,500 annually in
Ireland
ā¦more than obesity,
alcohol, road accidents,
drug misuse and HIV
combined
3
An assessment of the economic cost of smoking in Ireland
citing U.S. Department of Health and Human Services.
4. EU smoking prevalence ā 2021 Eurobarometer 506 survey
4
Fieldwork - August ā September 2020
5. Median lifelong smoker loses 10 years between 73-83ā¦
5
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Yearsā observations on male British
doctors. BMJ 2004
6. Risk accumulates over decades ā smoking cessation by 40 avoids most mortality risk
6
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Yearsā observations on male British
doctors. BMJ 2004
7. Smoking as a driver of health inequalities
7
Social class gradient drives
health inequalities
Farmers
Health Service Executive, Ireland
8. Eye-watering cost of being a (legal) cigarette smoker
86% tax
8
Pack per day
=
ā¬4,550/year
Jobseekers
=
ā¬10,556/year
43%
Tax rates & UC: GOV.UK UK government website / Retail price: Tesco.com
9. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2. Technologies to obsolete cigarettes
9
10. āPeople smoke for
the nicotine but
die from the tarā
(1976)
Professor Michael Russell 1932-2009
The central insight in smoking and health
10
Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430ā3
11. Smokeless tobacco
Tobacco based
Pure nicotine based
Heated
aerosol
Unheated
Vaping products Heated tobacco products
āHeat-not-burnā
Items are not shown to scale
Oral nicotine products
11
12. ā[Alternative Nicotine Delivery
Systems] 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 smokeā.
US Annual Review of Public Health
12
Abrams DB, Glasser AM, et al. Harm Minimization and Tobacco Control: Reframing Societal Views of
Nicotine Use to Rapidly Save Lives Annu Rev Public Health 2018
15. European Union smoking prevalence 2017 - Sweden
Sweden
15
European Commission: Eurobarometer 458, 2017
16. Smoking Disease
16
Ramstrƶm L, Wikmans T. Mortality attributable to tobacco among men in Sweden and
other European countries: an analysis of data in a WHO report. Tob Induc Dis. 2014
20. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2. Technologies to obsolete cigarettes
3. Risks and risk (mis)perceptions
20
21. Royal College of Physicians ā 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".
21
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
23. Public Health England reviews of biomarker data
23
Review of biomarker studies
McNeill A, et al Evidence review of ecigarettes and heated tobacco products 2018. A report
commissioned by Public Health England. London: Public Health England.
24. Public Health England reviews of biomarker data
24
McNeill A, et al Evidence review of ecigarettes and heated tobacco products 2018. A report
commissioned by Public Health England. London: Public Health England.
25. Risk perceptions are far out of line with expert judgement and getting worse
ASH / YouGov surveys 2013-2020 25
26. Bad news sells newspapers
26
Vlachopoulos C et al (2016) Electronic
Cigarette Smoking Increases Aortic
Stiffness and Blood Pressure in Young
Smokers. J Am Coll Cardiol 67:2802ā2803.
Origin
Vlachopoulos C et al (2003) Effect of
caffeine on aortic elastic properties and
wave reflection. J Hypertens 21:563ā70.
Context
See: Clive Bates, When you thought public health could go no lower - it just did, Counterfactual, 2016
30. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2. Technologies to obsolete cigarettes
3. Risks and risk (mis)perceptions
4. The public health mechanism and the pleasure principle
30
31. Evidence for beneficial population effect ātriangulatesā
ā¢ Also, user testimony
ā¢ Andā¦ it is what you would expect!!
