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End Game

A Tobacco Endgame for Scotland?

25 Apr, 17 | by Marita Hefler, News Editor

A Tobacco Endgame for Scotland?

Katherine Smith and Jasper Been

An editorial in the November 2016 edition of Tobacco Control argued that talk about ‘tobacco endgames’ and policies that go ‘beyond ‘business as usual’ is becoming mainstream in a small number of countries, of which Scotland is one (others include New Zealand, Canada, Finland and Ireland). The race is now on to see which of these countries will be first to cross the finishing line. Attendees at a recent meeting on developing Scotland’s tobacco ‘endgame’ strategy identified three key policy priorities for a Scottish ‘tobacco endgame’: restricting availability of tobacco; pursuing a ‘polluter pays’ approach with tobacco industry profits; and introducing incentives for disadvantaged smokers to quit.

Tobacco Control in Scotland

Scotland is one of many countries that have taken major steps to reduce tobacco use, and related health harms, in recent decades. Having been a leader in the establishment of smokefree public places, Scotland’s current tobacco control strategy, launched in 2013, was bold in its commitment to Scotland becoming ‘smokefree’ (defined as adult smoking rates of 5% or less) by 2034. If this ambitious aim is to be achieved, it will require radical policy initiatives, consistent with recent proposals for tobacco ‘endgame’ scenarios. To date, however, there has been limited discussion of what specific policies ought to be pursued in Scotland to achieve the 2034 ‘smokefree’ goal.

In order to start addressing this gap, on 24th October 2016, an Usher Institute of Population Health Sciences and Informatics/ESRC supported seminar took place in Edinburgh in which researchers, advocates, policymakers and practitioners came together to discuss what a tobacco ‘endgame’ for Scotland might look like. The session involved multiple presentations and ‘pitches’ for policy proposals from a range of experts. Everyone present then had the opportunity to put forward potential policy proposals before collectively voting to identify those with greatest support.

What is a ‘tobacco endgame’?

The concept of ‘tobacco endgames’ is an analogy taken from the game of chess, the idea being that when you’ve got fewer pieces on the board (towards the end of the game), you need to change tactics to win. In public health terms, talking about tobacco endgames marks an important shift in focus towards ‘seeking to end the tobacco epidemic, rather than control it’. Since ‘the essence of the endgame requires thinking outside the box’ the kinds of proposals that are put forward as potential tobacco endgame strategies are often rather more radical than those that we have seen implemented to date.

A recent review of tobacco endgame proposals identified a four broad potential strategies. Some focused on the product itself, others on restrictions for users, while others focused on the market and structural issues:

  • Product– make cigarettes less addictive or appealing, or implement strategies to displace combustible cigarettes with the less harmful alternative of e-cigarettes.
  • Users – restrict access through smokers’ licences or prescriptions for purchasing tobacco, as well as incrementally increase the legal age of purchase to gradually phase out tobacco.
  • Market mechanisms – reduce retail availability, ban combustible tobacco products, make non-combustible nicotine products easier to purchase than combustibles, restrict manufacture and importation of products, price caps.
  • Structural – create a new tobacco control agency, create a regulated market, state takeover of tobacco companies, introduce a performance-based regulation system.

Does Scotland need a ‘tobacco endgame’?

Devolution afforded Scotland a ‘window of opportunity’ in addressing public health challenges. The Scottish Government has implemented a range of tobacco control policies including banning smoking in enclosed public spaces, outlawing vending machines and point-of-sale displays, and, most recently, banning smoking in cars carrying children. While most of these policies have now been implemented in other parts of the UK, Scotland has demonstrated clear public health leadership in this area and its commitment to becoming ‘smokefree’ (i.e. adult smoking prevalence of 5% or less) by 2034 indicates a desire to continue leading on tobacco control.

Reflecting these developments, smoking rates are coming down and we now have the lowest rates of smoking among young people and adults that Scotland has seen in decades. There has also been a significant decrease in the proportion of children exposed to second-hand smoke (from 11% in 2014 to 6% in 2015), following a successful government campaign on this topic. However, the latest data suggest around 21% of Scotland’s population smoke, a figure that is still higher than other parts of the UK. Also, while smoking prevalence is decreasing across all social groups in Scotland, a marked social gradient in smoking rates still exists. Moreover, to achieve the endgame targets we will need a much more rapid decline in smoking amongst the most disadvantaged compared to more affluent groups.

