Almost three and a half decades after it was created by the World Health Organisation, the World No Tobacco Day this year has discussed the possibility of reducing nicotine in cigarettes to non-addictive levels. The move, in many ways, could have a seismic impact and bring about the most fundamental change in the world tobacco industry and public health.
In the US, over 140 organisations called on governments last week to phase out the sale of all cigarettes, among the signatories the Association of American Cancer Institutes and schools such as the Johns Hopkins Bloomberg School of Public Health. New Zealand is soliciting feedback on a proposal to reduce nicotine levels in cigarettes by 95 percent and eventually phase out the legal sale of cigarettes.
But reducing nicotine in cigarettes to non addictive levels is just one way of looking at the markets. But that might be just the start when it comes to tobacco regulation. Revenues in cigarettes amount to $68 billion in 2021, the market is expected to grow annually by 2.72 percent.
“The idea is to reduce or eliminate addiction. What drives cigarette smoking is becoming addicted to smoking,” said Neal Benowitz, a tobacco addiction researcher at the University of California at San Francisco. Scientists in 2018 said lowering nicotine to minimally addictive levels would result in 5 million smokers quitting within a year and 13 million within five years.
And nicotine reduction could be politically challenging and divisive. And it is here the focus and onus both comes on the World Health Organisation, speakers after speakers highlighted this issue at the recently concluded World E-Cigarette Summit at Washington, a two-day event which was attended by this correspondent from India.
There are over a billion smokers worldwide, over 80 percent of them living in the developing world. The WHO needs to push innovative, effective, and compassionate solutions to accelerate an end to this global epidemic.
First, a near-total ban would create a black market in cigarettes. For example, there could be high potential for a dangerous illicit market if the United States bans all but very low nicotine cigarettes while the rest of the world allows higher nicotine content. Worse, lower-nicotine cigarettes would not, in themselves, be any safer than regular cigarettes.
And then comes another very crucial issue. The speakers said the world needs to have a compassionate and dispassionate approach to vaping? For the record, the UK has taken a compassionate approach to vaping, including for groups for whom there is a very high smoking prevalence, such as people who experience mental health problems, misuse substances and those who experience homelessness.
This approach is also evidence based as e-cigarettes have been shown to be beneficial at an overall population level, particularly if youth uptake is constrained.
Prof Ann McNeil, Professor of Tobacco Addiction, Institute of Psychiatry, Psychology & Neuroscience, King’s College London dwelt on the mindset of today’s cigarette smokers.
She told this reporter that the world tobacco marketplace has changed with the introduction of new nicotine delivery devices. While the public health community has been addressing the dramatic increase of e-cigarette use among youth, FDA recently conducted qualitative research with adult smokers to ascertain their current attitudes and beliefs about cigarettes and other tobacco products.
“Focus group findings underscore that quitting cigarettes remains difficult. Smokers are often navigating multiple barriers to quitting, including stressors, perceived benefits of smoking, and persistent misperceptions about nicotine and addiction. Findings also revealed an increase in the belief that reducing use is an effective strategy for cessation, and there is low motivation among smokers to abstain from nicotine. An opportunity remains to further educate and address these misperceptions to support long-term cessation,” she said.
Kathleen Crosby, Director, Office of Health Communication & Education, FDA Center for Tobacco Products, said stigmatizing smoking has been at the heart of tobacco control efforts for decades, which may drive more people to quit but at the same time potentially create new difficulties for smokers, including self-isolation, creation of social groups that might become ‘hardened’ to changing smoking behaviors, and perceptions by the user and society that complete abstinence is the only option.
“The stigma associated with a wide variety of behaviors has impeded progress toward improving population health in some cases, such as the reticence in making products and services available that could reduce the risk when an individual addicted to a substance is not able to or chooses not to become completely abstinent (eg NRT, ENDS, smokeless tobacco).
“This presentation will explore some of the conflicting aspects of stigma in tobacco control, explore similarities and differences regarding the stigma of using different addicting substances, and consider some research, practice and policy directions,” she said.
