Future perspectives for reducing smoking related harm ... · Swapping cigarettes for an e-cigarette...

Future perspectives for reducing smoking related harm –what have we learnt ?

Karl E. Lund, PhD

Senior Researcher

• Tobacco Harm Reduction• What is it?• Do we need it?• Why is it so controversial?• What are the pros and cons?• What will the net public health effect be?

• The proof concept of tobacco harm reduction; snus use in Scandinavia

Smoking: 7 million deaths annually

Number of smokers: 1.1 billion

Europe: 1.4 million deaths annuallyA significant cause of health inequality

Consumption decreasing by 0.9% per year

A ‘Zero-vision’ (smokefree society) fulfilled in….

…2040 in Netherland

…2030 in Denmark

…2030 in Finland

…2025 in Sweden

…2025 in Norway

…2035 in Canada

…2030 in England

…2025 in Ireland

The ’Zero-vision’ will be achieved by intensified use of traditional means..

More information...

Stronger regulations.....

Higher taxes.....

Intensified campaigns.....

Denormalization.....

Increased assistance in smoking cessation.....

Cigarettes are bad….

More information....into populations already well informed

Stronger regulations...into societies already fairly well regulated

Higher taxes...into markets where cigarettes already appear costly

Intensified campaigns...against an audience already inoculated and ’imune’

Denormalize...a group already feeling stigmatized

Additional quit-smoking clinics – even though the present capacity is underutilized

Society has changed.............

More information....into populations already well informed

Stronger regulations...into societies already fairly well regulated

Higher taxes...into markets where cigarettes already appear costly

Intensified campaigns...against an audience already inoculated and ’imune’

Denormalize...a group already feeling stigmatized

Additional quit-smoking clinics – even though the present capacity is underutilized

Society has changed.............

Marginal

returns

from int

ensifyi

ng the

tradition

al weap

ons of t

obacco

control

Resistant and reactant Inoculated and imune Social class decentVulnerable groupsMental disordersLack of coping skills

Smokers possess other characteristics than those we targeded with traditional tools some decades ago........

The smokers have changed......

Tour de France

Smoking associated with low SES – vulnerable populations

Society

has cha

nged and

the sm

okers ha

ve chan

ged

– but the

tobacco

control

policy re

mains

A supplementary approach;Tobacco Harm Reduction (THR)

• ‘People smoke for the nicotine, but die from the tar’Prof Michael Russell (1976)

• Almost all risk attributable to tobacco arises from combustion

• Provide smokers with satisfactory low-risk alternatives to cigarettes that do not involve combustion but do provide nicotine• E-cigarettes• Snus• Heat-not-Burn

Target-group I: Established smokers unable or unwilling to quit nicotine

Enable (i) established smokers to reduce their own risk of tobacco-related disease by informing, facilitating and encouraging transition to risk-reduced nicotine/tobacco products…….

…. even though use of these products might cause exposure to toxins, continued nicotine addiction and periods of dual use

Tobacco-Harm-Reduction:

Target-group II: Youth susceptible to smoking

Make alternative nicotine products available to.....

ii) “The bad guys”

ii) ....potential smokers.....


F*** you !!!

Target-group II: Youth susceptible to smoking

Make alternative nicotine products available to.....

ii) “The bad guys” iii) “The good guys”

ii) ....potential smokers..... ...even though these products might also attract users from a segment of iii) youth who otherwise would have been nicotine abstinent.


ii) “The bad guys” iii) “The good guys”i) The established smokers

Tobacco-Harm-Reduction (THR) - three affected groups:

THR-products for recreational use (not limited to therapeutic use)

E-cigarettes Heat-not-burnSnus

Continuum of risk for nicotine containing products

Framework for assessments of health risk

Toxicological studies(chemical

composition)

Cell-studies(cytotoxicity)

Clinical studies(pharmacokinetics)

Epidemiological studies(long term)

Strength of evidence

Snus Yes Yes Yes Yes Strong

E-cigarettes Yes Yes Yes No Moderate

HnB Yes Few Few No Weak

Some selected papers on risk comparison:Levy et al (2004), Nutt et al (2014), Chen et al (2017), Stephens (2017), Lee (2013),

Althou

gh the

estim

ate of

5% de

gree is

disput

ed…..

