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E-cigarettes and public health
Counterfactual
www.clivebates.com@clive_bates
Five talking points
1. The value proposition
Legal recreational drug
Nicotine rewards and reinforcement
• Nicotine induces pleasure and reduces stress and anxiety. Smokers use it to modulate levels of arousal and to control mood.
• Smoking improves concentration, reaction time, and performance of certain tasks.
• Relief from withdrawal symptoms is probably the primary reason for this enhanced performance and heightened mood.
• In addition, conditioning has an important role in the development of tobacco addiction.
Source: Neal Benowitz, N Engl J Med. 2010 June 17; 362(24): 2295–2303.
Nicotine rewards and reinforcement
• Nicotine induces pleasure and reduces stress and anxiety. Smokers use it to modulate levels of arousal and to control mood.
• Smoking improves concentration, reaction time, and performance of certain tasks.
• Relief from withdrawal symptoms is probably the primary reason for this enhanced performance and heightened mood.
• In addition, conditioning has an important role in the development of tobacco addiction.
Source: Neal Benowitz, N Engl J Med. 2010 June 17; 362(24): 2295–2303.
Value proposition: a smokers’ cost-benefit analysis
1. Keep smokingBenefit: nicotine effects, ritual, brand-related
Cost: illness, money, social disapproval, addiction
2. Quit smokingBenefit: avoid smoking harm
Cost: withdrawal symptoms, 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”
I smoked for 45 years and tried every NRT product available, none of them worked. I continued to smoke even though my health was getting worse, resulting in emphysema and using oxygen daily.
September 2011 I discovered e-cigarettes and they worked. It was like someone handed me a miracle. In less than a week I stopped using regular cigarettes. I haven’t had a tobacco cigarette since.
Unsolicited comment left on www.clivebates.com
Why now? … battery development
Source: ICCNExergy
Five talking points
1. The value proposition
2. The prize
WHO – 1 billion deaths
From WHO Tobacco Atlas 2006 edition
The Endgame?
Smokers: WHO Tobacco Atlas 2006. Population: UN
0.0
1,000,000.0
2,000,000.0
3,000,000.0
4,000,000.0
5,000,000.0
6,000,000.0
7,000,000.0
8,000,000.0
9,000,000.0Projected global adult population growth
Adult popu-lation
Smoker pop-ulation at constant prevalence
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0Scenarios for future smoker population
Constant pre-valence (28%)
Global smoking prevalence de-clines to 15%
The endgame?
Scenario – 15% global prevalence by 2050
If all goes well
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0Scenarios for future smoker population
Constant preval-ence (28%)
Global smoking prevalence de-clines to 15%
Contested by tobacco control
HARM
The endgame – a nicotine product contest?
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0Scenarios for future nicotine markets
Constant preval-ence (28%)
Global nicotine prevalence de-clines to 15%
Contested by nicotine products
Contested by tobacco control
How far could low-risk nicotine products go?
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0Scenarios for future nicotine markets
Constant pre-valence (28%)
Global nicotine prevalence de-clines to 15%
Contested by low risk nicotine products
Contested by tobacco control
Global smoking prevalence de-clines to 5%Cigarettes and other combustible tobacco
How far could low-risk nicotine products go?
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0Scenarios for future nicotine markets
This boundary matters most for public health
How far could low-risk nicotine products go?
0.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0‘Modified Herzog scenario’ for future nicotine markets
Constant pre-valence (28%)
Global nicotine prevalence de-clines to 15%
Global smoking prevalence de-clines to 5%
Disclaimer: this is a Counterfactual scenario not a Wells Fargo Securities or Bonnie Herzog scenario
Five talking points
1. The value proposition
2. The prize
3. Harm reduction equation
A regulator’s instinct
Mitch Zeller(now) Director of the Center for Tobacco ProductsFDA
Strategies should be pursued that encourage the use of the cleanest and safest form of nicotine delivery
Source: Zeller M. Reflections on the endgame for tobacco: Tob Control. 2013 May; 22(Suppl 1): i40–i41.
