Session 1: 2021 Seminars

Information to follow

The  public health tobacco goal is to prevent early death and disease caused by burnt tobacco products, especially cigarettes. The WHO Framework Convention on Tobacco Control  (FCTC), which came into force 15 years ago, is central to this endeavour. A first step is for all countries to ensure the effective and equitable implementation of the FCTC, as summarised by the MPOWER interventions. However, this alone is insufficient. Even where these interventions have been fully applied such as in New Zealand and Australia, smoking rates are falling only slowly and most of the progress has occurred in privileged sections of society further marginalising the most vulnerable. The second step is for all countries to embrace tobacco harm reduction (THR) alongside traditional approaches. Innovations in the delivery of nicotine such as e-cigarettes and heat not burn products offer an opportunity to accelerate THR progress. Sweden, with the widespread use of snus and now the lowest rate of smoking in the world, provides proof of the value of THR. Regrettably, the widespread adoption of THR is facing many impediments, notably from WHO and well-funded advocacy groups guided by poor quality science. Success will involve: full implementation in all countries of all available interventions, including THR, with WHO providing evidence-based technical leadership and facilitating dialogue rather than encouraging prohibition of less harmful products. The short-term  measure of success will be for all countries to match the successes of the best performing countries and achieve a very low adult prevalence (<5%) of cigarette smoking by 2040.

Science is a social activity embedded within a complex research ecosystem, and conducted by highly-trained individuals who are nevertheless human. There are therefore external and internal factors – incentives and cognitive biases – that can shape the behaviour of scientists, the questions they ask, the methods they use, the analytical choices they make, and the conclusions they draw. The factors may be particularly important in research areas where there is considerable uncertainty, and where personal values may come into play. Understanding the nature and impact of these factors, and developing frameworks for arriving at consensus, will be important if we are to make genuinely evidence-based policy recommendations.

Cochrane is a global non-profit, known for producing unbiased and high-quality reviews of healthcare evidence. The Cochrane review of e-cigarettes for smoking cessation was first published in 2014 and has been updated four times since then. Every update brings more evidence showing that e-cigarettes can help people quit smoking, but disagreements persist on interpretation of this evidence base. Perceptions of uncertainty regarding the effectiveness of e-cigarettes for smoking cessation can have wide reaching consequences.

Every researcher can be potentially motivated by factors other than an objective search for truth. The clinical research community has addressed some of these factors by requiring declarations of competing interests. These mostly focus on financial links with companies that may stand to gain or lose from findings or views being presented. The rules are important but, like most rules, they need to be applied diligently and fairly if they are not to do more harm than good. In the field of e-cigarette research, this presentation will argue that unfair application of the rules is leading to significant bias. On the one hand, acceptance by researchers of research products from e-cigarette companies with no financial gain to researchers is judged by opponents of e-cigarettes as grounds for disregarding findings and heaping opprobrium on the researchers concerned. On the other hand acceptance of career-enhancing grants from organisations that are strongly opposed to e-cigarettes does not appear to be regarded as an issue. In this way, competing interest principles are arguably being weaponised in what some regard as a war on tobacco users rather than a war on tobacco. The application of competing interest principles needs to be scrutinised by the scientific and public health community to achieve balance

Current policy approaches to e-cigarette regulation in the USA give primacy to the need to protect children from addiction over fostering increased adult smoking cessation.  But, as well as failing to maximise the potential public health gain from adult use of new nicotine delivery products, the focus on minimizing children’s use of e-cigarettes might itself be a net contributor to harm at the population level, by inadvertently favouring the incumbent cigarette and hampering the transition to genuinely reduced risk alternatives.

This talk will give data from the Youth Risk Behavior Survey, conducted on a national sample of high school students in the USA, on risk behaviours in a number of domains, including drug use, violence, sexual behaviour, psychological wellbeing, and school attendance and performance.  Current use of e-cigarettes and cigarettes are both associated with the whole range of problem behaviours, with the association being stronger for cigarettes than for e-cigarettes.  Causal pathways between different behaviours cannot be identified, but the occurrence of any one behaviour tends to be positively associated with all of the others, lending support to the notion of shared vulnerability factors, the so-called common liability hypothesis.   On this model, the rise in popularity of e-cigarettes to overtake cigarettes among youth is better understood as product substitution, rather than as a concerning new risk for enticing otherwise innocent youth into cigarette use and nicotine addiction.

The talk will also update information from the National Youth Tobacco Survey on nicotine dependence in youth e-cigarette and cigarette users.  It remains the case that indicators of dependence are highest in those who smoke cigarettes, and considerably lower in e-cigarette users.  In 2020 only 254,000 (2.3%) of otherwise tobacco-naïve high school students used e-cigarettes on 20 or more days in the past month.   The estimated overall population burden of nicotine dependence in youth has decreased between 2012 and 2020.

Is scientific evidence underpinning the THR dialogue or is ideological opposition influencing the debate?