The following organisations have reviewed the evidence on e-cigarettes and found:

US National Academies of Sciences, Engineering and Medicine (NASEM):“E-cigarettes are far less harmful than conventional cigarettes”

US Food & Drug Administration (FDA):“Make no mistake. We see the possibility for e-cigarettes to provide a potential less harmful alternative for current addicted individual adult smokers who still want to get access to satisfying levels of nicotine without many of the harmful effects that come with combustion of tobacco”

American Cancer Society: “Based on current available evidence, using current generation e-cigarettes is less harmful than smoking cigarettes”

Public Health, England: “Our new review reinforces the finding that vaping is a fraction of the risk from smoking, at least 95% less harmful and of negligible risk to bystanders. Yet over half of smokers either falsely believe that vaping is as harmful as smoking or just do not know”

Royal College of Physicians (RCP):“E-cigarettes are significantly less harmful than tobacco cigarettes. In the UK, harm reduction is a recognised element of comprehensive tobacco control”

British Lung Foundation, The Royal College of General Practitioners, Royal Society for Public Health:“There is more evidence that e-cigarettes are safer than smoking, and a way to give up altogether. Swapping cigarettes for an e-cigarette can improve symptoms of lung conditions like asthma and COPD”

Cancer Research, UK (CRUK):“Evidence so far indicates e-cigarettes are far less harmful than tobacco, and may help smokers to cut down or stop smoking. We do not believe there is justification for an indoor ban on e-cigarettes”

Cochrane Tobacco Addiction Group (Cochrane TAG):“E-cigarettes may increase thye chance of quitting smoking long term. No serious side effects were associated with their use (up to two years)”

Truth Initiative:“Some smokers may be unable or unwilling to quit nicotine, and would benefit by completely switching to much lower harm nicotine delivery mechanism including well-regulated e-cigarettes”

….. th

ere is

medical

conse

nsus o

f a hu

ge risk

differ

ence…

Tobacco-Harm-Reduction converted into real-politics

Step 1: Allow access to the nicotine market – e.g:

E-cigarettes in UK (and EU)Snus in Norway & SwedenHnB in Japan & Korea

Trinn 2. Informera om riskskillnaden till rökning

Trinn 3. Ge de minst skadliga nikotinprodukterna marknadsfördelar över cigaretter

- lägre skattesats

- undantag från standardisering av paket

- undantag från regulering av smak

- undantag från reklamförbudet

- undantag från förbud mot innomhusbruk

- etc.


Step 1: Access to the nicotine market

E-cigarettes banned in more than 30 countries including Brazil, Singapore, Thailand, Mexico, Cambodia, India, Australia…



Step 2: Disseminate accurate information on risk difference

Step 3: Ge de minst skadliga nikotinprodukterna marknadsfördelar över cigaretter

- lägre skattesats

- undantag från standardisering av paket

- undantag från regulering av smak

- undantag från reklamförbudet

- undantag från förbud mot innomhusbruk

- etc.


Fong og studiene om risk belief

Percentage of smokers thinking e-cigarettes aremore/equally harmful than cigarettes

Courtesy dr. Geoff Fong

Very inconsistent withmedical consensus

What do we know?

- Sudden outbreak

- Acute course of illness

- Limited to the US (so far)

- Limited to vapers below 35 years

- 92% of patients report using oil-laden THC liquid

- Illegal, black market vaporizers/liquids

- Vitamin E-acetate in 89% of the tested THC-oils - used to thicken cannabis oil to make it appear more potent

Neither THC per se nor nicotine seem to the culprit

Percentage of smokers believing that nicotine causes most of the cancers in smoking

How do we communicate risks?




