Article

Big Tobacco, E-Cigarettes, and a road to the smoking endgame

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Abstract

The provision of the extraordinarily deadly product of cigarettes is dominated by a small number of large and incredibly profitable shareholder owned companies that are focussed on cigarettes. The legal duty of their managers to maximise shareholder wealth means that such companies vigorously fight any new public health measures that have the potential to disrupt their massive profit making, and have the resources to do so. Protecting the public health is therefore made a lot more difficult and expensive. We suggest that one way to counter this would be to actively design future tobacco control policies so that tobacco companies face mechanisms and incentives to develop in such a way that they no longer achieve the greatest shareholder value by focusing on cigarettes. A proper tobacco diversification and exit strategy for the shareholders of the profit-seeking tobacco industry would protect the public health by addressing the current addiction to the continuation of the cigarette market. The increasing popularity of e-cigarettes presents a particular opportunity in this regard, and we therefore suggest a possible policy response in order to start discussion in this area.

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... 9 The independents had strong incentives to market their NVPs as substitutes for cigarettes. 10 Starting in 2012, however, the major cigarette companies entered the NVP market; Lorillard acquired blu, Japan Tobacco acquired Logic, and RJ Reynolds and Phillip Morris developed their own e-cigarettes. 2,11 With high cigarette profits and established customer brand loyalties, 12 the cigarette companies, unlike independents, have financial incentives to protect their cigarette sales from being replaced by NVPs. ...
... Because most NVP purchasers are adult current or former smokers, 7,8 the changes prompted by the FDA's regulation of NVPs are likely to have an impact on cigarette smoking. 10,19 To provide insight into how the FDA's regulation of NVPs could change the NVP market and its impact on cigarette sales and smoking, this paper offers an economic analysis of competition in the US NVP market. With FDA regulations still in transition, we focus on the largely unregulated market prior to deeming to focus on the role of competition in that market. ...
... In addition, profit margins from cigarette firms' sales of NVPs are estimated to be substantially lower than for cigarettes and even negative in some years. 10 In addition to falling prices, competition can be gauged by the lack of coordinated pricing behavior. 20 Substantial variation has been found for Internet prices, 60,78 with heavy advertising of price discounts 79,80 including tweets on price promotions. ...
Article
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Objectives: Public health policies are often enacted without adequate consideration of the existing market structure or their impacts on that market structure. This paper provides context for the potential impact of regulations on nicotine vaping products (NVP) use by providing a structural analysis of competition in the US NVP market before FDA regulation. Methods: A literature review was conducted with the aim of providing a framework for analysis that: 1) defines the market; 2) evaluates market concentration; 3) identifies entry barriers; and 4) examines firm conduct. Results: The NVP market includes retail, internet sellers and vape shops. Although conventional retail became more concentrated after the major cigarette companies entered the NVP market, the vape shop and internet sectors remain substantially less concentrated, producing an overall low market concentration, with few entry barriers and competitive behavior. Conclusions: The largely unregulated US NVP market has been highly competitive, with a high degree of innovation. However, new FDA deeming regulations as applied to NVPs could make it difficult for smaller companies to remain in the market and could discourage new companies and new product innovations from entering the market.
... Quantitative studies report that a low level of TCPs in LMICs is associated with an increasing smoking prevalence (Anderson et al., 2016). For this reason, "developing countries represent key new markets for tobacco companies" (Esson and Leeder, 2004, p. 20), whereas tobacco companies try to establish alternative e-cigarette markets in HICs (Branston and Sweanor, 2016). Esson and Leeder (2004, p. 11), for example, refined the Lopez-model and pointed out that sub-Saharan African (1st stage), North African, and South-East Asian (2nd stage) regions are still at the beginning of the tobacco epidemic. ...
... Thus, we observe global connectedness (horizontality) in terms of market competition and interlinked commodity chains (verticality) between the Global South and North. For the research field of tobacco control at the global level, this could possibly imply that decreasing tobacco industry profits by lowering smoking rates and shifting to e-products (Branston and Sweanor, 2016) in developed high-income markets (social practice) might be a strong predictor for changing circumstances in the Global South (structure) that are caused by the externalization (mechanism) of tobacco-attributable production and consumption cycles (Graen, 2014(Graen, , 2015. ...
... In contrast to Lessenich's (2016, p. 60-76;2018, p. 41-53) third definition of externalization as a social practice (everyday habitus caused by consumption habits of ordinary individuals in HICs) and the idea of a potential "rebound effect" on HICs, tobacco control research does not support such a thesis. One could assume that a stronger shift to e-products by consumers in HICs (Branston and Sweanor, 2016) is associated with an increase in tobacco consumption among youth and female individuals in LMICs (Eriksen et al., 2015;Gilmore et al., 2015), although such a relationship needs to be studied by other methodological means. However, in the outcomes of health policy environments and tobacco production cycles, externalization theory's central idea of unequal exchange and exploitation is evident since TTCs and intermediate third parties (e.g., suppliers and governments) exploit vulnerable positions in the Global South to accumulate capital and maximize profit (Gilmore et al., 2015;Lee et al., 2012). ...
Article
Externalization theory assumes that risks and costs are systematically displaced from high-income countries (HICs) to low- and middle-income countries (LMICs). We review how and why transnational tobacco companies (TTCs) influence the local circumstances of LMICs that trigger externalization mechanisms, leading to tobacco-attributable risk outcomes. Our realist synthesis of scientific evidence and gray literature identifies externalization mechanisms with risk outcomes at the level of health policy, smoking trends, and tobacco production. The results reveal the mediating role of local and global third parties and intermediaries. Externalization mechanisms produce systematic tobacco-attributable inequalities between places located in HICs and those located in LMICs.
