Predicting the future of smoking in a rapidly evolving nicotine market‐place

The nicotine product market is global and rapidly evolving 1. Factory-made cigarettes still dominate the market accounting for nearly 90% of overall sales. However, overall cigarette sales globally have been steadily dropping by approximately 2% annually. In some parts of the world cigarettes have been displaced by less harmful forms of nicotine delivery. For example, in Sweden, oral snus has largely displaced cigarettes as the predominant form of tobacco consumed with corresponding reductions in the incidence of smoking-caused cancers, heart disease and respiratory diseases 2, 3. The eventual demise of conventional cigarettes has long been anticipated and planned for by cigarette companies. As one R.J. Reynolds’ executive observed in 1982, ‘if the exit gate from our market should suddenly open, we could be out of business almost overnight’ 4. As early as the 1960s, cigarette manufacturers were patenting nicotine vaping devices that could be used by smokers as substitutes for cigarettes, if and when competition emerged to threaten the conventional cigarette market 5, 6. In the late 1990s and early 2000s, market forces against cigarettes began to shift radically. Manufacturers were forced to admit that their cigarettes were deadly and addictive 7. A number of governments adopted more effective policies to reduce cigarette demand(i.e. excise taxes, public smoking bans, product and marketing regulations, graphic health warnings and mass media campaigns), and technologies emerged that allowed non-cigarette vaping manufacturers to market their products directly to consumers over the internet bypassing the marketing controls that had long allowed cigarette manufacturers to operate without real competition 8, 9. In United States and England, nicotine vaping products (NVPs) have displaced stop smoking medications approved by regulatory bodies as the most popular stop smoking aid used by adult smokers 10, 11. Vaping nicotine is not harmless, but it is much less harmful than smoking 12, 13. However, it is too early to know for sure what the long-term health risks and/or benefits of nicotine vaping will be, as those risks are not only influenced by the types of products used, but also by how the products are used and by whom. Vaping behavior is complex, and not as easily quantified as is smoking behavior. The motivations for vaping are also more varied than they are for smoking, and the products themselves differ widely in their nicotine delivery compared to cigarettes. Further complicating matters is the lack of consensus from public health officials about how best to regulate the evolving nicotine product market-place. Some jurisdictions have taken what they see as a cautious approach towards vaping products, relying on conventional smoking control policies to reduce smoking while erecting barriers limiting consumer access to NVPs 14. For example, Australia has among the strongest anti-smoking policies in the world, but has made it illegal to possess nicotine e-liquid without a doctor's prescription. Canada, another country with very strong anti-smoking laws, also, until recently, restricted the sale of NVPs in retail establishments absent government approval. However, unlike Australia, Canadian health authorities were less strict about enforcing the retail sales ban on vaping products, allowing vape shops to proliferate 15. Previous studies have reported that the restrictions on vaping products in Australia and Canada have suppressed vaping prevalence and influenced where vapers report purchasing their vaping products (i.e. primarily online for Australian vapers, and vape shops and online sources for Canadian vapers) 14. Beginning in May 2018, Canada began allowing the marketing and sale of vaping products in retail stores similar to what has been allowed in England and the United States. During the last two decades, England has adopted many of the same strong anti-smoking policies that have been implemented in Australia and Canada, but unlike Australia has encouraged smokers to switch to NVPs. On a national level, the anti-smoking policies in the United States are not as strong as they are in Australia, Canada and England, choosing instead to allow states and localities to lead tobacco control efforts, which has probably contributed to regional disparities in smoking rates. The United States is currently the largest vaping market in the world 1. In 2016, the US Food and Drug Administration (FDA) was granted authority to regulate nicotine vaping industry, but up until recently has resisted efforts to tightly regulate vaping products. However, that situation may be changing, as public health groups have raised concern about the risks of vaping and about the increased rates of youth vaping, pressuring the FDA to implement strict and costly approval criteria for product licensing 16. These four countries illustrate the complex relationships between smoking, vaping and the regulatory environments that help to shape the nicotine markets in each jurisdiction. The diversity of approaches taken by these four countries constitutes a unique natural experiment for measuring and understanding the impact of different regulatory environments. Thus, it is challenging to predict what the future impact that the evolving nicotine market-place may have on population health in any given jurisdiction. However, that is precisely the challenge that investigators involved with the International Tobacco Control Policy Evaluation (ITC) Project have taken on as reported in this special issue of Addiction. This issue contains 13 papers spanning a wide range of topics from broad descriptions of NVPs and usage patterns, motivations for using vaping products, beliefs and attitudes about nicotine vaping and the impact of various policies on vaping and smoking behaviors, and the projected impact on population health outcomes 17-29. These 13 papers point out some of the limitations of the data available on vaping, smoking-vaping transitions and health risks, and highlight the challenges in predicting how the evolving nicotine delivery market in different jurisdictions might impact population health. The answer to this may depend upon where one lives. In markets such as the United States and England, where the nicotine vaping industry has flourished, cigarette sales are declining quite rapidly. However, cigarette consumption is also falling in Australia, where public health officials have adopted policies suppressing the nicotine vaping market. The similarity in the basic trend of falling cigarette consumption in Australia versus the United States and England suggests that it is necessary to consider the impact of both policies designed to reduce smoking and policies that are relevant to vaping products (some of which are more restrictive and some of which are less restrictive). Perhaps access to NVPs is less critical in locations with strong smoking control policies already in place and where the smoking epidemic is on the wane. Conversely, the opposite might also be true in countries that have already implemented demand-reduction policies of the World Health Organization (WHO) Framework Convention on Tobacco Control (taxation, smoke-free, pictorial warnings, advertising bans and cessation support, corresponding to WHO's ‘MPOWER’ policy package) at the highest level. In such countries, lower-risk alternative nicotine products may make proportionately greater contributions to reducing smoking than in countries where WHO FCTC policies have not yet been fully implemented. Indeed, the diminishing reductions in smoking prevalence in high-income countries, where WHO FCTC policies have been strongly implemented, has been a central argument for why alternative nicotine products should be permitted and regulated in ways that encourage smokers to switch to them 30. It is also difficult to predict the possible impact of NVPs in countries where smoking rates are still increasing. In such countries, the impact of NVPs may depend on the combined effects of a number of factors including commitment to implementing the policies of the WHO FCTC, which has been shown to be associated with substantial reductions in smoking prevalence 31. As Yogi Berra is attributed to have said: ‘Prediction is difficult, especially about the future’ 32. K.M.C. has received payment as a consultant to Pfizer, Inc., for service on an external advisory panel to assess ways to improve smoking cessation delivery in health care settings. K.M.C. has also served as paid expert witness in litigation filed against the tobacco industry. G.T.F. has served as an expert witness on behalf of governments in litigation involving the cigarette industry. This study was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477) and by the National Health and Medical Research Council of Australia (APP 1106451). G.T.F. was also supported by a Senior Investigator Award from the Ontario Institute for Cancer Research.

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