All of this poses some significant challenges. Most pressing is how to reduce smoking in Scotland’s poorest and most disadvantaged communities (including, for example, those experiencing mental ill-health) while avoiding the stigmatisation of those who find it most difficult to quit smoking (and evidence here is limited). Increasing the price of tobacco is the only specific intervention consistently shown to have a positive equity effect in terms of smoking prevalence. Yet, while traditional tobacco taxes are progressive in health terms by promoting cessation, they are regressive in economic terms for those who don’t quit, and such taxes can exacerbate the stresses and material impacts of life on a low income. These broader effects have only recently begun to be studied and have not yet been explored in a Scottish context.

What kinds of approaches were suggested for Scotland?

Having had an overview of the ‘endgame’ options outlined above, four broad policy pitches for Scottish approaches were put forward at the event, before participants went on to suggest four broad and interlinked policy proposals:

  1. Re-orientating tobacco control to take a broader social determinants approach, focusing on addressing the underlying drivers of tobacco use, especially in poorer communities. This involves thinking about some of the upstream drivers of tobacco use, including the efforts of the tobacco industry. Evidence indicates that tobacco control in Scotland, as in many other contexts, is now overwhelmingly an inequalities issue and should therefore be addressed as such.
  2. Framing tobacco control as a human rights issue (especially for children) on the basis of the right to health and associated rights. Scotland is (usually via the UK) party to a range of international and regional human rights treaties, including the International Covenant on Economic, Social, and Cultural Rights and the Convention on the Rights of the Child, which means that the Scottish government can use obligations set out in these legal documents to help make the case for further tobacco control measures, especially where these protect children from tobacco use and exposure.
  3. Measures to reduce the local provision of tobacco retailing, which is currently ubiquitous across Scotland. Strong research evidence demonstrates the links between neighbourhood density of availability and smoking prevalence. Availability is also part of the inequalities story since the density of tobacco outlets in Scotland varies geographically, with deprived neighbourhoods having about 77% more places to buy tobacco than more affluent areas. So environments are currently heavily loaded against poorer communities and this needs to be addressed. Scenario modelling in New Zealand looked at the impacts of reducing density around schools, removing licenses and an overall availability reduction of 95%. This work suggests positive impacts in terms of raising prices of tobacco products and reducing smoking prevalence. We need to do similar work in Scotland.
  4. Strengthening and extending regulation of tobacco as an industrial epidemic. While measures have been taken to prevent the tobacco industry influencing health policy, its expanding interest in new technologies such as e-cigarettes potentially re-opens the policy door to tobacco industry interests. For some, this might be seen as offering tobacco industry interests a ‘way out’ through harm reduction, a route Philip Morris International has presented itself as considering. In contrast, this pitch suggested a need to continue to focus on the role of the tobacco industry, and for regulation to be increasingly shaped by the ‘polluter pays’ principle. This could form part of a wider approach to regulating producers of unhealthy commodities, including alcohol, as modifiable structural determinants of health.

Running across several of the pitches, there was also a plea to work collaboratively with those communities most negatively affected by tobacco use and associated health inequalities. This could help inform policy debates about what approaches are publicly supported and reduce the risk of stigmatising poorer communities.

What specific policies were suggested and which were most popular?

After hearing the pitches, the 37 participants formed small groups to consider specific proposals for a tobacco endgame in Scotland. Each group’s proposals were collated and similar suggestions combined. This resulted in 14 distinct policy proposals that were voted on anonymously by the participants (each participant had three votes). The bar chart below demonstrates that the three most popular strategies involve: restricting availability of tobacco around schools, pursuing a ‘polluter pays’ approach with tobacco industry profits (and investing revenue raised for health) and introducing incentives for disadvantaged smokers to quit (a policy that has already been successfully trialled for pregnant women in the West of Scotland but which is currently not in place).