... In contrast to this scenario, decades of misleading debates on tobacco dangers stemmed by 'Big tobacco' (e.g. Branston and Sweanor 2016;Friedman et al. 2015), has been followed by an era where tobacco is now a top priority for public health and safety organizations (Tanigaki and Poudyal 2019;Wagener et al. 2016). The recent upsurge in consumption due to the rising popularity of e-cigarettes has without a doubt furthered this trend (Branston and Sweanor 2016;Saebø and Scheffels 2017). ...
... Branston and Sweanor 2016;Friedman et al. 2015), has been followed by an era where tobacco is now a top priority for public health and safety organizations (Tanigaki and Poudyal 2019;Wagener et al. 2016). The recent upsurge in consumption due to the rising popularity of e-cigarettes has without a doubt furthered this trend (Branston and Sweanor 2016;Saebø and Scheffels 2017). For its part, cannabis rests somewhat in the middle; Western societies neither seem to fully normalize nor fully stigmatize the drug (Asbridge et al. 2016). ...
Article
In the last decade, there has been a significant surge in cannabis legalization, with Uruguay (2013), Canada (2018) and 19 U.S. states (2012-2022) having developed recreational cannabis policies. A growing literature analyzes legalization from a policymaking or public health standpoint. Yet only few studies have explored its discursive component . This article contributes to filling this gap by developing conceptual tools for cannabis policy discourse analysis. I first examine the history of cannabis policy in North America and find two main discursive clusters, i.e., moral and epistemic discourse. I then discuss existing typologies of cannabis regulation models and select that of Beauchesne, which distinguishes between three models: prohibition 2.0, public health and harm reduction, and commercialization. At the intersection of discursive clusters and these regulation models, I identify six mutually exclusive frames of cannabis policy: moral panic, medical/health, reparations/vulnerabilities, harm reduction/risk mitigation, laissez-faire/liberalism, and illicit market/revenue.
... [3][4][5][6] Such profitability has been highlighted as a key driver of the global tobacco epidemic given that public tobacco companies have a fiduciary duty to continue to seek profits for their shareholders, which currently means selling deadly tobacco products. 7,8 Furthermore, two of the four major TTCs are based in the UK, a very profitable tobacco market in its own right, 9,10 and where all four have significant market shares. In 2017, £9.5bn was generated in excise duty from the sale of tobacco products in the UK, 11 while the UK Department of Health estimated the cost of smoking to the economy was in excess of £11bn per year in England alone 12 (84% of the total UK population) and other estimates suggest an even higher cost. ...
... This larger surcharge could be applied only on the profits from combustion tobacco sales, with a smaller surcharge applying to profits from electronic nicotine delivery systems (ENDS) in an attempt to reflect their relative harm and encourage a corporate shift away from combustible tobacco. 8,71 Limitations of this study ...
Article
Background: A key driver of the global tobacco epidemic is the massive profit earned from manufacturing tobacco products despite high levels of product taxation. Two of the four major Transnational Tobacco companies are based in the UK, where there is growing evidence of corporate tax avoidance by transnational firms and where there are calls for the industry to pay more towards the harms caused by tobacco products. Objectives/methods: UK tobacco company profit and corporation tax data between 2009 and 2016 is obtained from publically available sources. The intention is not to perform a piece of forensic accounting but to establish the broad pattern of profit and taxation in order to inform consideration of tobacco product and firm taxation, and hence public health. Results: Very little profit based taxation has been paid in the UK despite high levels of reported profits, both in the domestic market and globally. Conclusions: The UK needs better reporting and corporate taxation standards. Tobacco companies should be made to pay more profit based taxation, such as by extending the surcharge on corporation tax currently paid by UK banks, and by making sure companies pay appropriate taxes when reorganizing corporate structures.
... For instance, in 2015 the combined profit after taxation of the four transnational tobacco companies (TTC) British American Tobacco (BAT), Philip Morris International (PMI), Japan Tobacco (JT), and Imperial Brands was US$20bn (£13bn) (3)(4)(5)(6). Such profitability has been highlighted as a key driver of the global tobacco epidemic given that public tobacco companies have a fiduciary duty to continue to seek profits for their shareholders, which currently means selling deadly tobacco products (7,8). Furthermore, two of the four major TTCs are based in the UK, a very profitable tobacco market in its own right (9,10), and where all four have significant market shares. ...
... The intention should be to increase this rate (over time) to ensure that the companies more meaningfully meet the societal costs they are responsible for. This larger surcharge could be applied only on the profits from combustion tobacco sales, with a smaller surcharge applying to profits from reduced risk products in an attempt to reflect their relative harm and encourage a corporate shift away from combustible tobacco (8,72). ...
Article
Background: A key driver of the global tobacco epidemic is the massive profit earned from manufacturing tobacco products despite high levels of product taxation. Two of the four major Transnational Tobacco companies are based in the UK, where there is growing evidence of corporate tax avoidance by transnational firms and where there are calls for the industry to pay more towards the harms caused by tobacco products. Objectives/Methods: UK tobacco company profit and corporation tax data between 2009 and 2016 is obtained from publically available sources. The intention is not to perform a piece of forensic accounting but to establish the broad pattern of profit and taxation in order to inform consideration of tobacco product and firm taxation, and hence public health. Results: Very little profit based taxation has been paid in the UK despite high levels of reported profits, both in the domestic market and globally. Conclusions: The UK needs better reporting and corporate taxation standards. Tobacco companies should be made to pay more profit based taxation, such as by extending the surcharge on corporation tax currently paid by UK banks, and by making sure companies pay appropriate taxes when reorganising corporate structures.