Step 3: Risk-proportionate regulation - tax differentials reflecting the likely difference in risk

- competitive advantages for non-combustibles over cigarettes- tax cigarettes higher- wrap cigarettes uglier- limit flavors in cigarettes - hide cigarettes at the outlet- restrict indoor smoking

Tobacco-Harm-Reduction:Step 1: Market accessStep 2: Correction of misperceptions on riskStep 3: Risk-proportionate regulation

High taxPlain packsDisplay ban

Advertising banNo flavors

Strong use restrictions

I want out of here

Boiling smokers

E-cigarettes

Snus

Heat-not-Burn

Step 3: Risk-proportionate regulation

Why switch?

i) Established smokers

Step 1: Deny market access Step 2: Fail to correct misperceptions Step 3: Regulate non-combustibles the same way as cigarettes

We might as well smoke !!

ii) “The Bad Guys”

…then, I will not be tempted to try nicotine

iii) “The Good Guys”

Step 1: Deny market access Step 2: Fail to correct overestimation of risk Step 3: Regulate non-combustibles the same way as cigarettes

The real politics of Tobacco Harm Reduction:How to weigh the pros and cons?

What will be the net-effect on public health from Tobacco-Harm-Reduction policy?

iii) “The Good Guys”ii) “The Bad Guys”i) Established smokers

The answer can be deducted from:

Never-smokers: What is the excess risk compared to non-use?• Absolute risk

Smokers: What is the risk-reduction compared to continued smoking?• Relative risk

What is the relationship between smokers and never-smokers in uptake and use?• User-configuration

?

Given an anticipated risk difference in relation to cigarettes;

How many of the iii) The Good Guys will have to pick

up e-cigarettes in order offset the health gain from

each i) Established smoker or each of ii) The Bad

Guys who start to vape instead of smoke cigarettes?

Risk-use equilibrium:

Harm from e-cigarettes in relation to tobacco cigarettes

(%)

Number who choose to vape instead of smoke

Number of never-smokers that have to pick up e-

cigarettes

Net resulton public health

1 1 100 0

2 1 50 0

5% 1 20 0

10 1 10 0

15 1 6,7 0

20 1 5 0

25 1 4 0

Risk-use equilibrium


(%)



cigarettes


1 1 100 0

2 1 50 0

5% 1 20 0

10 1 10 0

15 1 6,7 0

20 1 5 0

25 1 4 0


Step 1: Allow market access Step 2: Correct inaccurate risk perceptions Step 3: Risk-proportionate regulation


(%)



cigarettes to offset the gain


1 1 100 0

2 1 50 0

5% 1 20 0

10 1 10 0

15 1 6,7 0

20 1 5 0

25 1 4 0


Step 1: Allow market access Step 2: Correct inaccurate risk perceptions Step 3: Risk-proportionate regulation

During this talk one you will decide to swop cigarettes for e-cigarettes ...and succeed permanently..

...and by that reduce the risk of a future smoking related diseaseto 5% of what you would have had as a continued smoker

Making the switch


...but during this talk a number of never-smokers also consider to start vaping....

ii) “The Good Guys”

How many of the will have to start vaping to offset the health gain from the one that swopped cigarettes with e-cigarettes?

ii) “The Good Guys”


If the risk of vaping makes up 5% of the risk from smoking – the answer 20 Risk-use equilibrium

Former smokers makes up the majority of vapers in the UK

Ex-smoker

Smoker

Never smoker

Source: Smokefree GB Sept 2019

Portugal

• If all the remaining Portuguese smokers (25%) switched completely from cigarettes to e-cigarettes…..

• …but the entire adult population in Portugal took up vaping…..

• ..the net public health effect would still be positive, provided that vaping makes up 5% of the risks from smoking

If a ban on flavors will demotivate ONE smoker from switching to e-cigarettes,TWENTY never-smokers must also be demotivated to restore the public health effect

Who should have the burden of proof?

Proponents must demonstrate that a flavor ban will protect 20 never-smokers from vaping for each smokers who will refrain from making a switch because flavors are banned


* Oral, low-toxicity smokeless tobacco product* Moist powder of pasteurized finely ground tobacco leaves* Pre-baked portions wrapped in cellulose* Discrete to use, no spitting

The proof concept of tobacco harm reduction – use of snus in Norway and Sweden

Respiratory26%

Cardiovascular35%

Lung Cancer29%

Other cancers8%

Diabetes2%

When smokers die from smoking-related diseases, they die from…

Respiratory26%

Cardiovascular35%

Lung Cancer29%

Other cancers8%

Diabetes2%

Weak/none

None

None

Weak

Weak

Smoking-related diseases – association with snus use

Cigarettes95%

Snus5%

Cigarettes61%

Snus39%

Source: Directorate Customs & Exice

The changing nicotine market in NorwaySales volume (weight)