 

 

 

 

 

What next?

Overall, participants at the seminar seemed broadly supportive of the idea that Scotland now needs to develop a clearer conception of a tobacco endgame. Admittedly this only reflects the views of an invited group of health professionals (researchers, practitioners, policymakers and advocates) whose concerns focus on improving public health and reducing health inequalities. For others, the idea of a tobacco endgame might seem at odds with a liberal policy environment, or else simply feel impractical. Nonetheless, if the Scottish Government is serious about achieving a smokefree Scotland by 2034 then we need to advance discussion about potential ways forward. This becomes pressing given that Scotland’s current tobacco control strategy ends in 2018, with endgame thinking having an opportunity to shape development of a new strategy. The suggestions emerging from this event represent a further contribution, as do those from bigger events such as the 2016 Scottish Smoking Cessation Conference, but discussions also need to become far broader, public, and inclusive. Given the risks of stigmatising smokers, particularly those living in more deprived communities, it will be particularly important to engage these groups in such discussions and this is a topic that researchers in GRIT (the Group for Research on Inequalities and Tobacco) will be pursuing.

Katherine Smith is a Reader in the Global Public Health Unit and member of GRIT (Group for Research on Inequities and Tobacco at the University of Edinburgh. Jasper Been is a member of the Usher Institute of Population Health Sciences and Informatics at the University of Edinburgh and Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands.

Acknowledgements:

Thanks are due to everyone who participated in the 24th October 2016 seminar and to Ash Scotland and GRIT (the Group for Research on Inequalities and Tobacco), the Chief Scientist Office of the Scottish Government, the Farr Institute and the Usher Institute at the University of Edinburgh, for supporting this event. We also acknowledge ESRC funding for this event via a seminar series grant (‘Tobacco and Alcohol: Policy challenges for public and global health’, Grant No. ES/L001284/1). Finally, we would like to thank Lynn Morrice and Rebecca Campbell for organising practical aspects of the event.

 

Is Philip Morris’ claim it wants to phase out conventional cigarettes credible?

1 Dec, 16 | by Marita Hefler, News Editor

In recent months, Philip Morris International has been claiming it wants to lead the push to a smoke free world and  wants to work with governments towards the phase out of conventional cigarettes. The claims have been met with scepticism, but do they stand up to scrutiny?

At an investor day held in late September 2016, PMI chief executive officer Andre Calantzopolous outlined the company’s strategic priorities, which include “to continue leading the combustible product category and deliver against our current growth algorithm” and for “Reduced risk products (RRPs) to ultimately replace cigarettes to the benefit of all stakeholders”. Calantzopoulos described the ‘excellent combustible fundamentals’ which include: improving cigarette industry volume/trend mix, and broad and balanced geographic footprint with expansion opportunities. While these are not exactly the words of a leader who wants to get out of the cigarette business, he also states that the company is committed to achieving widespread conversion to RRPs, and that PMI “welcome all alternatives to achieve a combustion-free world as quickly as possible.” Together these contradictory priorities sound very much like a bet each way.

At first glance, the latter rhetoric sounds like the company has finally – after more than 50 years of denial and deceit about the harms of tobacco – realised that not only is the tobacco business ethically and morally bankrupt, but it is also the wrong profit-making horse to back. However, a closer look suggests that reduced risk products may be yet another cynical tactic for the company to position itself as a socially responsible entity that deserves to be treated as part of the solution, rather than the problem.

The glaring omission in the rhetoric is the most obvious alternative for PMI to meaningfully contribute to achieving a combustion-free world: announce a date by which the company will phase out combustible products entirely. Calantzopoulos is on record as stating the iQOS (I Quit Ordinary Smoking) technology which appears to be the platform it is pinning most hope on, put the industry “on the cusp of a revolution”. At the September meeting, he told investors that almost one million smokers have already converted to RRPs and it had captured nearly 3% of the Japanese cigarette market. Wells Fargo Securities tobacco analyst Bonnie Herzog estimates that iQOS could displace 30% of the global combustible market by 2025.