... The control of tobacco may be addressed properly to create awareness among them and proper measures should be taken to prevent smoking among the young population. About the minors' cigarette buying pattern that though the sale of tobacco products to youth is prohibited by the law (Barkat, 2012). However, minors have little trouble purchasing cigarettes, with more than one third (38.3%) of age (13-15) year old reporting they are buying cigarettes in stores. ...
Article
Full-text available
Though there is a tendency among teenagers to not care about the adverse effect of tobacco but long-term smoking causes a serious problem in health. The objective of this study is to explore the prevalence, perception and awareness of minors and adolescents on cigarette selling and buying in Bangladesh. In this study, a quantitative oriented qualitative method has been used. The study reveals that overall 63% of the respondents are currently smoking. The proportion of smoking among the buyers is significantly higher (p<0.001) than sellers. A higher majority of the participants (93%) perceived that selling cigarette to minors is not good practice. A majority of the buyers (79%) and sellers (85%) have never been prevented from buying and selling cigarettes in the respective areas by any authorized personnel or even the general public. Majority of the respondents (86%) have no knowledge about any law on tobacco control in the country. About one quarter of the respondents (24%) perceived that the main causes of non-implementation of the law are the citizens' reluctance to obey and negligence of the concerned authority to implement the law. It also explores that a tendency to get rid of from frustration is the main reason to smoke tobacco. The findings suggest that an awareness building program should be launched by the government including NGOs, academic institutes and voluntary organizations to raise awareness on the bad effects of tobacco.
... In 2019, manufacturers will be required to submit quantities of harmful and potentially harmful chemicals to the FDA Center for Tobacco Products. The FDA and MFDS both prohibit selling e-cigarettes to people who are under 18 in the U.S. and 19 in South Korea (Branston & Sweanor, 2016). However, data analysis revealed that most of the South Korean and U.S. e-cigarette websites did not mention that ecigarettes can only be sold to individuals who are over 18 in the U.S. and 19 in South Korea. ...
Thesis
Electronic cigarettes (e-cigarettes) are battery-powered devices that create artificial smoke containing nicotine and carcinogens. Research has found that e-cigarettes negatively impact the health of users as well as nonusers. Although the Food and Drug Administration (FDA) in the U.S. and the Ministry of Food and Drug Safety (MFDS) in South Korea currently regulate e-cigarettes, these regulations do not extend to online marketing of these misunderstood products. Through the lens of framing theory, the purpose of this study was to explore, analyze, and compare how e-cigarettes are marketed online in South Korea and the U.S. This study analyzed 55 South Korean e-cigarette websites and 95 U.S. e-cigarette websites. Each website was coded for 14 criteria, including age confirmation, framing variables, use of cultural heuristics, and social media connection. This study concluded that South Korean and U.S. e-cigarette websites generally ignore the important health risks associated with their products. In addition, important cultural differences in marketing strategies were found. Implications extend to important aspects of public practice.
... In addition, transitions may vary over time for individual cohorts. As individuals within a cohort age, their vaping patterns may depend not only on current use and public policies, but also previous use and policies [37,[52][53][54][55]. Longitudinal studies will be needed to track these cohort-specific patterns. ...
Article
Background and aims The long‐term population health impact of nicotine vaping products (NVPs) use among smokers is unknown, and subject to a range of plausible assumptions about the use and health consequences of NVPs. While NVPs use may substitute for cigarette smoking and thereby aid in quitting cigarette use, it is also possible that smokers who would have otherwise quit would instead delay quitting cigarettes. We aimed to develop a cohort‐specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life years lost (LYL). Design A cohort‐specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life years lost (LYL) was developed by gender for two birth cohorts, aged 30 and 50 years in 2012. Extensive sensitivity analyses were conducted. Setting United States. Participants Smokers in two birth cohorts, aged 30 and 50 years in 2012. Measurements Data were from the 1965–2012 National Health Interview Surveys and the 2014/15 Tobacco Use Supplement of the Current Population Survey. The model incorporated a range of plausible assumptions from published literature about transition rates from regular smoking to exclusive NVP and dual use, from dual use to exclusive NVP use and from exclusive NVP use to no use. Findings Compared with the no‐NVP scenario, the male (female) model projected 17.8% (19.3%) fewer PDs and 22.9% (26.6%) fewer LYL for the 1982 cohort and 5.4% (7.3%) fewer PDs and 7.9% (11.4%) fewer LYL for the 1962 cohort. These gains were sensitive to NVP use over time, age of initial NVP use, transitions from smoking to dual, exclusive NVP and no use and relative NVP mortality risks. Conclusions Nicotine vaping product (NVP) use in the United States is projected to have a net positive impact on population health over a wide range of plausible levels of NVP use, transitions to dual, exclusive NVP and no use and NVP risks. However, net impact is sensitive to parameter estimates.
... Yet, as for any corporation, the fiduciary imperative remains. The TI, whatever the improvements in its products, will always prioritise decisions on the basis of profitability and corporate growth (Branston & Sweanor, 2015). From a critical public health perspective, the concern here is that the interests of the investors will always be preferred if the 'win-win-win' for society, customers, and shareholders hits problems. ...
