Friday 4th December Seminars

The EU Tobacco Products Directive was a milestone in tobacco control, covering everything from tracking and tracing of tobacco products to banning flavours in cigarettes, large pictorial health warnings on cigarette packs to regulation of e-cigarettes. But the in the years since the TPD came into force in May 2016 it has become clear that a review of the regulations is needed, particularly with respect to e-cigarettes and novel nicotine products. There are loopholes in the legislation which are being exploited by the tobacco industry. The evidence is growing that e-cigarettes can help smokers who can’t or don’t want to quit using nicotine, to stop smoking and stay quit, thereby significantly improving their health and wellbeing. This is a major public health benefit which needs to be sustained. However, just as crucially all novel nicotine products need to be regulated to minimise the risk of youth uptake. This presentation sets out ideas for how the regulations should be revised in the light of these two objectives.

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THE WHO FCTC and the associated MPOWER package of interventions provide a comprehensive approach to tobacco control including, at least in theory, tobacco harm reduction. Implementation of these interventions has been limited particularly for the most effective measures such as excise tax increases and comprehensive bans on advertising and sponsorship. Even in countries which have fully implemented WHO’s recommendations marked failures in tobacco control are evident. For example, in New Zealand which has for three decades been progressively implementing WHO recommendations, inequalities in cigarette smoking rates have not been reduced and adult daily cigarette smoking rates are 13%. The enormous potential of tobacco harm reduction has not been realized. In part, this is because of divisions within the tobacco control community and fears of youth vaping. New Zealand vaping legislation was passed in August 2020 and, despite several limitations, has the potential to accelerate progress toward New Zealand’s ambitious, but achievable, Smokefree 2025 goal with <5% of adults smoking cigarettes a daily. The New Zealand experience provides lessons for countries at all stages in their efforts to reduce the dreadful burden of death and disease caused by cigarette smoking, especially the need for evidence-based tobacco harm reduction strategies.

Several countries have proposed 'smokefree targets', including New Zealand and Ireland, which set their goals for 2025. They are certain to fail.  England has recently made a commitment "to make smoked tobacco obsolete by 2030". Someone now has to fill in the blanks: what should be done to bring this about? Imagine if everyone involved was paid by results and their livelihoods depended on meeting the goal. Imagine too that they had permission to take heretical measures? What would they do? Maybe a grand masterstroke like a cigarette prohibition or an aggressive reduced-nicotine rule?  Or maybe something smarter than that? This presentation takes a look at the playbook.

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As the U.S. election is underway and we wait to hear if there is a new Administration / Congressional leadership, this session will explore the material implications for tobacco control and public health policies that would result. With election results for both branches of government likely to remain in flux for weeks, there is one political truth that holds to be self evident regardless of electoral outcome: Democrats in all levels of government routinely turn to the Campaign for Tobacco-Free Kids and Bloomberg Philanthropies for guidance on how to approach tobacco policy issues. These two non-profits are held in high regard as deeply trusted partners by virtually all Democrats, and actively encourage policymakers to advance universal flavor bans, increased taxes, and nicotine caps in all tobacco products. This means that wherever we find Democrats in power, we need to contemplate these suite of policies as real possibilities; whether that’s in the White House, Congress, state legislatures, or state administrations.

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Implementation of the PMTA deadline, and continuing regulatory pressure in areas of policy such as flavours and youth access to vaping products have been discussed widely in the media and resulted in a huge amount of regulatory change in the US. But what implications does all this have on regulation in other global markets, including Europe where discussions are about to start on a revision of the Tobacco Products Directive? And how has the market reacted to the changing legal landscape? As we look ahead to a new market environment where other reduced risk products are being offered to consumers such as heated tobacco and nicotine pouches, how does the changing market for combustible alternatives affect development of policy and regulation in this area?

The UK Stop Smoking Services in a new era:  Robert West leads a conversation with three stop smoking advisor/service practitioners to explore the real-life experiences of cessation services. Much of the conversation around e-cigarettes focuses on scientific, policy and regulatory debates.  This session will look at how this translates in practice and ask:

• How has vaping influenced or changed the stop smoking service and how does this fit within the traditional NRT and Medicinal tool kit
• Do you think there is a value for a medicinal e-cigarette that can be prescribed
• What concerns do service users have about e-cigarettes
• What was the experience of developing vaping policies within the local government and/or health hierarchies
• Flavours and nicotine limits remain contentious issues   -what are your views
• How long should people vape for
• What advice would you give to a commissioner who wanted to add vaping to their menu of options for service users
• have e-cigarettes had a positive or negative impact on stop smoking services and the community they serve.