31
Professor Robert West, UCL. Presentation at SRNT-Europe 2019
32. Randomised controlled trial ā e-cigs versus NRT
886 smokers
1 year quit status
18% E-cigarette
9.9% NRT
Hajek P et al.. A randomized trial of e-cigarettes versus nicotine replacement
therapy . New England Journal of Medicine. 2019 32
33. Cochrane review ā October 2020
More people probably stop
smoking for at least six months
using nicotine e-cigarettes than
using nicotine replacement
therapy
Nicotine e-cigarettes may help
more people to stop smoking
than no support or behavioural
support only
33
Hartmann-Boyce J, McRobbie H, Lindson N, et al. Electronic cigarettes for smoking
cessation. Cochrane Database Syst Rev 2020
35. The public health mechanism is not āsmoking cessation medicationā
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
35
36. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2. Technologies to obsolete cigarettes
3. Risks and risk (mis)perceptions
4. The public health mechanism and the pleasure principle
5. The youth vaping epidemic ā a harder look
36
37. Youth vaping in Ireland
ā¢ The 2019 Health Behaviour in School-aged
Children (HBSC) study found that 22% of 12-
17 year olds had ever used e-cigarettes with
9% using them in the last 30 days
ā¢ The findings suggest that smoking, alcohol
consumption, and use of e-cigarettes are
interlinked. Most participants felt that e-
cigarette users also smoked cigarettes with
only a minority thinking that users just vaped.
Cigarettes remain more popular than e-
cigarettes, particularly at teenage discos.
37
40. E-cigarettes were the most
commonly cited tobacco
product currently used by
27.5% of high school
students (4.1 million)
The US āyouth vaping epidemicā
40
US Department of Health and Human Services
41. 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
41
42. We can distinguish between frequent and infrequent use
Frequent use
ā„20 days per
month
Infrequent use
ā¤ 19 days per
month
9.4%
18.1%
Most teen
vapers (66%)
are not
frequent users
42
Derived from: Jarvis M et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey
2017-2019 reveal about high school e-cigarette use in the USA? Qeios 2020 [Personal communication Martin Jarvis]
43. We can distinguish between prior tobacco users and never-users
8.8% 18.7%
Most teen
vapers (68%)
are prior
tobacco users
Prior tobacco use
Never used tobacco
43
Derived from: Jarvis M et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey
2017-2019 reveal about high school e-cigarette use in the USA? Qeios 2020 [Personal communication Martin Jarvis]
44. We can segment by both frequency and prior tobacco use
Prior tobacco use
Never used tobacco
Frequent use
ā„20 days per
month
Infrequent use
ā¤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
44
Derived from: Jarvis M et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey
2017-2019 reveal about high school e-cigarette use in the USA? Qeios 2020 [Personal communication Martin Jarvis]
45. We can segment by both frequency and prior tobacco use
Prior tobacco use
Never used tobacco
Frequent use
ā„20 days per
month
Infrequent use
ā¤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
Few teen
vapers (5%) are
both tobacco
naĆÆve and
frequent users
45
Derived from: Jarvis M et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey
2017-2019 reveal about high school e-cigarette use in the USA? Qeios 2020 [Personal communication Martin Jarvis]
46. We can identify a significant group who may benefit
Frequent use
ā„20 days per
month
Infrequent use
ā¤ 19 days per
month
1.4% 8.0%
10.7%
7.4%
Most of the
teen frequent
vapers (85%)
are prior
tobacco users
ā vaping may
be helping
them
Prior tobacco use
Never used tobacco
46
Derived from: Jarvis M et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey
2017-2019 reveal about high school e-cigarette use in the USA? Qeios 2020 [Personal communication Martin Jarvis]
47. Six things you need to know about tobacco harm reduction
1. Smoking has not gone away
2. Technologies to obsolete cigarettes
3. Risks and risk (mis)perceptions
4. The public health mechanism and the pleasure principle
5. The youth vaping epidemic ā a harder look
6. Policymaking and perverse consequences
47
48. ā¦if a risk-averse, precautionary approach
makes e-cigarettes:
ā¢ less easily accessible
ā¢ less palatable or acceptable
ā¢ more expensive
ā¢ less consumer friendly
ā¢ pharmacologically less effective
ā¢ inhibits innovation ā¦
ā¦then it causes harm by perpetuating
smoking.