At the September 2016 investor day, Calantzopoulos was not shy about framing RRPs as a public health solution with enormous potential, claiming “…if we can encourage a meaningful portion of adult smokers to rapidly switch to RRPs that meet this standard, it is likely to create a significant additional population health benefit relative to current regulatory efforts.” He called on the public health community to embrace this approach, and noted “we are very much encouraged by the growing number of pre-eminent public health advocates that already support the principle of tobacco harm reduction through products and science.”

The public health community has seen similar promises before: the promise of reduced risk products is nothing new, and the safety of iQOS is largely untested. If these products fail, as their predecessors have done, PMI will have benefited from iQOS and other reduced risk products being branded consistently with its combustible tobacco products.

Presumably anticipating such objections, Calantzopoulos noted, “I fully recognise there is scepticism and a deficit of trust in our determination to lead the effort to achieve a combustion-free world as soon as possible. Although we cannot change the past, we can certainly change the future and transform our company.”

Indeed, PMI can certainly change the future and transform the company. Nothing will accelerate the transition to a smoke free world more effectively than PMI withdrawing completely from the combustibles market, supported by the intensive consumer engagement strategies it is already using to promote uptake of iQOS.

Public health advocates who are willing to work with the tobacco industry on joint harm reduction approaches would do well to remember the fable of the scorpion and the frog, in which the frog agrees to carry the scorpion across a stream. Halfway across, the scorpion stings the frog. As they both start to drown, the frog asks ‘why?’, to which the scorpion replies ‘it’s my nature’.

This is an edited version of an article which was published in the Worldwide News & Comment section of the November edition of Tobacco Control. 

Additional links:

Can prohibition work? The case of India’s smokeless tobacco ban

27 Aug, 15 | by Marita Hefler, News Editor

Pankaj Chaturvedi, Sanjay Seth, Prakash C Gupta, Ashima Sarin 

Tata Memorial Hospital, Mumbai

‘Bans don’t work’ is a common response to measures to restrict or outlaw tobacco supply. Libertarians decry such measures as excessive ‘nanny state’ intervention; others point to the USA experience of alcohol prohibition in the 1930s, often held up as a failed experiment (although the truth is more nuanced; as a public health measure, prohibition was more effective than conventional wisdom holds).

Today, India is proving that prohibition can have a place in public health. Gutka, an industrially manufactured smokeless tobacco product has now been banned in the majority of the country, with encouraging results.

Gutka is made from crushed areca nut, tobacco, catechu, slaked lime and sweet or savory flavorings or fragrance. In December 2014, a former gutka industry owner went public with revelations that harmful chemicals are used as cheap substitutes for flavouring. He turned whistle blower after he was affected by mouth cancer, which necessitated facial surgery, chemotherapy and radiation treatment.

Spurred by attractive packaging in single-dose plastic packs affordably priced at 2-3 cents/pack, and widespread marketing targeted at children and adolescents, the gutka market has rapidly expanded in the last decade to be worth more than US$8 billion. The growth of the industry has caused havoc with public health, especially oral health.  According to the Global Adult Tobacco Survey (GATS) India 2009-10, around 13% of males and 3% of females used gutka in India. Among young people aged 15-24, smokeless tobacco use was 23% for males, and 8% for females. Oral cancer is increasing, especially among youth. Use of smokeless tobacco usage is a key risk factor for cancer (mainly oral, oesophageal, and pancreatic), stroke, ischaemic heart disease,  type 2 diabetes, adverse reproductive and developmental effects such as stillbirth, preterm birth and low birth weight.

The legal basis for the gutka ban was the Food Standards and Safety Act notified in 2011, section 2.3.4 of which specified that “Product not to contain any substance that may be injurious to health: tobacco and nicotine shall not be used as ingredients in any food product.”At the direction of the Supreme Court, the Ministry of Health and Family Welfare (MoHFW) constituted a high level Expert Committee to collate the evidence on harmful effects of smokeless tobacco and areca nut. In February 2011 the Ministry submitted this report, commonly called National Institute of Health and Family Welfare (NIHFW) Report to the Supreme Court. Several Civil Society NGOs urged the highest court to ban the manufacture and sale of all products found to be injurious to health by the NIHFW health report.