Article
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The tobacco market has been transformed by the arrival of e-cigarettes and array of alternative nicotine delivery systems (ANDS). Public health has struggled to cope with these changes and clear divisions are apparent, but less is known about the tobacco industry (TI) response. This first empirical study to examine TI and independent ANDS companies’ business strategies fills this gap. Primary data were collected through 28 elite interviews with senior/influential TI and independent stakeholders, triangulated with a documentary analysis of company reports, investor analyses, market research, and consultation responses (1022 documents). A deliberately emic analysis shows that tobacco multinationals were initially disconcerted by ANDS, but logic provided by the fiduciary imperative is enabling them to turn a potential threat into profitable opportunities. Interviewees argue market changes played to their strengths: customer links, expertise in nicotine, and enormous financial resources. This enabled portfolio diversification in which combustible and ANDS coexist; providing potential to develop robust scientific and regulatory positions and hope of retrieving corporate reputations. The principal threat for major tobacco players comes from the independent sector, which is prepared and able to satisfy bespoke consumer needs. Multinationals by contrast need to turn ANDS into a genuinely mass-market product appealing to its global customers. They are making progress. Given the continued buoyancy of the combustibles market, they have extensive resources to continue their efforts. Disruptive innovations are not unique to tobacco control. Equivalent technological solutions – with concomitant business opportunities − are emerging in obesity and alcohol fields with implications for public health.
... Instead, use can be influenced by such as product appeal, handiness, flavours, price, accessibility, device characteristics and risk perceptions Weier, 2018). addition, the generally mistrusted tobacco industry's increasing involvement in the e-cigarette market, through buying up brands and creating their own versions, serve as an additional complicating factor (Branston & Sweanor, 2016;Kamerow, 2013). ...
Thesis
Full-text available
The e-cigarette has made the contemporary nicotine and tobacco landscape more complex. The use of e-cigarettes, called vaping, was initially promoted to help people stop smoking, however, is currently also associated with alternative user motives, attractiveness to young people, split-risk approaches and divergent legislation. In this dissertation, the aim is to examine the culture of vaping and social meaning of e-cigarettes in Norway. Drawing on multiple data sources and sociological lenses, the thesis shows various processes of meaning making and user patterns among adults who have experienced the increasing stigma of smoking, and adolescents growing up in the post-smoking era. The thesis identify several co-existing cultures, including: a vaper culture associated with ex-smokers' substitute use, a vaper subculture were e-cigarettes represents more complex lifestyle products, and a youth vaper culture marked by experimentation. http://urn.nb.no/URN:NBN:no-89070
... Of particular interest are tobacco endgame policies adopted by a few countries including Finland [93,94]. The goal of the Tobacco-free Finland 2030 Network is to create a tobacco-and nicotine-free country [95]. ...
Article
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Background: The Nature Step to Respiratory Health was the overarching theme of the 12th General Meeting of the Global Alliance against Chronic Respiratory Diseases (GARD) in Helsinki, August 2018. New approaches are needed to improve respiratory health and reduce premature mortality of chronic diseases by 30% till 2030 (UN Sustainable Development Goals, SDGs). Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends. Planetary health and human health are interconnected, and both need to be considered by individuals and governments while addressing several SDGs. Results: The concept of the Nature Step has evolved from innovative research indicating, how changed lifestyle in urban surroundings reduces contact with biodiverse environments, impoverishes microbiota, affects immune regulation and increases risk of NCDs. The Nature Step calls for strengthening connections to nature. Physical activity in natural environments should be promoted, use of fresh vegetables, fruits and water increased, and consumption of sugary drinks, tobacco and alcohol restricted. Nature relatedness should be part of everyday life and especially emphasized in the care of children and the elderly. Taking "nature" to modern cities in a controlled way is possible but a challenge for urban planning, nature conservation, housing, traffic arrangements, energy production, and importantly for supplying and distributing food. Actions against the well-known respiratory risk factors, air pollution and smoking, should be taken simultaneously. Conclusions: In Finland and elsewhere in Europe, successful programmes have been implemented to reduce the burden of respiratory disorders and other NCDs. Unhealthy behaviour can be changed by well-coordinated actions involving all stakeholders. The growing public health concern caused by NCDs in urban surroundings cannot be solved by health care alone; a multidisciplinary approach is mandatory.
... We recognise that there are arguments that commercial supply methods are the only viable systems, 63 or that moving profit incentives towards less harmful products is more realistic than removing profits. 64 Current non-specialist retailers of tobacco products may also challenge the goals and principles set out, given the widespread (though arguably erroneous) view that tobacco is essential to the survival of their business. [65][66][67] The framing of tobacco and nicotine supply in media and policy discussions will be important in helping create support for policy change. ...
Article
There is a growing literature on regulating the supply of tobacco products to achieve tobacco-free goals. This article suggests three goals and eight principles that could underpin regulatory approaches to the supply of tobacco and non-prescription nicotine products. The primary principles are that tobacco and nicotine products should not be seen as normal consumer products, should not be supplied for profit, and that the tax revenue from the supply of the products should first be used to reduce tobacco and nicotine use.
... How many recreational users of snus or vape would avoid cigarettes completely could be influenced by accurate information and appropriate marketing. Until differential marketing according to risks is actually implemented (Branston & Sweanor, 2016;Chaloupka, Sweanor, & Warner, 2015;Kozlowski, 2007), it is hard to know the impact that products like SLT or vaping could have on cigarette use. But it is unethical as well as lacking a scientific basis to maintain that there is so Page 14 of 23 A c c e p t e d M a n u s c r i p t little reason to believe that consumers would respond to adequate information on differential risks that there is no point in even considering removing their blindfold. ...
