Reduced nicotine rule: a terrible idea to be pursued relentlessly
Prohibition or profit motive: competing visions for the endgame
1. Prohibition or profit motive?
Competing visions for the endgame
Global Forum on Nicotine
6th June 2015
Clive Bates
Counterfactual
www.clivebates.com
2. Global cigarette consumption - still rising
Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA
2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010
Billionpieces
Global cigarette consumption 1980-2012
Total cigarette
consumption
3. Global cigarette consumption - still rising
Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA
2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010
Billionpieces
Global cigarette consumption 1980-2012
Developing countries
Developed countries
6. 2040 ‘endgame’ – the story so far
Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012.
JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040
Billionpieces
Global cigarette consumption - phase out by 2040
7. 2040 ‘endgame’ – eliminating tobacco
Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012.
JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040
Billionpieces
Global cigarette consumption - phase out by 2040
8. 2040 ‘endgame’ – reducing to 5 percent adults
Data source 1980-2012: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012.
JAMA 2014; 311: 183–92. Curve forced to zero with linearly increasing rate of decline from 2012
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040
Billionpieces
Global cigarette consumption - phase out by 2040
15. It may be prohibited but is definitely not gone
15.7
23.4
0
5
10
15
20
25
Cigarettes Marijuana
Percent
Marijuana and cigarettes
US high school prevalence 2013
Source: CDC MMWR Youth Risk Behavior Surveillance — United States, 2013
Current use: used at least once in last 30 days
Approximately age 14-18 – grade 9-12
19. Big Tobacco: half a trillion dollars
0
20
40
60
80
100
120
140
PMI Altria BAT JTI ITC
(India)
Imperial Reynolds Lorillard
Market capitalisation – April 2015 (billion US dollars)
Total = $550 billion
20. Charter of Fundamental Rights of the European Union
Everyone has the right to own, use, dispose of and bequeath his or her lawfully
acquired possessions. No one may be deprived of his or her possessions, except in
the public interest and in the cases and under the conditions provided for by law,
subject to fair compensation being paid in good time for their loss. The use of
property may be regulated by law in so far as is necessary for the general interest.
Fifth Amendment: Takings or Just Compensation Clause
…nor shall private property be taken for public use without just compensation.
21. What’s the right thing to do?
Right thing to do?
• Legitimate objective
• Appropriate relationship between citizen and state
• Respect for rights, property, liberty
• Harm principle
Right way to do it?
• Unintended consequences
• Proportionate
• Non-discriminatory
• Evidence based
23. Much safer recreational nicotine delivery
Vapour products
‘Heat not burn’ tobacco
Smokeless tobacco
Novel nicotine products ‘Crossover’ NRT
Inhalers
+ 25 years innovation to come
24. Multi-criteria estimate of nicotine product harms….
Nutt DJ et al Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach – European Addiction Research March 2014
25. Harm reduction categories – risk continuum?
0
20
40
60
80
100
120
Cigarettes Smokeless E-cigs NRT
Crudeestimateofrisk–Cigs=100
From analysis of the constituents of
e-cigarette vapour, e-cigarette use
from popular brands can be expected
to be at least 20 times safer (and
probably considerably more so) than
smoking tobacco cigarettes in terms
of long-term health risks
Professor Robert West
Professor Ann McNeill
Professor Peter Hajek
Dr Jamie Brown
Ms Deborah Arnott
26. Value proposition: a smoker’s cost-benefit analysis
1. Keep smoking
Benefit: nicotine, sensory, taste, ritual, brand-
related
Cost: illness, money, stigma, addiction
2. Quit smoking
Benefit: avoid smoking harm, take control, cash
savings
Cost: withdrawal, craving, sustained willpower, lost
smoking benefits
3. Switch to e-cigs
Benefit: most smoking benefits*, no/minor
smoking harms, personalisation, buzz, cash saving
Cost: addiction?
* Full benefits – subject to continued innovation
“Quit
or die”
27. Global cigarette consumption - still rising
Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA
2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1980 1985 1990 1995 2000 2005 2010
Billionpieces
Global cigarette consumption 1980-2012
Total cigarette
consumption
28. Global cigarette consumption – trend to 2030
Data source: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA
2014; 311: 183–92.
y = -1.4623x2 + 86.419x + 4888.9
R² = 0.9932
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030
Billionpieces
Global cigarette consumption and trends – parabolic trend
Global
29. Cigarette consumption continues on trend
Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking
prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2010 2015 2020 2025 2030
Billionpieces
Extrapolation of trend (parabolic curve)
Global cigarette
consumption
30. Hypothetical introduction of new nicotine products
Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking
prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2010 2015 2020 2025 2030
Billionpieces
New non-combustible nicotine with high initial but declining growth
Low risk nicotine
consumption
Global cigarette
consumption
31. Hypothetical introduction of new nicotine products
Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking
prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2010 2015 2020 2025 2030
Billionpieces
New non-combustible nicotine with high initial but declining growth
This boundary is
harder to move.
This boundary is
easier to move.
32. In the long term it may displace smoking
Consumption 2010-2030 on parabolic trend projection from 1980-2012 data from Ng M, Freeman MK, Fleming TD, et al. Smoking
prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92.
