Presentation at the Post Tobacco: Recreational Nicotine and Society held in Stockholm 11 October 2021.

1. Science-based Policy
or
Policy-based Science?
Clive Bates
Counterfactual
Post Tobacco: Recreational Nicotine and Society
Stockholm
11 October 2021

2. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

3. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

4. “People smoke for
the nicotine but
die from the tar”
(1976)
Professor Michael Russell 1932-2009
The central insight in smoking and health
4
Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3

5. Smokeless tobacco
Tobacco based
Pure nicotine based
Heated
aerosol
Unheated
Vaping products Heated tobacco products
“Heat-not-burn”
Items are not shown to scale
Oral nicotine products
5

6. “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”.
Disrupt the dominance of the cigarette
6
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

7. European Union smoking prevalence 2017
7
European Commission: Eurobarometer 458, 2017

8. European Union smoking prevalence 2017 - Sweden
Sweden
8
European Commission: Eurobarometer 458, 2017

9. Smoking Disease
9
Ramström 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

10. Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
The strongest evidence for reduced harm is reduced exposure
10
Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-
Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017

11. Public Health England reviews of biomarker data
11
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.

12. Public Health England reviews of biomarker data
12
McNeill A, et al Evidence review of ecigarettes and heated tobacco products 2018. A report
commissioned by Public Health England. London: Public Health England.

13. Heated tobacco (iQOS) versus smoking abstinence – exposure biomarkers
13

14. The fundamental innovation
Battery Energy Density

15. A technology transition - cars

16. A technology transition - electricity

17. 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.

18. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

19. Three perspectives
1. Predatory: the nicotine maintenance strategy of Big Tobacco
– Fundamental and irreconcilable conflict between the interests of the
tobacco industry and public health
FCTC Article 5.3 Guidelines
2. Harm reduction: save millions of lives by reducing smoking
– Appropriate for the protection of public health
FDA
3. The pleasure principle: leave us alone, we just like nicotine
– Candy doesn’t have to have a point. That’s why it’s candy.
Charlie and the Chocolate Factory

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
20
University College London, Smoking in England, Smoking Toolkit Survey, 2020

21. Smoking and vaping 2019 – Great Britain (ONS)
ONS, E-cigarette use in Great Britain in 2019, July 2020
~3m vapers
~8m smokers
21

22. Smoking and vaping – “making smoking products obsolete”
5% prevalence
Two-thirds cut
22
ONS, E-cigarette use in Great Britain in 2019, July 2020

23. 5. The irreconcilable conflict principle: cannibalising cigarette sales
Total - steady decline
Cigs – rapid decline
Heated Tobacco – sharp rise
Phillip Morris International Data

24. Extremely rapid decline in smoking
0
5
10
15
20
25
30
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Norway: daily tobacco use
women age 16-24 - per cent
17 percent
1 percent

25. Gentle decline in overall nicotine use
0
5
10
15
20
25
30
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Norway: daily tobacco use
women age 16-24 - per cent

26. 0
5
10
15
20
25
30
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Norway: daily tobacco use
women age 16-24 - per cent

27. Near elimination of daily smoking by switching to snus
0
5
10
15
20
25
30
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Norway: daily tobacco use
women age 16-24 - per cent

28. A new front in the war on drugs?

29. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

30. The weirdness of harm: the lifeblood of tobacco control

31. “EVALI” E-cigarette and Vaping Product Associated Lung Injury
31

32. Bad news sells newspapers
32
Vlachopoulos C et al (2016) Electronic
Cigarette Smoking Increases Aortic
Stiffness and Blood Pressure in Young
Smokers. J Am Coll Cardiol 67:2802–2803.
Origin
Vlachopoulos C et al (2003) Effect of
caffeine on aortic elastic properties and
wave reflection. J Hypertens 21:563–70.
Context
See: Clive Bates, When you thought public health could go no lower - it just did, Counterfactual, 2016

33. Weirdness of harm: why people quit
Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.

34. Weirdness of harm: driver of abstinence
Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.

35. Addiction
Addiction is marked by a change in behavior caused
by the biochemical changes in the brain after
continued substance abuse. Substance use becomes
the main priority of the addict, regardless of the harm
they may cause to themselves or others.
Addiction Center
A compulsive, chronic, physiological or
psychological need for a habit-forming substance,
behavior, or activity having harmful physical,
psychological, or social effects
Meriam Webster Dictionary
Addiction is a complex condition, a brain disease
that is manifested by compulsive substance use
despite harmful consequence. People with
addiction (severe substance use disorder) have an
intense focus on using a certain substance(s),
such as alcohol or drugs, to the point that it takes
over their life.
American Psychiatric Association
Addiction is defined as a chronic, relapsing
disorder characterized by compulsive drug
seeking and use despite adverse
consequences.
National Institute on Drug Abuse (NIDA)

36. Addiction and harm
Addiction is marked by a change in behavior caused
by the biochemical changes in the brain after
continued substance abuse. Substance use becomes
the main priority of the addict, regardless of the harm
they may cause to themselves or others.
Addiction Center
A compulsive, chronic, physiological or
psychological need for a habit-forming substance,
behavior, or activity having harmful physical,
psychological, or social effects
Meriam Webster Dictionary
Addiction is a complex condition, a brain disease
that is manifested by compulsive substance use
despite harmful consequence. People with
addiction (severe substance use disorder) have an
intense focus on using a certain substance(s),
such as alcohol or drugs, to the point that it takes
over their life.
American Psychiatric Association
Addiction is defined as a chronic, relapsing
disorder characterized by compulsive drug
seeking and use despite adverse
consequences.
National Institute on Drug Abuse (NIDA)

37. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

39. US Youth vaping epidemic

40. US Youth vaping epidemic

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
≥20 days per
month
Infrequent use
≤ 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
≥20 days per
month
Infrequent use
≤ 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
≥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
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
≥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
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. Weaponising ‘kids’

48. Weaponising ‘kids’

49. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?

50. 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

52. Royal College of Physicians – unintended consequences
52
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.

53. …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
53
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.

54. Agenda
1. Innovation (and its enemies)
2. Nicotine as a recreational drug
3. The weirdness of harm
4. The “youth vaping epidemic”
5. Why so much opposition?
Thankyou!
Counterfactual
clivedbates@gmail.com
www.clivebates.com
@clive_bates