Momentum for the gutka ban, however, came from tobacco victims themselves; survivors of cancers of mouth and throat, widows and families of tobacco victims. Known as  ‘Voice of Tobacco Victims’ (VoTV), the campaign featured patients and their family members, supported by their treating oncologists and public health researchers, telling their stories of initiation and addiction to gutka and consequences of disease, financial ruin and agony.

Started in 2011, the target audience for the VoTV was top policy makers, bureaucrats, social influencers, media and politicians. The appeal from patients made direct emotional connections; politicians and bureaucrats made promises and media gave prominent coverage to stories. The VoTV doctors and staff provided scientific evidence, made the advocacy demands very specific, and followed up with bureaucrats and politicians until the objective was met. Ultimately, the first gutka ban was declared by the state of Madhya Pradesh on 1st April 2012. Thereafter, state after state notified the ban. For some states who refused to implement bans, public interest litigations were filed and High Court judgments forced them to declare gutka ban. By the end 2012, 14 of India’s 29 states had notified the ban and in April 2013, the Supreme Court directed all states to comply.

The extent of enforcement of the ban varies a great deal across states, but there have been some common findings by studies. The first major impact assessment report came in 2014, from a study conducted by the Johns Hopkins University Bloomberg School of Public Health and the World Health Organization. Surveys were conducted with 1,001 current and former gutka users and 458 tobacco product retailers in seven states (Assam, Bihar, Gujarat, Karnataka, Madhya Pradesh, Maharashtra and Orissa) and Delhi. Interestingly, 90% of respondents desired that the government should ban the manufacturing, sale and distribution of other forms of smokeless tobacco.

According to the study, there was virtually no retail outlet where pre-packaged gutka was on display. Ninety two percent of respondents supported the ban and 99% agreed that bans are good for the health of India’s youth. Of the respondents who continue to use illegal pre-packaged gutka, half reported they consume less since the bans. 80% believed that ban will motivate them to quit, and nearly half of attempted to do so. Of the respondents that quit since the bans, a substantial proportion in each state (from 41- 88%) reported that they “quit using gutka because of the ban”. The study was a rapid survey in 7 states, rather than a nationally representative survey.

Post the bans, however, most gutka manufacturers started selling two packets: one the same mixture but without tobacco; and, a small packet containing just tobacco, often given free. Users were urged to combine and mix the ingredients of two packets to create their own gutka. This innovation adversely affected the purpose and consequent impact of the ban and was possible due to weak enforcement of the law. However, 11  states took the remedial step to ban the sale of processed and packaged smokeless tobacco and flavored areca nut products.

A concern for public health policy makers and researchers was to determine if gutka chewers switched to smoking following the ban. Studies have consistently shown that there is almost no switch over to smoking. In fact, the whole campaign for gutka ban, aided by other tobacco control measures, seems to have impacted sales of all forms of tobacco. According to the Index of Industrial Production (IIP) data, output of tobacco, declined by 12.1% in March 2015 from a year ago.

The Euromonitor report on Smokeless Tobacco in India  published in December 2014, revealed that up to 2010, volume sales as well as value sales of smokeless tobacco were increasing, was more or less stagnant in 2011 and by 2013, there was 84% decline in volume sales and 82% decline in value sales compared to the peak in 2010. Further, compared to 2012-13 figures Euromonitor predicted the decline in sale volume to be 85% and value to be 80%. Euromonitor clearly attributed this decline to gutka ban. Also, for the first time in the history of cigarette industry in India, volume sales have started declining.

These findings assume even greater importance when looked along with economic impact of tobacco use in India.  According to report by MOHFW, health care losses due to treatment of tobacco-related illnesses were US$16.5 billion [Rs.1.04 trillion] in 2011. In comparison, in 2013-14, the Government’s earnings from tobacco taxes were US$2.83 billion [Rs.17,800 crores].