Article
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The United States provides an example of a country with (a) legal tobacco/nicotine products (e.g., snus, other smokeless tobacco, cigarettes) differing greatly in risks to health and (b) respected health information websites that continue to omit or provide incorrect differential risk information. Concern for the principles of individual rights, health literacy, and personal autonomy (making decisions for oneself), which are key principles of public health ethics, has been countered by utilitarian arguments for the use of misleading or limited information to protect public health overall. We argue that omitting key health relevant information for current or prospective consumers represents a kind of quarantine of health-relevant information. As with disease quarantines, the coercive effects of quarantining information on differential risks need to be justified, not merely by fears of net negative public health effects, but by convincing evidence that such measures are actually warranted, that public health overall is in imminent danger and that the danger is sufficient to override principles of individual autonomy. Omitting such health-relevant information for consumers of such products effectively blindfolds them and impairs their making informed personal choices. Moral psychological issues that treat all tobacco/nicotine products similarly may also be influencing the reluctance to inform on differential risks. In countries where tobacco/nicotine products are legally sold and also differ greatly in disease risks compared to cigarettes (e.g., smokeless tobacco and vape), science-based, comprehensible, and actionable health information (consistent with health literacy principles) on differential risks should be available and only reconsidered if it is established that this information is causing losses to population health overall.
Article
The game of tobacco use began in Europe in 1560 when the first tobacco seeds were sent from Lisbon to the king of France, by Jean Nicot. From kings' and nobles' exclusive use, it gradually and progressively became popular among the public, as a new player. Eighty-eight years ago (1929), Fritz Linkint, an extraordinary researcher in Germany, while reviewing existing evidence regarding a wide range of cancers potentially caused by smoking, indicated that smoking was a cause of respiratory disease. Despite the overwhelming accumulated evidence of the negative effects of nicotine intake, the prevalence of tobacco use is not expected to decline in the near future. What have we missed thus far in the game that claims more than seven million deaths annually worldwide? Although tobacco use is recognized as a major health problem, the persistent habit creates a dissonance between public health initiatives to reduce tobacco consumption and the choices citizens are making. To understand this dissonance, consideration first must be given to the social meaning attributed to smoking. Second, the political dissonance between health imperatives and social agendas is discussed with regard to relevant theory. Third, health promotion strategies can make a strong contribution to win the game from a negentropic perspective, that is to say, a public health vision that is structured towards an overarching goal.
Article
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Introduction US tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use (‘vaping’) in the USA to accelerate tobacco control progress. Methods A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts. Findings Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016. Conclusions The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.
Article
Some supporters of electronic cigarettes have argued that they should be considered a form of harm reduction, analogous to that which has been successful with narcotics. In this viewpoint, we contend that this argument is based on highly selective use of the evidence, coupled with a fundamental misunderstanding of a comprehensive harm minimisation strategy. This includes not only harm reduction but also reduction in demand and supply-two elements that are explicitly rejected by many advocates of electronic cigarettes. We contend that, in the absence of all three elements, there is a danger that electronic cigarettes will delay the achievement of a tobacco-free world.
Technical Report
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We have previously pointed towards the extreme profitability of the UK tobacco manufacturing/import market (henceforth tobacco market) when suggesting that the public interest would be served by regulating tobacco companies using utility company style pricecaps (Gilmore et al.,2010; Branston and Gilmore, 2014). The profitability of the tobacco industry is now topical as the current UK government, and the main opposition Labour party, have both outlined plans for a levy on the UK tobacco industry. The basic idea is that the industry should explicitly pay more towards the costs their products impose upon society and which are currently born by all taxpayers. Implicit within this idea is that the industry is earning significant profits from which a fuller contribution could be made towards the societal costs engendered. Thus, we seek to examine the current profitability of the UK market and comment upon the different possibilities that exist for such a levy since the details are not yet fixed.
Article
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Objectives: We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users. Methods: Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years. Results: Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18-24 (14.2%) was higher than adults 25-44 (8.6%), 45-64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers. Conclusions: There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.
Article
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Electronic cigarettes are a recent development in tobacco harm reduction. They are marketed as less harmful alternatives to smoking. Awareness and use of these devices has grown exponentially in recent years, with millions of people currently using them. This systematic review appraises existing laboratory and clinical research on the potential risks from electronic cigarette use, compared with the well-established devastating effects of smoking tobacco cigarettes. Currently available evidence indicates that electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes. Research will help make electronic cigarettes more effective as smoking substitutes and will better define and further reduce residual risks from use to as low as possible, by establishing appropriate quality control and standards.
Article
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To characterize e-cigarette use, users and effects in a sample of Electronic Cigarette Company (TECC) and Totally Wicked E-Liquid (TWEL) users. Online survey hosted at the University of East London with links from TECC/TWEL websites from September 2011 to May 2012. Online questionnaire. One thousand three hundred and forty-seven respondents from 33 countries (72% European), mean age 43 years, 70% male, 96% Causacian, 44% educated to degree level or above. Seventy-four percent of participants reported not smoking for at least a few weeks since using the e-cigarette and 70% reported reduced urge to smoke. Seventy-two percent of participants used a ‘tank’ system, most commonly, the eGo-C (23%). Mean duration of use was 10 months. Only 1% reported exclusive use of non-nicotine (0 mg) containing liquid. E-cigarettes were generally considered to be satisfying to use; elicit few side effects; be healthier than smoking; improve cough/breathing; and be associated with low levels of craving. Among ex-smokers, ‘time to first vape’ was significantly longer than ‘time to first cigarette’ (t1104 = 11.16, P < 0.001) suggesting a lower level of dependence to e-cigarettes. Ex-smokers reported significantly greater reduction in craving than current smokers (χ21 = 133.66, P < 0.0007) although few other differences emerged between these groups. Compared with males, females opted more for chocolate/sweet flavours (χ21 = 16.16, P < 0.001) and liked the e-cigarette because it resembles a cigarette (χ23 = 42.65, P < 0.001). E-cigarettes are used primarily for smoking cessation, but for a longer duration than nicotine replacement therapy, and users believe them to be safer than smoking.