There is growing and widespread concern about youth use of e-liquid flavours. Findings from a review of recent research evidence confirms that young people prefer fruit and sweet flavoured e-liquids. People like vaping liquids that taste and smell good. Do flavours, therefore, tempt young people to start using nicotine, on a pathway from vaping towards tobacco smoking dependence? Or  do flavoured e liquids divert young people away from harmful tobacco smoking, and support smoking quit attempts? For adult smokers, particularly perhaps those who are vulnerable and find it most difficult to quit, might enjoying using e-liquid flavours actually promote not only cessation, but sustained tobacco smoking abstinence? The evidence will be considered within a context where societal discourses of ‘protecting innocent children’ prevail, alongside deficit based moral discourses positioning nicotine addiction as ‘bad’.  Furthermore, international regulations categorising e-cigarettes as tobacco products cause considerable confusion, through implication by association that potential e-cigarette harms are on a par with the known serious harms of tobacco smoking. There is serious, consequential, misinterpretation of observational evidence. Might it be time to consider flavouring, as one aspect of the sensory pleasure of e-cigarette use, as a positive means to supporting long term smoking abstinence?

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Even before the Covid-19 pandemic the UK was a widely divided nation in terms of health outcomes and quality of life. Contributing to this is tobacco smoking and dependence. Smoking rates are disproportionately high amongst those living with substance disorders, without secure accommodation and with a severe mental illness. Early in the pandemic it was highlighted that smokers living with these comorbidities were at increased risk of infection and needed help to quit smoking and to reduce risky smoking practices. In this talk case examples and survey data will highlight some of the third sectors response through the offer of an e-cigarette to adults seeking shelter and using drug services. The precariousness of this 'tobacco teachable moment' will also be discussed, highlighting how poor science and media reporting can undermine these efforts.

When it comes to the vape industry, there are two contrasting public health narratives. According to one, plucky little vape shops are helping people stop smoking; according to the other, the tobacco industry uses e-cigarettes as a fiendish new way to enslave our kids. There is little understanding of the wide range of players in the industry, their changing market strategies and most importantly, the impact of these strategies on smokers deciding to switch. Drawing on research with smokers, vapers and vape shops in the North of England, I will outline some of the approaches used by industry players to survive in a crowded market, including offering specialist expertise, building consumer trust and ensuring good product distribution. I will contrast these strategies with the overwhelming customer emphasis on price, explain some of the reasons for this and draw some conclusions about the global prospects for tobacco harm reduction.

The scientific agenda for research on reduced risk tobacco products remains splintered and counterproductive. This is because stakeholders have different goals in mind for what research ought to be able to demonstrate and which positions it should support. Tobacco and nicotine companies, naturally, hope to demonstrate that new, alternative products, compared to cigarettes or other combustibles, carry less individual health risks. Regulators more or less are open to harm reduction science, but have not been clear on defining what types of methods and evidence qualify. Regulators are also wary of potential risks because no tobacco or nicotine product is, strictly speaking, risk free. Tobacco control activists’ agenda is to demonstrate irredeemable harms attached to any and all tobacco or nicotine consumer products, or at least to raise sufficient doubts about potential future harms vs benefits. This has resulted in an asymmetric research agenda focused on harms not benefits. This agenda is driven by mythologies that perversely attract scientists’ attention yet cannot be adequately addressed within the scope of current scientific methods (e.g., the “gateway” hypothesis, nicotine-caused brain damage, e-cigarettes don’t help smokers quit). This has led to wheel-spinning and little forward progress. I will discuss ways that the scientific community can address these myths, reassert its scientific authority, and establish a positive research agenda moving forward.

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The presentation will consider what needs to happen for less risky alternatives to kill off smoking. It will include some thoughts on what motivates efforts by activists and regulators that are preventing smokers from switching to less harmful options; and provide a review of some of the developments that are improving the competitiveness of less harmful alternatives against cigarettes.

In this session Dr Jasjit S. Ahluwalia reflects on the broader issues surrounding the science and evidence on e-cigarettes and tobacco harm reduction.  With thoughtful consideration, he will discuss the available health evidence on pulmonary, cardio vascular and cancer and consider this in context of all users and product evolution and safety.  He will ask:

• What do we know?
• What do we need to find out?
• …and finally, does it matter?

The stunning success of tobacco control rests on two pillars:  unimpeachable scientific evidence about the harm caused by inhaling (either directly or passively) combustible tobacco smoke, and damning evidence of the duplicity of the tobacco industry.   Today, the controversy over the use of tobacco harm reduction devices threatens those pillars.   In their zeal to protect youth from the hazards of vaping, too many well-meaning researchers and advocates have gone beyond the evidence to overstate the dangers of harm reduction.    In so doing, and at a time when authorities are suspected of disseminating “fake news,” we risk undermining our scientific and moral credibility, thereby damaging our prospects of further curbing the still devastating tobacco epidemic.

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