Royal College of Physicians ā unintended consequences
48
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
49. 3. Perverse consequences: warnings
This product contains
nicotine which is a highly
addictive substance.
49
Required by EU Tobacco Products Directive 40/14/EU
50. 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
Iām 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)
50
ASH / YouGov surveys adults 2019
51. 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
Iām 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)
51
ASH / YouGov surveys adults 2019
52. Perverse consequences: warnings
ā[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.ā
52
Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative
relative risk message on smokersā willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
53. 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
53
55. CDC, Tobacco Product Use and Associated Factors Among Middle and
High School Students ā 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
55
56. Perverse consequences: flavour bans
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 56
57. Possible consequences ā a flavour ban
ā¢ The intended outcome - abstinence from nicotine and not adopting any other risk behaviour
ā¢ Using tobacco flavoured vape products instead of other flavoured products
ā¢ Accessing flavoured vapes via an illicit supply chain (a black market)
ā¢ Relapsing back from vaping to smoking ā both teenagers and adults
ā¢ Not switching from smoking to vaping and continuing to smoke
ā¢ Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping
ā¢ Using other tobacco or nicotine products ā hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches
ā¢ Buying from foreign suppliers in person or via the internet and importing for personal use
ā¢ Buying from foreign suppliers to resell to others through informal networks
ā¢ Making and mixing their own flavours at home or buying or selling home-mixed flavours
ā¢ Using vapes that are made to look tobacco flavoured but have other flavours
ā¢ Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids
ā¢ Using flavours made for vaping but ostensibly marketed for another purpose
ā¢ Switching to cannabinoid (THC or CBD) vapes
ā¢ Initiating smoking instead of initiating vaping
ā¢ Adopting another risk behaviour that may be worse
57
58. 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
58
59. 59
1. Smoking remains a major burden
2. Low-risk alternatives available
3. Good evidence for reduced harm
4. Market and consumer-based solution
5. Keep the youth issue in perspective
6. Exploit the opportunity, manage the risks
Editor's Notes
Vaping products
Top row shows:
1st generation cig-a-likes
2nd generation ego or āpenā type devices
3rd generation tanks / mods type
Bottom row shows
Large electronic hookah
Small shisha pipes
Electronic pipe
ā¦ there are many other configurations
Heated tobacco products ā sometimes referred to as heat-not-burn to distinguish between combustible products
Shows the iQOs, Ploom and Glo products
Novel nicotine products - shows
Nicoccino ā a nicotine containing film
Zonnic ā a range of nicotine products ā lozenges, gum etc
Voke ā a cold aerosol (approved but not marketed)
Niorette ā cross-over NRT
Smokeless tobacco
Snus
Moist snuff
Tobacco-based lozenge
Donāt worry if you arenāt mathematicalā¦ this is just codifying common senseā¦.
The simple idea is that a the impact of reduced risk alternative to cigarettes is the risk reduction per user multiplied by the number of users who switch. Both terms are important.
The first term is really determined by toxic exposure arising from continued nicotine use ā a product characteristic. For e-cigs and snus this is 95-99% - at least 20-fold improvementā¦
The second term is why we donāt want to be too prescriptive and end up dissuading people from take the 95-99% reduction and carrying on with the greatest danger.
Thatās why alarm bells should ring when there are plans to restrict reduced risk only to the ācleanest and safestā - or there are plans to ban things that might make these products attractive ā like flavourings ā or to have regulators control ingredients ā or attempt to remove all residual toxins (some of which might be important for flavour)
The consumer and mechanisms of market competition should be the primary driver of what makes these products attractive ā not regulators who may insist they are safe at the expense of making them less attractive
[The equation could be elaborated to have a second termā¦ those that use the reduced risk products who would otherwise have stopped completely. Not shown here because the residual risk is so low ā the reduced risk products are not that much difference to quitting completely].