Article
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Objective: A system of price-cap regulation has previously been suggested to address the market failure inherent to the tobacco industry. This would benefit public health directly (eg, by making it extremely difficult for the industry to sell cut-price cigarettes, or use price as a marketing strategy) and indirectly (eg, by reducing the available money the industry has for spending on marketing and lobbying). This paper explores the feasibility of applying such a scheme in the UK. Methods: The impact of price-capping is modelled using optimistic and conservative scenarios, each with different assumptions, and using 2009 and 2010 profit data for the major companies selling tobacco in the UK. The models are used to calculate by how much would profit be reduced through the imposition of price caps, and thus, how much revenue could be raised in additional taxes, assuming the end price the consumer pays does not change. Results: Tobacco companies enjoy massive profit margins, up to 67%, in the UK. The optimistic scenario suggests a potential increase in UK tobacco tax revenue of £585.7 million in 2010 (£548.4 million in 2009), while the conservative model suggests an increase in revenue of £433.6 million in 2010 (£399.2 million in 2009). This would be approximately enough to fund, twice over, UK-wide antitobacco smuggling measures, and smoking cessation services in England, including the associated pharmacotherapies, to help people stop smoking. Conclusions: Applying a system of price-cap regulation in the UK would raise around £500 million per annum (US$750 million). This is likely to be an underestimate because of cautious assumptions used in the model. These significant financial benefits, in addition to the public health benefits that would be generated, suggest this is a policy that should be given serious consideration.
Article
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Electronic nicotine delivery systems (ENDS, also called electronic cigarettes or e-cigarettes) are marketed to deliver nicotine and sometimes other substances by inhalation. Some tobacco smokers report that they used ENDS as a smoking cessation aid. Whether sold as tobacco products or drug delivery devices, these products need to be regulated, and thus far, across countries and states, there has been a wide range of regulatory responses ranging from no regulation to complete bans. The empirical basis for these regulatory decisions is uncertain, and more research on ENDS must be conducted in order to ensure that the decisions of regulators, health care providers and consumers are based on science. However, there is a dearth of scientific research on these products, including safety, abuse liability and efficacy for smoking cessation. The authors, who cover a broad range of scientific expertise, from basic science to public health, suggest research priorities for non-clinical, clinical and public health studies. They conclude that the first priority is to characterize the safety profile of these products, including in long-term users. If these products are demonstrated to be safe, their efficacy as smoking cessation aids should then be tested in appropriately designed trials. Until these studies are conducted, continued marketing constitutes an uncontrolled experiment and the primary outcome measure, poorly assessed, is user health. Potentially, this research effort, contributing to the safety and efficacy of new smoking cessation devices and to the withdrawal of dangerous products, could save many lives.
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Mainstream economic theory outlines four main causes of market failure and it is already well established that two of these (information failure and externalities) exist in a tobacco market. A third cause of market failure, market power, is also a serious problem in many tobacco markets. Market power--combined with unintended and often overlooked consequences of tobacco tax policies, notably that gradual increases in specific taxes may allow the industry to disguise significant price increases--has, at least in high income countries, given cigarette manufacturers considerable pricing power and profits. This paper examines ways this market failure could be addressed and proposes as a solution a system of price cap regulation wherein a cap is placed on the pre-tax cigarette manufacturers' price but not on the retail price that consumers face. Well established in the utilities industry, price cap regulation would set a maximum price that cigarette companies can charge for their product based on an assessment of the genuine costs each firm faces in its operations and an assumption about the efficiency savings it would be expected to make. Such a system would achieve three main benefits. First, it would address the problem of market failure and excess profits while simultaneously allowing current tobacco control policies, including tax and price increases, to expand--thus tax increases would remain a central tenet of tobacco control policies and retail prices could continue to increase. Second, it would increase government revenue by transferring the excess profits from the industry to the government purse. Third, it would bring numerous public health benefits. In addition to addressing market power, while simultaneously allowing tobacco control policies to expand, it could offer a means of preventing down-trading to cheaper products and controlling unwanted industry practices such as cigarette smuggling, price fixing and marketing to the young. The paper outlines in some detail how such a system might be developed in the UK, while briefly exploring how it could be applied elsewhere, including in markets with state monopolies.
Article
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Regulation of nicotine levels in cigarettes and other tobacco products is now possible with the passage of the Family Smoking Prevention and Tobacco Control Act (FSPTCA) in 2009, giving the US Food and Drug Administration (FDA) authority to regulate tobacco products, and with Articles 9-11 of the WHO Framework Convention on Tobacco Control. Both regulatory approaches allow establishing product standards for tobacco constituents, including nicotine. The FSPTCA does not allow nicotine levels to be decreased to zero, although the FDA has the authority to reduce nicotine yields to very low, presumably non-addicting levels. The proposal to reduce levels of nicotine to a level that is non-addicting was originally suggested in 1994. Reduction of nicotine in tobacco products could potentially have a profound impact on reducing tobacco-related morbidity and mortality. To examine this issue, two meetings were convened in the US with non-tobacco-industry scientists of varied disciplines, tobacco control policymakers and representatives of government agencies. This article provides an overview of the current science in the area of reduced nicotine content cigarettes and key conclusions and recommendations for research and policy that emerged from the deliberations of the meeting members.