1997-1999 2015-2017

2 kg/per capita 1.1 kg/per capita

Cigarettes

Cigarettes & Snus

Snus E-cigarettes & Tobacco

E-cigarettes

0

10

20

30

40

50

60

1996-2000 2006-2009 2015-2019

Self-reported use (daily + occasional) of nicotine productsNorway, 1996-2019

Source: NIPH/SSB/IPSOS

%nicotineusers

Cigarettes CigarettesSnus

Snus

Males Females

1987 20172000 201720001987

Aids used in most recent quit attempt for smokingNorway 1997-2017

SNUS

Quit-line

Web-site

Champix/ZybanGP/Nurse

Snus – not embedded in Tobacco Control Strategy• Small price difference to cigarettes• Overestimation of health risk• Not recommended in smoking cessation• No advertising

• Why the transition from cigarettes to snus?• Passive smoking • Indoor smoking ban

Brr, brr…

Welcome to Norway:- 4 months of frost

Welcome to Sweden:- Sibirian winds

Welcome to Norway:- 200 days of rain

Welcome to Norway – a paradise for bathing and BBQ

12 Euro

Take home message: Stay away fro

m Norway !!

• Scandinavian smokers’ options under indoor smoking bans:• Either acquire survival kit for outdoor smoking….• …or switch to snus

Smokers’ frost-mask

Tired of being left out in the cold?

Get yourself a ‘Smokers’ wall’!Easy to mount

• Scandinavian smokers’ options under indoor smoking bans:• Either acquire survival kit for outdoor smoking….• …or switch to snus

2

7

12

17

22

27

32

37

34 39 44 49 54 59 64 69 74 79

Smok

ing

prev

alen

ce 2

017

Tobacco Control Score (2016)

Smoking prevalence (2017) vs Tobacco Control Score (2016) in EuropeEurobarometer March 2017; 458: 11 & Ass. Eur Cancer Leagues 2017

NorwaySweden

UK

FranceGreece

Finland

Denmark

IrelandIceland

Spain

NetherlandsPoland

Outliers

Conclusions:

• It is unnecessary that smokers (and potential smokers) should risk their life for their nicotine dose

• There are recreational low-risk alternatives available on the nicotine market that can compete with cigarettes

• Where users have a range of options to get their nicotine dose, regulation should facilitate transitions to products with reduced risk• Availability• Correct misperceptions of risk• Risk-proportionate regulation

• Tobacco-harm-reduction will most definitely produce net-benefit to public health

It is difficult for us in tobacco control to realize and accept that e-cigarettes, snus and HnB may have greater potential to make smoking obsolete

than the regulations we have spent a lifetime fighting for

Ignorance ……..

Ignorance is spreading……..

Ignorance is spreading like an epidemic……..

E-mail: [email protected]

We have to think more – and feel less – about tobacco-harm-reduction

Conflict of interest:

- no ties to pharmaceutical or nicotine/tobacco industry

- expert witness in 5 litigation cases against the tobacco industry

- employed by a Government entity answerable to the Ministry of Health and Care Services

E-mail: [email protected]

Topic Opponents Proponents

Political aim: Tobacco-free Society Reduction of smoking related mortality

Alternative nicotine

products:

Therapeutic use only Recreational use will always exist

Nicotine addiction: Unacceptable Acceptable if health risk are low

Regulation/taxation: Restrictive for all nicotine

products

Risk-proportional regulation

Use in smoking

cessation:

No! – might delay cessation Yes! - The potential of making smokers switch

Communicating risk: No nicotine products are

risk-free

The huge misperceptions of relative risk must be

corrected

Contrasting risk: Compare to no nicotine use Compare to smoking

Risk-reduction

potential:

Unknown (no long-term

studies)

Huge (based on toxicological/physiological

testing)

Product innovation: Precaution principle Novel products may outperform cigarettes

Nicotine industry: Can’t be trusted Willing to cooperate

Product palatability: Should demotivate never-

smokers

Should motivate smokers to switch

Future perspectives for reducing smoking related harm ... · Swapping cigarettes for an e-cigarette...

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