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Future perspectives for reducing smoking related harm –what have we learnt ?
Karl E. Lund, PhD
Senior Researcher
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• 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
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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
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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
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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….
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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.............
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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
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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......
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Tour de France
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Smoking associated with low SES – vulnerable populations
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Society
has cha
nged and
the sm
okers ha
ve chan
ged
– but the
tobacco
control
policy re
mains
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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
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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:
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Target-group II: Youth susceptible to smoking
Make alternative nicotine products available to.....
ii) “The bad guys”
ii) ....potential smokers.....
Tobacco-Harm-Reduction:
F*** you !!!
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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.
Tobacco-Harm-Reduction:
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ii) “The bad guys” iii) “The good guys”i) The established smokers
Tobacco-Harm-Reduction (THR) - three affected groups:
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THR-products for recreational use (not limited to therapeutic use)
E-cigarettes Heat-not-burnSnus
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Continuum of risk for nicotine containing products
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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),
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Althou
gh the
estim
ate of
5% de
gree is
disput
ed…..
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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…
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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.
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Tobacco-Harm-Reduction converted into real-politics
Step 1: Access to the nicotine market
E-cigarettes banned in more than 30 countries including Brazil, Singapore, Thailand, Mexico, Cambodia, India, Australia…
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Tobacco-Harm-Reduction converted into real-politics
Step 1: Access to the nicotine market
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.
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Step 2: Disseminate accurate information on risk difference
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
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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
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Percentage of smokers believing that nicotine causes most of the cancers in smoking
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How do we communicate risks?
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Tobacco-Harm-Reduction converted into real-politics
Step 1: Access to the nicotine market
Step 2: Disseminate accurate information on risk difference
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
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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
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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”
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…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
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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
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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
?
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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:
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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
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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
Step 1: Allow market access Step 2: Correct inaccurate risk perceptions Step 3: Risk-proportionate regulation
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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 to offset the gain
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
Step 1: Allow market access Step 2: Correct inaccurate risk perceptions Step 3: Risk-proportionate regulation
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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
Risk-use equilibrium
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...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”
Risk-use equilibrium
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If the risk of vaping makes up 5% of the risk from smoking – the answer 20 Risk-use equilibrium
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Former smokers makes up the majority of vapers in the UK
Ex-smoker
Smoker
Never smoker
Source: Smokefree GB Sept 2019
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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
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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
Risk-use equilibrium
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* 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
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Respiratory26%
Cardiovascular35%
Lung Cancer29%
Other cancers8%
Diabetes2%
When smokers die from smoking-related diseases, they die from…
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Respiratory26%
Cardiovascular35%
Lung Cancer29%
Other cancers8%
Diabetes2%
Weak/none
None
None
Weak
Weak
Smoking-related diseases – association with snus use
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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
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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
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Cigarettes CigarettesSnus
Snus
Males Females
1987 20172000 201720001987
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Aids used in most recent quit attempt for smokingNorway 1997-2017
SNUS
Quit-line
Web-site
Champix/ZybanGP/Nurse
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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
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Brr, brr…
Welcome to Norway:- 4 months of frost
Welcome to Sweden:- Sibirian winds
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Welcome to Norway:- 200 days of rain
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Welcome to Norway – a paradise for bathing and BBQ
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12 Euro
Take home message: Stay away fro
m Norway !!
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• Scandinavian smokers’ options under indoor smoking bans:• Either acquire survival kit for outdoor smoking….• …or switch to snus
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Smokers’ frost-mask
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Tired of being left out in the cold?
Get yourself a ‘Smokers’ wall’!Easy to mount
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• Scandinavian smokers’ options under indoor smoking bans:• Either acquire survival kit for outdoor smoking….• …or switch to snus
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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
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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
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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 ……..
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Ignorance is spreading……..
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Ignorance is spreading like an epidemic……..
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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]
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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