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Objective: To outline a novel strategy for controlling the tobacco market. Arguments: More comprehensive controls over the tobacco market are essential and long overdue. Effective controls need to encourage the development of less harmful products; control commercial communication to ensure that potential harms are highlighted relative to any benefits; and provide mechanisms to move consumers away from tobacco use, or at least towards less harmful alternatives. Achieving this by regulating the existing industry is one strategy. This paper puts the case for an alternative: to have marketing controlled by an agency (called here the Tobacco Products Agency, or TPA) which tendered to manufacturers for product and which distributed to retailers in ways that reduce incentives to bend or break the law. The TPA would be backed by legislation that made tobacco a controlled substance with possession sale and use only allowed as permitted by the regulations, which in reality would be only as provided by the TPA. Conclusions: The overall effect of such a model, which we call a "regulated market model", would be to eliminate most of the incentives and remaining opportunities for commercial promotion of tobacco and to create incentives to encourage the development of less harmful tobacco products. Such a model preserves the competition inherent in a free market, but directs it towards the challenge of reducing the harm from tobacco use.
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Current tobacco control strategies seek primarily to decrease the demand for cigarettes through measures that encourage individuals to adopt healthier behaviours. These measures are impeded and undermined by tobacco corporations, whose profit drive compels them to seek to maintain and expand cigarette sales. Tobacco corporations seek to expand cigarette sales because they are for-profit business corporations and are obliged under law to maximise profits, even when this results in harm to others. It is not legally possible for a for-profit corporation to relinquish its responsibility to make profits or for it to temper this obligation with responsibilities to support health. Tobacco could be supplied through other non-profit enterprises. The elimination of profit driven behaviour from the supply of tobacco would enhance the ability of public health authorities to reduce tobacco use. Future tobacco control strategies can seek to transform the tobacco market from one occupied by for-profit corporations to one where tobacco is supplied by institutions that share a health mandate and will help to reduce smoking and smoking related disease and death.
Article
In the face of a rapidly evolving nicotine-product marketplace, policymakers could consider differentially taxing these products to maximize incentives for tobacco users to switch from the most harmful products to the least harmful ones.
Article
Two contrasting viewpoints by Stimson and Chapman in this edition illustrate the divisions in the public health community over e-cigarettes. Stimson argues that we should embrace and promote e-cigarettes, while Chapman highlights the pitfalls of this simplistic approach. Such contrasting views are perhaps inevitable given the infant evidence base surrounding this rapidly emerging technology, but the consequent uncertainty about the population impacts of e-cigarettes should preclude an overly firm stance either for or against—as we outline below, it is simply too early to know. Two key questions surround this debate: are e-cigarettes an opportunity or threat to public health and how can we ensure benefits are maximized and harms minimized? As Michael Russell wrote in 1976, ‘people smoke for the nicotine but they die from the tar’. E-cigarettes deliver the nicotine without the tar, as their use involves no combustion. Common sense therefore dictates that e-cigarettes are significantly less harmful than cigarettes, and for the individual smoker who cannot or does not want to quit, there is little doubt that switching to e-cigarettes will be beneficial. The population-level impacts, however, are far less certain. If taken up only by smokers or those who would otherwise have taken up smoking and if effective as a cessation aid, e-cigarettes will undoubtedly be a force for good. Conversely, if the heavy marketing of e-cigarettes, which has been found …
Article
Gerry Stimson chides the health and medical communities for what he sees as deplorable lack of leadership in embracing and supporting the rising popularity of electronic cigarettes as a harm reduction tool. He thinks a lot of this has to do with those who have worked all their professional lives in tobacco control feeling blind-sided by a disruptive technology that we had nothing to do with. We are apparently so gracelessly self-absorbed and small-minded in maintaining support for the glacial pace of our woefully inept suite of comprehensive tobacco control policies (now embraced by a mere 178 nations via the World Health Organization’s Framework Convention on Tobacco Control), that we need to ‘soberly reflect’ on our myopia and sound the trumpets for a driver of cessation and harm reduction of such promise that the world has never seen. His essay has a lot to say about the dramatic rise in ‘popularity’ of e-cigarettes and their promise in turbo-charging smoking cessation. However, amazingly, it …
Article
The recent study by Goniewicz and colleagues1 points to the increasing popularity of electronic cigarettes among people who want to quit smoking, adds to the growing scientific evidence about their real-world use and in turn raises questions about their potential to reduce smoking-related disease. Smoking is the leading cause of preventable death and disease globally, associated with nearly 6 million deaths annually; in the European Union smoking rates average 29% of the adult population, with 700 000 premature deaths each year. Most smokers want to quit smoking but find it hard to give up nicotine. Progress with reducing smoking continues, but the pace is slow. It is hard to see how the current non-communicable disease burden can be met without a drastic reduction in smoking prevalence. It is also hard to see how that can come about with current anti-smoking measures. The package of interventions in the European Tobacco Products Directive, including large health warnings and bans on small packs, is on the evidence of the European Commission’s own impact assessment likely to reduce tobacco consumption only by ∼2% over 5 years, which translates into ∼0.5% decline in prevalence in that time. Elsewhere, similarly modest historical gains have …
Article
