1. Strategy – what is the purpose of tobacco and nicotine policy?
1.1 What are the goals of tobacco and nicotine policy?
The primary public health policy goal should be the reduction of disease: trying to stop people dying in agony of cancer, collapsing with heart attacks and living in misery with COPD. In practice, this means concentrating on the goal of smoking cessation, especially among middle-aged adults – the population most at risk. There are many possible goals for tobacco/nicotine policy: to improve wellbeing, reduce harm, reduce disease, get rid of smoking, stop all tobacco use, stop nicotine use, protect non-smokers, protect adolescents, destroy the tobacco industry – to name a few. It used to be easy to say “all of the above” and that basically works if cigarettes are dominant and most people want to quit smoking. But with the rise of reduced-risk tobacco and nicotine products, it is no longer so easy because there are important opportunities that are lost if the objectives are indiscriminate. This is because the new products create trade-offs – for example, we can achieve deeper reductions in disease by promoting switching to lower-risk nicotine products, but that might mean more nicotine use. When policymaking demands a priority, the policy should in my view focus primarily on the greatest harms, and these are the major non-communicable diseases.
1.2 What is ‘tobacco harm reduction’?
Tobacco harm reduction is a public health strategy that makes use of regulation, fiscal measures, communications and support services to reduce the harms associated with tobacco or nicotine use, including the secondary harms induced by tobacco or nicotine policy. In practice, this primarily means encouraging smokers or would-be smokers to adopt non-combustible nicotine products such as e-cigarettes rather than combustible, smoking products such as cigarettes. Harm reduction is widely practised in public health, for example in illicit drugs and sexual health, because ‘abstinence-only’ approaches are ineffective. Harm reduction is acknowledged as within the definition of tobacco control in the Framework Convention on Tobacco Control.
1.3 What products are involved?
There are four broad categories of non-combustible consumer nicotine products. Vaping products, heated tobacco products, smokeless tobacco products, and oral nicotine products.
Most of this briefing will concentrate on vaping products, but we have already seen proof-of-concept in Scandinavia with snus (a form of smokeless tobacco) driving smoking down to the world’s lowest level, with clear public health benefits as a result.
1.4 Shouldn’t we aim for a nicotine-free society?
No, no more than we are aiming for an alcohol-free or caffeine-free society (which most of us are not), and definitely not by coercion or prohibition. Almost all societies at present and in history have made quite widespread recreational, ceremonial or spiritual use of psychoactive substances of some sort. Nicotine is not benign but as a recreational drug, it relatively innocuous. It does not cause intoxication, accidents and injuries, violence, physical or sexual vulnerability, hallucinations, incapacitation, incoherence, blackouts, overdoses or social problems like family breakdown or loss of employment. Unlike alcohol, which is linked to serious health risks, nicotine is not a cause of serious disease in its own right.
Societies should take a mature approach to substance use, and acknowledge that nicotine is a legal recreational drug, and that drug prohibitions have severe costs. Once we have recognised that, the challenge is to try to ensure that nicotine is available to adults who want it in its least damaging forms (i.e. not smoking). It is possible that people will eventually choose not to use nicotine and it will wither away by choice and consumer preference. However, an attempt to bring this about by force of law risks the creation of unregulated and irresponsible black markets forming to meet demand.
If there is to be an overarching public health goal, it should be focussed on a ‘smoke-free society’ not a ‘nicotine-free society’. However, in pursuit of any overarching goal, the means are as important as the ends and we should never pursue public health goals by imposing a tyranny against a particular group. Policymakers should resist excessively coercive and punitive measures, reject prohibitionist approaches and take a more enlightened approach to nicotine by suppressing the authoritarian reflexes that have served society so badly in other areas of public health. The idea of a nicotine-free society owes its roots to a War-On-Drugs mindset and that war is not going well. Its origins are in a puritanism that is ineffective and counterproductive for public health in the modern world.
- Abrams D et al. Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives, Annual Review of Public Health, 2018 [link]
1.5 What is the ‘endgame’ for tobacco?
A range of strategies has been proposed for bringing about the end of tobacco – the so-called ‘tobacco endgame’. These include (I paraphrase):
- Outright prohibition
- A cap and trade system: ‘the sinking lid” that steadily reduces the total quantity of tobacco products that can be placed on the market
- A system of raising the age for legal of sale of tobacco by one year every year, thus creating a “the smokefree generation”
- Removing almost all the nicotine from cigarettes and other combustibles
- Nationalising tobacco companies and making them reduce sales
- Regulating tobacco companies to require them to reduce sales by law
A detailed critique of these ideas is included in further reading below. But in summary, these are unlikely to work, mainly because of the degree of coercion and appropriation involved.
A much more plausible endgame would be built on ‘creative destruction’ through market forces. This means the contraction of smoking to very low levels through its technological obsolescence by superior products (vaping etc). This would be achieved by:
- Focussing the endgame on smoking, not on nicotine or tobacco
- Accurately communicating risk and the comparative risk of smoking, vaping and the full range of low-risk products
- Ensuring regulation is proportional to risk and encourages switching from smoking to vaping
- Use of the tax system to incentivise switching
- An approach to regulation that encourages innovation and experimentation with consumer preferences – given the pace of innovation in this field, we have to imagine how the vaping products of 2030 will compete with smoking.
If the alternatives are good enough, there will be no need to prohibit cigarettes. But if they are not good enough it will be very difficult to ban cigarettes. Whatever approach is taken to the endgame, we need really good alternative products.
- Clive Bates. The tobacco endgame: a critical review of the policy ideas, 2015 [link]
- Clive Bates & Carrie Wade. FDA wants to reduce nicotine in cigarettes – what could possibly go wrong (and right)? 2017 [link]
- Attorney General Miller (Iowa) and 17 others, Tobacco Product Standard for Nicotine Level of Combusted Cigarettes, July 2018 [link]