Discussion of tobacco harm reduction with some Irish data mixed in. 29 March 2021

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 smoking…
Smoking prematurely kills
around 5,500 annually in
Ireland
…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 – 2021 Eurobarometer 506 survey
4
Fieldwork - August – September 2020

5. Median lifelong smoker loses 10 years between 73-83…
5
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Years’ observations on male British
doctors. BMJ 2004

6. Risk accumulates over decades – smoking cessation by 40 avoids most mortality risk
6
Doll R, Peto R et aI. Mortality in relation to smoking: 50 Years’ 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
=
€4,550/year
Jobseekers
=
€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. “People smoke for
the nicotine but
die from the tar”
(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;1:1430–3

11. 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
11

12. “[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 smoke”.
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

13. Snus: proof of concept
13

14. European Union smoking prevalence 2017
14
European Commission: Eurobarometer 458, 2017

15. European Union smoking prevalence 2017 - Sweden
Sweden
15
European Commission: Eurobarometer 458, 2017

16. Smoking Disease
16
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

17. Tobacco Free Ireland – ambitious target
17

18. Tobacco free Ireland
18
No progress
Tobacco Free
Ireland launch
Oct 2013

19. Tobacco free Ireland
19
Dec 2025

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 – 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.

22. Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
The strongest evidence for reduced harm is reduced exposure
22
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

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 67:2802–2803.
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

27. “EVALI” E-cigarette and Vaping Product Associated Lung Injury
27

28. “EVALI” E-cigarette and Vaping Product Associated Lung Injury
28

29. American risk communications - Centers for Disease Control & Prevention (CDC)
29

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 ‘triangulates’
• Also, user testimony
• And… it is what you would expect!!
31
Professor Robert West, UCL. Presentation at SRNT-Europe 2019

32. Randomised controlled trial – 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 – 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

34. The public health mechanism
34

35. The public health mechanism 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
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 – a harder look
36

37. Youth vaping in Ireland
• 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
• 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

38. UK experience
38
Low levels of
regular youth
vaping
ASH / YouGov surveys 2013-2020

39. UK experience
39
Vaping concentrated in
young smokers (black
bars)
ASH / YouGov survey 2020

40. E-cigarettes were the most
commonly cited tobacco
product currently used by
27.5% of high school
students (4.1 million)
The US “youth vaping epidemic”
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
≥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. 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 – a harder look
6. Policymaking and perverse consequences
47

48. …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
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
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)
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
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)
51
ASH / YouGov surveys adults 2019

52. 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.”
52
Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative
relative risk message on smokers’ 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

54. Banning e-liquid flavours
54

55. CDC, Tobacco Product Use 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
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 – 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)
• Relapsing back from vaping to smoking – both teenagers and adults
• Not switching from smoking to vaping and continuing to smoke
• 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
• 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
• Initiating smoking instead of initiating vaping
• 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