The findings here reaffirm the fact that investment into tobacco control policies represent a win-win situation for government, public health and the people and families of tobacco users or potential users. India’s experience shows that prohibition may be a credible tobacco control option in certain situations. In this case, the product was primarily manufactured in one country and cross border supplies could be reasonably controlled. In addition, the ban appears to have led to denormalisation of gutka. By declaring the product as illegal, the consequential massive earned media in the country convinced the public (90%+ approval ratings) that banning this product was good for public‘s health. This also countered the massive brand equity makers had built up around their gutka brands – the “stench” of a banned product led to erosion of the brand values (although possibly for this reason, makers have increased surrogate ad budgets – to revive their brands). The ban has effectively disrupted supply, especially reducing access to children.

USA: Massachusetts town considers tobacco sales ban

16 Nov, 14 | by Marita Hefler, News Editor

The small town of Westminster, Massachusetts (population 7300) is considering banning the sale of all products containing nicotine within its city limits.  PBS reports the town’s health board has put forward a proposal, with the three member board to make a decision in late December. If the proposal is adopted,  products purchased elsewhere would still be allowed to be used in the town. The full PBS video report and transcript are here.

According to Lawrence Friedman, a constitutional law professor at New England Law School in Boston quoted in this Newsweek report, the proposed ban would not face any constitutional barriers. He cites examples of several counties in Arkansas which have prohibited the sale of alcohol, and notes that as long as the prohibition applies uniformly to all businesses it would likely be on safe legal ground. The Newsweek report also includes a link to the full proposal.

Reports from the Asia Pacific Association for the Control of Tobacco #APACT2013 Conference

29 Aug, 13 | by Marita Hefler, News Editor

 

Editor’s note: The first edition of the ASEAN Tobacco Control Atlas was launched to coincide with the conference. Click here to read additional reporting by SEATCA and download the report. Dr Marewa Glover from the University of Auckland Centre for Tobacco Control Research writes here about how e or m health ideas are an area that need more attention, and here about the importance of helping smokers quit to achieve Endgame goals.

—————

E. Ulysses Dorotheo, MD, FPAO

Southeast Asia Tobacco Control Alliance (SEATCA)

Framework Convention Alliance (FCA)

The Asia Pacific Association for the Control of Tobacco (APACT) marked a milestone with its 10th APACT Conference in Chiba, Japan last 18-21 August 2013, with a record 785 delegates from 42 nations participating.

In his David Yen Memorial Lecture, Mr. Kyoichi Miyazaki traced the conference’s history back to the visionary advocates who contributed to APACT’s establishment in 1989 and its early years of growth (particularly David Yen, Ted Chen, Judith Mackay, Prakit Vathesatogkit, Gregory Connolly, Richard Daynard, Terry Pechacek, Takeshi Hirayama, David Sweanor, Nigel Gray, Martin Kawano, and Kwan-Mo Chung, among others) in response to pressure to open the Asian markets to United States (US) tobacco companies wishing to invade the region.

Dr. Judith Mackay immediately followed up with a forward-looking plenary lecture on the tobacco endgame in line with the conference theme “Ending the Tobacco Epidemic – Protecting and Keeping Healthy Lives”, and over the next few days, best practices for measures to reduce tobacco consumption, such as optimal tobacco taxation, cost-effective cessation, and smoke-free policy advocacy, were discussed in plenary sessions, symposia, and poster presentations. Particular recognition was given to Australia for legislating the world’s first plain packaging of tobacco products, to Thailand for standing up to Big Tobacco’s intimidation by litigation for requiring the world’s largest (85%) pictorial health warnings, and to New Zealand for trendsetting a 2025 endgame target.

In contrast, the conference also recognized the varying degrees of tobacco control implementation in individual countries and underscored the need for full and accelerated FCTC implementation across our region in order to slow the tobacco death clock. Indonesia, for example, remains the only Asian country not a party to the FCTC, and conference host, Japan, still has no national law to protect the public from secondhand smoke. In this regard, delegates and speakers also shared experiences relating to the increasing incidence and overtness of tobacco industry interference in public policy (e.g. through their so-called Corporate Social Responsibility (CSR) activities, litigation against effective tobacco regulation, and stakeholder engagement in international trade policies) and called on governments to immediately and fully implement FCTC Article 5.3 and its guidelines, to ban CSR activities by the industry, and to explicitly exclude tobacco products from international, regional, and bilateral trade and investment agreements, such as the Trans-Pacific Partnership agreement currently being negotiated, noting that, except for the US, all TPP negotiators are Parties to the FCTC.

