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![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](https://image.slidesharecdn.com/drugscience-bates-feb2021-final-210214092636/85/Vaping-and-Tobacco-Harm-Reduction-40-320.jpg)
Uploaded byClive Bates
Vaping and Tobacco Harm Reduction
This document provides information on vaping and tobacco harm reduction. It discusses how smoking kills over 96,000 people annually in the UK and notes that median smokers lose 10 years of life expectancy. It then examines smoking prevalence data in different areas and populations in the UK. The document discusses evidence that vaping is substantially less harmful than smoking and may help smokers quit. It notes concerns that restrictive policies could perpetuate smoking. The summary concludes by outlining a framework for risk-proportionate regulation of tobacco and nicotine products.
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Vaping and Tobacco Harm Reduction
- 1. Vaping and tobaccoharm reduction 10 February 2021 Clive Bates Counterfactual www.clivebates.com Webinar 1
- 2. Well research tollof 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
- 3. Median smoker loses10 years between 73-83… 3
- 4. 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
- 5. 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
- 6. 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
- 7. 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
- 8. 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
- 9. Very high prevalencein 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
- 10. Levelling up -eye-watering cost of being a smoker 79% tax Pack a day = £3,760 per year 10
- 11. “People smoke for thenicotine 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 11
- 12. Smokeless tobacco Tobacco based Purenicotine 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
- 13. “A diverse classof 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
- 14. Snus: proof ofconcept 14
- 15. European Union smokingprevalence 2017 15
- 16. European Union smokingprevalence 2017 - Sweden Sweden 16
- 17.
- 18. The public healthmechanism 18
- 19. Smoking and vaping2019 – Great Britain (ONS) ONS, E-cigarette use in Great Britain in 2019, July 2020 ~3m vapers ~8m smokers 19
- 20. Smoking and vaping– “making smoking products obsolete” ONS, E-cigarette use in Great Britain in 2019, July 2020 5% prevalence Two-thirds cut 20
- 21. 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
- 22. Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidencefor reduced harm is reduced exposure 22
- 23. Royal College ofPhysicians – 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
- 24. Risk perceptions arefar out of line with expert judgement and getting worse ASH / YouGov surveys 2013-2020 24
- 25. “EVALI” E-cigarette andVaping Product Associated Lung Injury 25
- 26. “EVALI” E-cigarette andVaping Product Associated Lung Injury 26
- 27. “EVALI” looks exactlylike localised supply chain contamination 27
- 28. 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
- 29. 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
- 30. The public healthmechanism 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
- 31. The public healthmechanism: “value propositions” – the 7 Ps Value Price Promotion Place Product Positioning People Packaging 31
- 32. The public healthmechanism: 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 32
- 33. 2. The publichealth 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
- 34. Evidence for beneficialpopulation effect ‘triangulates’ • Also, user testimony • And… it is what you would expect!! 34
- 35. Royal College ofPhysicians – unintended consequences 35
- 36. …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
- 37. 3. Perverse consequences:warnings This product contains nicotine which is a highly addictive substance. It is not recommended for use by non-smokers 37
- 38. 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) 38
- 39. 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
- 40. Perverse consequences: warnings “[Ourfindings] suggest that the TPD nicotine addiction e-cigarette health warning may reduce smokers' willingness to use, and likelihood of purchasing an e- cigarette.” 40
- 41. This product islikely 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
- 42. E-cigarettes were themost commonly cited tobacco product currently used by 27.5% of high school students (4.1 million) The US “youth vaping epidemic” 42
- 43. Drill down intothe 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
- 44. We can distinguishbetween 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
- 45. We can distinguishbetween 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
- 46. We can segmentby 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
- 47. We can segmentby 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
- 48. We can identifya 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.
- 50. Perverse consequences: flavourbans 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 50
- 51. 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
- 52. CDC, Tobacco ProductUse 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
- 53.
- 54. 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 54
- 55. 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
- 56. Summary 1. Smoking remainsa 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 56
Editor's Notes
- #13 Vaping products Top row shows: 1st generation cig-a-likes 2nd generation ego or ‘pen’ type devices 3rd generation tanks / mods type Bottom row shows Large electronic hookah Small shisha pipes Electronic pipe … there are many other configurations Heated tobacco products – sometimes referred to as heat-not-burn to distinguish between combustible products Shows the iQOs, Ploom and Glo products Novel nicotine products - shows Nicoccino – a nicotine containing film Zonnic – a range of nicotine products – lozenges, gum etc Voke – a cold aerosol (approved but not marketed) Niorette – cross-over NRT Smokeless tobacco Snus Moist snuff Tobacco-based lozenge
- #31 Don’t worry if you aren’t mathematical… this is just codifying common sense…. 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 – a product characteristic. For e-cigs and snus this is 95-99% - at least 20-fold improvement… The second term is why we don’t want to be too prescriptive and end up dissuading people from take the 95-99% reduction and carrying on with the greatest danger. That’s why alarm bells should ring when there are plans to restrict reduced risk only to the ‘cleanest and safest’ - or there are plans to ban things that might make these products attractive – like flavourings – or to have regulators control ingredients – 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 – 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 term… those that use the reduced risk products who would otherwise have stopped completely. Not shown here because the residual risk is so low – the reduced risk products are not that much difference to quitting completely].