In 2003, I published a paper in this journal1 arguing for the consideration of a regulated market model (RMM) for tobacco, a mechanism by which the mass marketing, but not manufacture, of tobacco products would be taken out of the hands of for-profit companies and given to an agency with a harm reduction charter. This agency would determine what was sold and under what conditions, and retailers would effectively become its agents. In that time, nobody has identified any conceptual flaw in the model. The arguments against it are that it would not happen (true if no-one argues for it), that regulation is anathema to governments, that it would put government in the embarrassing position of selling harmful products (the paper suggested government control of the agency but that is not essential), that the proposal lacks advocacy appeal as it is a mechanism rather than a solution, and that to pursue it would divert limited energy from more conventional solutions.2 This critique assumes that we will be able to achieve everything we want with the continuation and expansion of current strategies, something I doubt.3 4 The paper had some effects. It was a stimulus to Callard and colleagues5 6 to develop a model which would operate outside of government control and was among the first of what is now a steady stream of thinking about endgame solutions.7–12 The big questions are whether radical solutions are required for the tobacco problem and whether …
Article
To assess the profile, utilization patterns, satisfaction and perceived effects among users of electronic cigarettes ('e-cigarettes'). Internet survey in English and French in 2010. Online questionnaire. Visitors of websites and online discussion forums dedicated to e-cigarettes and to smoking cessation. There were 3587 participants (70% former tobacco smokers, 61% men, mean age 41 years). The median duration of electronic cigarette use was 3 months, users drew 120 puffs/day and used five refills/day. Almost all (97%) used e-cigarettes containing nicotine. Daily users spent $33 per month on these products. Most (96%) said the e-cigarette helped them to quit smoking or reduce their smoking (92%). Reasons for using the e-cigarette included the perception that it was less toxic than tobacco (84%), to deal with craving for tobacco (79%) and withdrawal symptoms (67%), to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with situations where smoking was prohibited (39%). Most ex-smokers (79%) feared they might relapse to smoking if they stopped using the e-cigarette. Users of nicotine-containing e-cigarettes reported better relief of withdrawal and a greater effect on smoking cessation than those using non-nicotine e-cigarettes. E-cigarettes were used much as people would use nicotine replacement medications: by former smokers to avoid relapse or as an aid to cut down or quit smoking. Further research should evaluate the safety and efficacy of e-cigarettes for administration of nicotine and other substances, and for quitting and relapse prevention.
Article
We discuss some of the practical and ethical questions that may arise for a jurisdiction where a sinking lid endgame strategy for tobacco supply is implemented. Such a strategy would involve regular required reductions in the amount of tobacco released to the market for sale, sufficient to achieve the desired level of commercial sales by a target date. Tobacco manufacturers would periodically bid to the government for a residual quota. Prices would increase as supply reduced. The price level would be influenced by demand, which in turn would reflect the impact of other interventions to reduce demand and the changing normality of smoking. Higher priced tobacco could result in increased smuggling, theft, illegal sales and short-to-medium-term aggravation of some social inequalities. We suggest that the strategy be introduced in conjunction with a range of complementary interventions that would help reduce demand, and thus help ensure that the possible adverse effects are minimised. These complementary interventions include: providing comprehensive best practice smoking cessation support, better information to smokers and the public, strengthened regulation of tobacco retailing and supply, further controlling the pack and product design, measures to restrict supplies that bypass the increases in product price, strengthened enforcement and combating industry attacks. General prerequisites for a sinking lid strategy include public support for the goal of a tobacco-free society, and strong political leadership. The likely context for initial success in jurisdictions includes geographical isolation and/or strong border controls, absence of significant tobacco production and/or manufacturing and low government corruption.
Article
Where are we going in tobacco control long-term, and how will we get there? This issue of Tobacco Control features three new contributions to the growing ‘endgame’ literature with possible answers to those questions: big-picture radical ideas that seek to propel the tobacco control movement more quickly towards a time when the global tobacco disease pandemic that began in the 20th century will be ended. Could the multitude of social structures and institutions that sustain the tobacco problem be unlinked? Could altered market forces—price controls, supply controls—render tobacco less attractive to those who profit most from continuing to addict new generations? Could there come a time when cigarettes—the most deadly consumer product ever made—will no longer be commercially sold? Can a stake someday be driven through the heart of the tobacco industry? Endgame thinkers are the visionaries of the tobacco control movement. Early contributions to this literature, many of which were first published in this journal, included Borland's regulated market model1; Callard, Thompson and Collishaw's work on restructuring the industry so that it was incentivised to reduce consumption2; and calls for phasing out smoked tobacco products through various approaches.3–5 Others in this broad genre of work include Chapman's6 call for licensing smokers, work on nicotine and other types of ingredient regulation to …
Article
On February 25, 1994, the Food and Drug Administration (FDA) released a letter to the Coalition on Smoking or Health announcing its intention to consider regulating cigarettes. The agency's premises were that the vast majority of tobacco users self-administer the product for the drug effects of nicotine and to sustain addiction and that cigarette manufacturers control the levels of nicotine in cigarettes to maintain this addiction. The FDA further raised the possibility of regulating cigarettes on the basis of their nicotine content to prevent addiction. On February 28, 1994, the ABC news program Day One presented evidence that tobacco manufacturers . . .
State wants to have legal challeng brought aginst its plan to introduce plain packaging for ciagrettes referred to EU court. Irish Independent
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The Tobacco Endgame: A critique of policy proposals aimed at ending tobacco use. The counterfactual: What's the right thing to do? Analytical advocacy -getting beyond the rhetoric of campaigners
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Lead in petrol 'makes the mind give way' in European Environment Agency 2013 Late lessons from early warnings: science, precaution
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JTI's response to the UK Department of Health's Consultation on the Standardised Packaging of Tobacco Products and associated expert reports
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Could E-cigs become the ultimate nicotine maintenance device? Addiction
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