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2010 2015 2020 2025 2030 2035 2040
Billionpieces
New non-combustible nicotine with high initial but declining growth
Global cigarette
consumption
Low risk nicotine
consumption
35. Diminishing and negative returns to regulation
Net
health
Net
harm
Valuetosociety
Regulatory costs,
burdens and
restrictions
Builds
confidence
Destroys viable firms
and products
Compromises design
& consumer appeal
Sweet Spot
36. Morgan Stanley on FDA deeming regulations
The greater barriers to entry (slower approval process, higher
costs, higher product standards), will ultimately take a toll on
the number of available products and rationalize the category.
This could result in the larger tobacco companies dominating
the category in the future, given the burden it would place on
smaller manufacturers.
37. Opportunity not threat
Regulator
Consumers Public health
Business Government
Find that sweet spot
Big vision, win big
Tell the truth,
focus on disease
Fight for your interests
and spread the word
Innovative, competitive
not predatory
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +36 billion per year
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +36 billion per year
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +37 billion per year
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +37 billion per year
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +37 billion per year
In April 2013 the journal Tobacco Control published a special supplement on the ‘end game’ for tobacco: http://tobaccocontrol.bmj.com/content/22/suppl_1.toc
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.
These are some of the main ideas:
Lowering nicotine content: the idea of federal regulation of the nicotine content of cigarettes such that the nicotine content of cigarettes would be reduced over time, resulting in lower intake of nicotine and a lower level of nicotine dependence. When nicotine levels get very low, cigarettes would be much less addictive. As a result, fewer young people who experiment with cigarettes would become addicted adult smokers and previously addicted smokers would find it easier to quit smoking when they attempt to do so. Main issue: people more or less seek a desired nicotine intake – as nicotine concentrations go down, exposure to harmful toxins would go up causing more harm. No regulator could do this. Loose tobacco, RYO, black market…
Sinking lid: seeks to end tobacco use through the imposition of progressive limits on the amount of commercial tobacco released for legal sale, and the use of auction to license suppliers for the remaining portion. Using a biannual reduction of 5% of the initial volume, the authors foresee a phasing out of commercial tobacco within two decades. Main issue: same effect and challenges as raising taxes only vastly more complicated. Note equivalence of emissions trading and carbon taxes in climate policy.
Tobacco free generation. The tobacco-free generation proposal advocates legislation precluding the sale and supply of tobacco to individuals born after a certain year. The legal age limit goes up by 1 year each year. Main issues: Vastly overstates role and effectiveness of age limitations and retail controls. Creates dividing line in adult consumers – 42 year olds allowed to buy, but not 41 year olds. Policy reductio ad absurdum
Nationalisation: establishment of a ‘non-profit enterprise with public health mandate’ (NPE), which would remove profit-making from the entire tobacco supply system and replace duty to shareholders with an unencumbered responsibility to meet the public health goal of phasing out smoking. Regulated market model: a harm reduction model where the marketing is under the control of a non-profit entity (a regulated market) is required to curtail the incredible power of for-profit marketing and to allow tobacco marketing to be done in ways that further the goal of minimising tobacco-related harm. Implausible seizure of shareholder property rights (nb companies owned by pension funds etc).
Performance based regulation: rests on the simple proposition that the tobacco companies themselves should be required to achieve sharply improved public health outcomes’. He suggests that this can be done through the imposition of legal requirements on tobacco companies to reduce the number of people who smoke their products and to impose effective financial penalties on those who fail to do so. Main issue: cannot be translated into a plausible business model for a tobacco company – what would the employees do at work? Note different to schemes where energy companies save energy and recover costs through tariffs.
Abolition: Robert Proctor's appeal for ‘Abolition’ of commercial tobacco. He proposes to ban the sale and manufacture of cigarettes, and to permit the smokers to grow their own tobacco. Instead of seeking to better regulate the market, transform it or impose performance requirements on it, Proctor seeks to collapse the organised supply. Politically infeasible due to the one-two billion users.
This si my own conceptualisation of the risks – it my be a few points different in reality but there are two characteristics:
A very low risk elative to cigarettes
A residual risk that is not very large and probably within the normal range of things we accept without huge regulatory oversight (eg. Bacon, BBQs, cheese, coffee etc)
This looks at the choices faced by smokers – the first two represent the ‘quit or die’ proposition.
The third is a new value proposition in which smokers can switch and get almost all of the benefits (and some new ones like personalisation) and almost none of the costs.
This value proposition will get stronger with advancing innovation, as recreational experience matches that of smoking. But it does need regulators to enable this.
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
On a linear basis over 30 years
Developed –16 billion per year
Developing +53 billion per year
Global +36 billion per year
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
Source of data: http://jama.jamanetwork.com/article.aspx?articleid=1812960
Supplementary data: http://jama.jamanetwork.com/data/Journals/JAMA/929635/JOI130117supp1_prod.pdf?v=635489893529930000
This comment from David Adelman of Morgan Stanley July 2014 reflects the reality of heavy regulation – it plays to the advantages of companies with strong balance sheets able to support their vapour subsidiaries through regulatory approvals, while killing off the competition. Just about everything called for by the public health community plays into this dynamic – bans, meds regulation, massive amounts of testing etc