The 10th APACT further recognized the importance of the youth as future leaders who must be meaningfully engaged to realize the tobacco endgame in the Asia Pacific region, because just as in 1989, continuing collaboration is needed to overcome Big Tobacco, which relentlessly targets young people of Asia for its profits.

The next APACT Conference will be in 2016 in Qingdao, China.

An enormous set of lungs demonstrate in graphic detail the effect of smoking

An enormous set of lungs demonstrate in graphic detail the effect of smoking

Tobacco harm reduction and e-cigarettes: setting a unified research agenda

29 May, 13 | by Marita Hefler, News Editor

 

Marisa de Andrade & Gerard Hastings

Institute for Social Marketing, University of Stirling

marisa.deandrade1@stir.ac.uk

Recent discussions about an endgame for tobacco have built on a sense that we in the tobacco control (TC) movement know where we are going. The consistent application of evidence based strategies, from adbans to tax increases, was, it seemed, driving an inevitable progression towards a smoke-free world; the only question was ‘when would the prevalence line cross the X axis?’

Tobacco harm reduction (THR) has been a carefully modulated dimension of this debate. Now this balance has been unsettled by the sudden arrival onto the market of a wide range of e-cigarettes and other Nicotine Containing Products (NCPs). The development suggests both opportunities (such as greatly reduced harm for the heavily addicted) and threats (like the potential rehabilitation of the tobacco industry), and in the process throws up multiple research questions. This THR Research Agenda commissioned by Cancer Research UK presents a first attempt to map these questions.  It was informed by a review of the academic and grey literature and consultations with twelve TC experts.

It quickly became apparent that research questions could be grouped into four broad (and sometimes overlapping) areas: impacts on the individual; the tobacco control movement; the political environment; and philosophical issues.

A taxonomy of harm reduction research

 

 

 

 

 

 

 

 

A taxonomy of harm reduction research

Individual

According to the National Institute of Health and Care Excellence (NICE) draft HR guidance, e-cigarettes offer a cleaner vehicle for the delivery of nicotine as ‘the harm associated with cigarette smoking is almost entirely caused by the toxins and carcinogens found in tobacco smoke’. Ongoing evaluations of safety (short and long-term) are recommended by the health body, a call which a recent German Cancer Research Center report and presentation to the European Parliament also makes very strongly.

This research needs to be balanced with an examination of efficacy: how effective are NCPs and e-cigarettes as smoking cessation aids and at helping smokers cut down, and what impact does this have on quitting? We also need to know how NCPs are being used – for dual use, temporary abstinence, long-term as a tobacco substitute or part of a quit attempt – and by whom, covering age, socio-economic status, gender and ethnicity. By extension, potential impact on individual and population level inequalities also needs to be assessed.

More broadly there is a need to examine how key stakeholders, including smokers, non-smokers, policymakers, primary healthcare staff, journalists, children and young people, are perceiving HR, NCPs and all related commercial and social marketing activity.

Tobacco control

Developments in THR and e-cigarettes also raise strategic questions for tobacco control.  What priority should the TC community give to HR relative to other tobacco control approaches? We need to know how, if at all, HR interacts with these other approaches and specifically with complete cessation (eg do NCPs and/or e-cigarettes help or hinder quit attempts?) and youth prevention (eg could they act as a gateway to smoking?). In each case the net needs to be thrown wide to capture the effects not just of the products themselves, but the way they are presented and promoted in digital and conventional media.

The regulatory response is varying around the world and the efficacy and wider impact of these alternate models needs to be examined. In the UK, for example, where NCPs could soon be regulated by the Medicines and Healthcare products Regulatory Agency (MRHA), questions arise about how marketing will be overseen. What would the official channels be for reporting potential breaches, and how would this fit within the regulator’s remit? How well does this regime operate compared with other jurisdictions where tighter controls (eg complete adbans) are in place? More broadly, how did these different approaches arise?