Let’s take this discussion forward.
Is the e-cigarette use among adolescent smokers associated with subsequent smoking? Consider this study by Ruoyan Sun, PhD, David Mendez, PhD, and Kenneth E. Warner, PhD demonstrates that when controlling for more potential covariates, the strong and positive relationship between vaping by adolescent never smokers and subsequent trial of cigarettes decreases steadily.
Interestingly, this is the first study to control for both use of other tobacco products and other drugs (marijuana and alcohol in our case), along with commonly included variables. The study had reported reduced associations between vaping and subsequent smoking, adjusting for these covariates. The study also provides empirical evidence that raises questions about the strength of relationship between youth vaping and subsequent trials of cigarettes.
So what should be the public health objectives: Preventing nicotine use or ending smoking?
A myriad of studies find that tobacco control policies targeting e-cigarettes can increase combustible tobacco use, presumably by reducing incentives to choose vaping over smoking. “Given evidence that vaping nicotine is likely far less harmful than smoking combustible cigarettes, these unintended consequences may translate into substantial costs for population health,” Abigail Friedman, Assistant Professor, Department of Health Policy and Management, Yale School of Public Health, said in his speech.
Adolescent substance use, more than e-cigarettes; Assistant Prof Jennifer Pearson, Assistant Professor in Health Administration and Policy, School of Community Health Sciences, University of Nevada, US, says adolescents who are frequent users of multiple substances such as alcohol, marijuana, and cigarettes are at significantly higher risk of negative mental, physical, and substance use outcomes in adulthood, but studies often fail to focus on poly substance use, especially among younger adolescents.
So here comes the big question? Are current e-cigarette policies aligned with health equity goals?
Prof Pearson says much of the current tobacco control agenda is focussed on preventing youth vaping. “I find that I have more questions than answers: Should our focus be on nicotine addiction or combustible use? Is youth vaping similar to youth marijuana use – an experimental phase that will pass? What is the endgame?”
Currently, the e-cigarette marketplace is only partially regulated. The FDA has received millions of applications from manufacturers who want to continue to market their e-cigarettes. The U.S. Courts have required e-cigarette manufacturers to have a marketing authorization from FDA to continue marketing their products after September 9, 2021. So, what is FDA doing to create a regulated e-cigarette marketplace by September? How will the FDA address youth initiation of e-cigarettes? For example, how will FDA determine which flavors and e-cigarette types (e.g., open e- cigarettes) will receive marketing authorization? In addition to minimizing youth initiation of e-cigarettes, how is FDA going to help adult combusted cigarette smokers have access to e-cigarettes that allow them to switch away from smoking to vaping?
Eventually, there needs to be a transition to a regulated marketplace. A paper presented at the summit offered an interesting perspective: “With the PMTA process for ENDS now fully underway, the United States is on the verge of a transformed ENDS marketplace – one in which the products lawfully on the market are there because FDA has reviewed the scientific evidence and found their availability to be appropriate for the protection of public health (APPH), and company marketing is subject to heightened oversight by FDA. The combined efforts of FDA and PMTA applicants have created increased potential for such ENDS determined to be APPH to be embraced by the evidence-based public health community as preferable alternatives to combustion cigarettes – and help make smoking history.”
Speakers said cigarette smoking is commonly viewed as a chronic, relapsing problem requiring long-term, repeated attention and multiple quit attempts. Yet the question of whether e-cigarettes may assist with cessation is often examined with a binary, single event, “all or nothing” lens. There may be advantages of using e-cigarettes within a relapse prevention/recovery of smoking abstinence framework when more adaptively used in targeted, individually tailored situations. There are potential approaches of how e-cigarettes can be used in sequential quit attempts to promote abstinence following smoking lapses; the potential role of transitions in self-identity away from being a “smoker”; and research designs to maximize more targeted and tailored approaches to help identify a role for e-cigarettes.