Reducing Global Burden of Tobacco and Nicotine-Related Noncommunicable Diseases

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Let's play the role of strategic advisors. Imagine an international public health organization has hired us. Our mission is to reduce the global burden of non-communicable diseases associated with tobacco and nicotine use, and provide recommendations. What would we do?

Firstly, let us define, restrict, and quantify the issue. According to the Global Burden of Disease study published in The Lancet in 2019, approximately 1.1 billion people consumed 7.4 trillion cigarettes. Globally, 7.7 million deaths were attributed to smoking-related diseases, causing a loss of 200 million disability-adjusted life years. Apart from the burden of death, smoking also brings additional economic and health harms. Policy responses, such as stigmatization campaigns and smoking restrictions, may have valid reasons to reduce disease and protect non-smokers, but they increase the burden on continuing smokers. This issue is mostly caused by smoking - inhaling the products of burning tobacco - rather than by directly using nicotine drugs.

Secondly, we need to determine why this problem still exists. Is it simply a matter of informing people when it causes so much harm? For anti-smoking pioneers since the 1960s, the answer seemed obvious. Doctors would educate people on the risks, and smokers would re-evaluate their interests and quit or never start smoking. Some analysts believe that this may be the only effective anti-smoking strategy, but it has been very slow to take hold. Our working theory is that there is a strong potential demand for nicotine and it may become addictive. We identify that for some people, the use of nicotine may be reasonable or attractive due to its emotional control, cognitive advantages, and pleasure sensations. We note that there is a long time lag between positive reinforcement experiences from smoking and the most serious health effects, and people tend to underestimate or downplay future negative consequences compared to immediate gratification today. However, if we can differentiate the experience of using nicotine from the harm of smoking it, there may be a way to address this issue.

Thirdly, there are issues with what we are already doing. It may be the case that evidence-based tobacco policies have not been as effective as intended across multiple countries and generations. Despite coordinated efforts spanning 50 years, around one in seven adults still smoke in the UK and US, and around one in four adults in the European Union smoke. Given that 80% of smokers are in low and middle-income countries, we must ask whether strict and sustained regulation, fiscal measures, and advocacy efforts to reduce smoking and nicotine use are viable and sustainable. Or will progress be slow and incremental, as seen in Europe and North America? We continue to look for signs that the World Health Organization Framework Convention on Tobacco Control (FCTC) is making a difference, but surprisingly, there is little credible evaluation. An existing analysis published in BMJ found no evidence "to suggest that progress in reducing global tobacco consumption has been accelerated by the FCTC treaty mechanisms.

Fourthly, can established measures go further? The issue with increasing current leverage is that we may begin to encounter obstacles of public agreement and political acceptability (politicians are only willing to take a certain level of hardline stance on their constituents), or we may start to see unintended minor consequences escalate. For example, high tobacco taxes may trigger a black market or negative behavioral response. The public may think that smoking bans in the workplace can protect workers, but do they have the same feelings about banning outdoor smoking? We may increase enforcement, but the danger is that these measures begin to appear restrictive, excessive or unfair. Should we escalate and simply ban cigarettes or compel manufacturers to remove nicotine instead? After all, if this is the problem, why not take the most direct way to solve it? Once again, given the experience of drug and alcohol prohibition, public agreement, political will and negative consequences are all foreseeable.

Fifth, what innovations can accelerate progress? Here, there is a potential game-changer. If the underlying need is for the experience of nicotine use, and the harm is caused by smoking and inhaling combustion products, then there is a clear path forward. Our main strategic recommendation is to do everything possible to refocus the nicotine market from dangerous smoking products onto safer smokeless products, estimated to have over 100 million users. Adopting this strategy for two reasons. Firstly, it provides a relatively simple way for existing smokers to transition to a product that eliminates almost all additional risks of continuing to smoke. When smokers switch, they need not give up nicotine, the sensory experience, or most of the behavioral rituals. Secondly, these products offer low-risk alternatives for people who hope to use nicotine in the future. This second function is essential because we believe that stopping future nicotine use is much like how we can reduce caffeine, alcohol, or marijuana use. For our efforts to reduce demand for nicotine, it mainly relies on measures to convey information and address the harm caused by smoking. But this is precisely the harm we are trying to eliminate. We need to rethink our relationship with nicotine.

Sixthly, how can we accelerate the process? Here, we can rely on the economist Joseph Schumpeter's concept of "creative destruction," which refers to the constant process of thoroughly changing the economic structure from within, destroying old structures and creating new ones through industrial mutations. Should we wait for this process to run its course? Of course not! Four key background pressures will inevitably drive creative destruction in the cigarette market. The correct strategy for governments, civil society, and the tobacco industry is to shape their efforts to increase the speed of smoking cessation, thereby creating a viable, low-risk nicotine market.

The Information Environment: What Do People Think of Smoking and Alternatives? What Do Reliable Professionals and Organizations Recommend? What Are Newspapers Reporting, and How Reliable Are Scientists' Findings as Conveyed in Scientific Papers and Press Releases? Significant Efforts Have Been Made in Tobacco Control to Combat Misconceptions Regarding Relative Risk and to Discourage Smokers Who Would Choose to Quit. The Information Environment Is Highly Polluted with Harmful Misinformation.

Regulatory Environment - Regulations can encourage consumers to move from high-risk products to low-risk products, a method known as "risk-proportionate regulation." However, the regulatory environment for tobacco alternative products is filled with disproportionate regulations, including outright bans, flavor bans, nicotine level restrictions, advertising bans, and more. Similarly, the current trend protects the cigarette trade.

Financial Environment - The taxation system can incentivize consumers, retailers, and manufacturers to prefer low-risk, smokeless alternatives over high-risk cigarette products. However, there are ongoing calls to increase taxes on e-cigarettes and heated tobacco products to the same level as cigarettes. This approach is contrary to the current direction of taxation.

How do market conditions affect the emergence of product improvements and new companies in the innovation environment? Is market competition or oligopoly formation a barrier to innovation? Does pushing products to the market (such as the US Food and Drug Administration) or notifying and complying with standards (such as the European Union) require significant regulatory costs and delays? Should innovators be allowed to communicate and explain their innovations to consumers or should advertising and other commercial communication be prohibited? Is innovation meant to improve the customer experience related to cigarettes or is it primarily aimed at regulatory compliance that has little impact on product users?

These pressures will fundamentally change the tobacco market, potentially destroying some companies but revitalizing others. Determined goal-driven strategists will shape these four environments to leverage market dynamics for public health. This will mean challenging those who claim to represent public health interests while doing everything possible to slow market-based extinction of cigarettes. They may slow necessary and inevitable transitions and lead to thousands of deaths. But ultimately, innovation will prevail. Every stakeholder involved should understand the implications and take appropriate action.

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