The impact, if any, of HR and the use of NCPs on the denormalisation of smoking is currently unknown. Does e-cigarette use, for example, model smoking?  More specifically, to what extent, if at all, do the new products undermine smoke-free legislation, or the packaging, point of sale (POS) display and advertising of them undermine tobacco marketing controls? Potential conflicts with current regulation could also raise concerns relating to the Framework Convention on Tobacco Control (FCTC).  Specifically, how should Article 5.3 be interpreted and deployed when the tobacco industry (TI) is investing so heavily in HR and associated products?

Political

The FCTC also raises political debates.  Is the TI using HR to engage in and influence health policy, perhaps via third parties (either commercial or public)? What, if any, conflict of interest does TI investment in reduced risk products present? Could it, for instance, undermine or remove public health gains from HR? And what is the TI’s business strategy with regard to NCPs and the implications for TC? Under what circumstances, if at all, could the TI come to be seen as a legitimate stakeholder? Is the tobacco TI using HR as a corporate social responsibility or stakeholder marketing strategy? If so, how is this happening and what are the potential dangers?

It is also necessary to know how research on HR and NCPs is being funded, and what impact will this have on TC. What, if any, similarities are there between TI interest in HR and its past activities around filtered, safe and low tar, cigarettes? What, if any, links will develop between the tobacco and pharmaceutical industry and what are the implications for TC?

International implications also need to be addressed.  What impact do decisions made in one country have on the rest of the world, and what can be learnt from countries where both smoking rates and HR activities are low?

Philosophical

More broadly still, HR and NCPs raise questions about the fundamental purpose of public health. Is it an acceptable and effective public health practice to promote an addictive product? How does this vary between cultures and classes? What, if any, impact does HR have on the individual’s sense of agency and his or her ability to address wider health behaviours?

Finally, does the resulting accumulation of corporate power present any threats to TC or public health more generally?

Conclusion

There is a new sense of uncertainty in tobacco control.  THR has been presenting alternate perspectives for some years in an appropriately cautious fashion, but the sudden arrival on the scene of heavily marketed e-cigarettes and other NCPs has greatly energised the debate.  It is vital that the tobacco control movement agrees a unified strategy to address these developments; amidst all the uncertainty there is one certainty: any divisions will be ruthlessly exploited by vested interest. This taxonomy of harm reduction research provides a first step towards this unified strategy.

Open Access Supplement on Tobacco Control End Games

17 Apr, 13 | by Becky Freeman, Web Editor

A fully open access supplement of Tobacco Control is now available. With 20 articles contributed by 27 authors it is rich with ideas and possibilities.

F1.medium

Dr Kenneth Warner sets the scene for this themed supplement:

In this supplement, some of the world’s most brilliant tobacco control scholars, strategists and activists, including those who originated the principal endgame concepts, offer a wide range of observations pertinent to contemplating the endgame. With other colleagues, these authors gathered together in Ann Arbor, Michigan, last June at a workshop hosted by the University of Michigan School of Public Health to contemplate the very notion of an endgame and to debate the merits of the various endgame proposals brought to light to date. The workshop was sponsored by grants from the American Legacy Foundation and the Robert Wood Johnson Foundation, who also sponsored the development and distribution of this supplement. On behalf of the workshop organisers and participants and the supplement authors, I express our deep gratitude to these visionary organisations for their willingness to encourage thinking outside the box.

The papers published in this volume are not the proceedings of the workshop, although they certainly reflect both the subject matter covered and the diversity of issues and perspectives that characterised the lively proceedings.

The goal of the workshop—and indeed the goal of this supplement—was never to produce a consensus on any of the challenging questions that pervade the subject of the tobacco endgame; it is far too early to do so. Rather, as one participant put it, the intent of the workshop was to serve as ‘an intellectual ice-breaker’ for the field of endgame studies. We hope this supplement will play a similar role for the broader tobacco control community, opening up the debate, enlisting a wider array of tobacco control and public health professionals, and thereby hastening the determination of answers to the challenging questions. While we struggle today with often widely divergent perspectives and beliefs, we all share the same vision of the final words to this story: ‘The end’.

 

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