Harm reduction equation
Harm reduction = Reduced risk x Number who switch
Product toxicity & other risks
Product appeal
Consumer preference
Harm reduction categories – risk estimates
Cigarettes Smokeless E-cigs NRT0
20
40
60
80
100
120
Crud
e es
timat
e of
risk
– C
igs
= 10
0
0
More regulationLower risk
regulated e-cig “unregulated” e-cig
10 100
cigarettee-cigarettes
0 100
Focus on the right relative risk - illustration
Five talking points
1. The value proposition
2. The prize
3. Harm reduction equation
4. Much safer, many dead
Harm reduction equation
Harm reduction = Reduced risk x Number who switch
Product toxicity & other risks
Product attractiveness
Consumer preference
Analysts
We remain very bullish on the vast potential of e-cigs given the rapid pace of innovation. [We believe] that the benefits of e-cigs are becoming increasingly apparent to consumers, helping to drive trial and repeat purchases aided by stepped-up advertising and a lot of internet “buzz”
Bonnie Herzog, Wells Fargo Securities
Regulation – the dead hand
Reduced appeal
Increased cost
Greatly reduced variety & niche
products
Slower innovation pace
Fewer, duller innovations
Boring branding & marketing
Less personalisation
Trusted brands & firms
destroyed
Black market, DIY response
Harm reduction equation
Harm reduction = Reduced risk x Number who switch
Trade offs
Conclusion 1. The perfectly risk free product that no-one wants is useless for public health
Conclusion 2. A diverse range of products with substantially reduced risk lets each smoker decide which product is best
Much safer, many dead: regulatory triple negative
Tough on harm reduction
Tough on e-cigarettes
Easy on harm
Five talking points
1. The value proposition
2. The prize
3. Harm reduction equation
4. Much safer, many dead
5. The desperate search …for a problem
FDA Pre-Market Tobacco Application
FDA seeks evidence on population effects:
• +/- quitters– The increased or decreased likelihood that existing users of tobacco
products will stop using such products; and
• +/- starters– The increased or decreased likelihood that those who do not use
tobacco products will start using such products.
Harm reduction equation with population effects
Harm reduction = Reduced risk x Number who switch - Extra smokers + Extra quitters
Gateway exitsComplete cessation
Extra quittingNormalising non-smoking
Gateway to smokingDual use
Reduced quittingNormalising smoking
Gateway effects
Smoking followed e-cig use
E-cig use caused the smoking
Smoker does not revert to e-cigs or quit later
… and e-cigs not displacing smoking elsewhere
For there to be net harm caused by e-cigs…
CDC announcement 6 September 2013
“E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012”CDC Press release
"The increased use of e-cigarettes by teens is deeply troubling. Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”Tom Frieden, CDC Director
“These data show a dramatic rise in usage of e-cigarettes by youth, and this is cause for great concern as we don’t yet understand the long-term effects of these novel tobacco products.”Mitch Zeller, Director of FDA Center for Tobacco Products
CDC Press release 5 September 2013
Probing the CDC survey
• High school use doubled? – Ever use from 4.7 to 10.0%– Current use (last 30 days) from 1.5% to 2.8%
• High school cigarette smoking?– Decreased from15.8% to 14.0%
• E-cigs use in adults?– About doubled
• What would have happened had there been no e-cigs? – Can’t say, but…– 80.5% of e-cig current-users are current smokers– Zero evidence for a ‘gateway’ effect– Zero evidence of ‘marketing to youth’– Data consistent with experimentation and e-cigs displacing smoking
Five talking points
1. The value proposition
2. The prize
3. Harm reduction equation
4. Much safer, many dead
5. The desperate search …for a problem
Conclusion
• Be positive about the (vast) potential at individual and population level
• Put the (minor and mostly implausible) risks in perspective
• Regulate as though the 1 billion matter most
Thank you…
Counterfactual
www.clivebates.com@clive_bates