Smokeless Fuels the Tobacco Debate
More than ever, people are shunning tobacco. In England, adult smoking prevalence fell to 15.5% in 2016. Although smoking is declining worldwide, it is on the rise in Eastern Mediterranean and African regions. Despite its dwindling popularity in many countries, smoking remains the leading preventable cause of illness and premature death in the world.
Helping people quit smoking for good is a priority for health services. Tobacco companies, having taken control of the e-cigarette market, are aligning themselves with the “smoke free” message. Their centrepiece, however, is composed of new devices that heat tobacco to extract nicotine without combustion so users inhale an aerosol infused with nicotine in place of smoke - as opposed to an e-cigarette that heats a liquid that may or may not contain nicotine. The manufacturers maintain these new devices play no role in tobacco cessation but appeal to smokers who don’t want to miss out on nicotine.
Smoking quit rates in England are at an all-time high with e-cigarettes playing their part. In the UK around 2.85 million people currently use an e-cigarette, almost all of whom are smokers or ex-smokers. Around 1.5 million report that they have quit while 1.3 million remain dual users, switching between an e-cigarette and tobacco. Small numbers of people vape nicotine-free liquids, and e-cigarette use among "never smokers" remains very rare, at less than 1%.
It’s the failure to completely kick nicotine addiction that remains most troublesome for insurers seeking to differentiate smokers from non-smokers.
The stated opinion of Public Health England (PHE) is that e-cigarettes are 95% less harmful than tobacco.1 They have concluded that heated tobacco devices may be considerably less harmful than tobacco cigarettes but more harmful than e-cigarettes. The U.S. Food and Drug Administration (FDA) also remains to be persuaded that heated tobacco devices are less harmful than e-cigarettes.2 It wants nicotine in cigarettes reduced to non-addictive levels and has granted no company the right to specifically claim that their product is less risky than cigarettes.
Over half the studies available to PHE were paid for by tobacco companies. Research that is free of such obvious commercial interest is needed if we are to understand whether or not heated tobacco products complement or replace cigarettes.
In tests, PHE found heated tobacco products deliver less nicotine than the tank style e-cigarettes favoured by 80% of UK vapers, and consistently below the levels drawn from burned tobacco. Users find them less enjoyable, too. For smokers this is mainly to do with “throat hit” the sensation of swallowing down smoke. It’s a problem the manufacturers acknowledge; satisfying committed smokers using a plastic contraption in place of a real cigarette is not easy.
Changing people’s behaviour is notoriously hard to achieve, more so when an element of the behaviour is maintained through addiction. Smoking behaviour is particularly complex and the industry serving it depends on maintaining that addiction. There are parallels with the failure of public health initiatives to influence people to act on healthy eating, exercise and sexual health, use of alcohol, illicit drugs and tobacco.
While the evidence presented by the tobacco companies is fulsome and even impressive, questions will inevitably linger over the validity of evidence sponsored by an industry which has a track record of making unfounded claims of reduced risk. Insurers need to see that heated tobacco devices significantly reduce the risk of disease and not encourage more smoking or delay quitting. Meanwhile, as nicotine is a core component and doubts remain over dual usage, insurers must charge users of heated tobacco products the full smoker tariff.
- McNeill A., Brose LS., Calder R., et al., Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. London: Stationery Office, 2018. https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review.
- Reuters (2018) FDA’s tobacco stance faces test with Philip Morris iQOS device, 22 January 2018, available at https://www.reuters.com/article/us-health-tobacco-pmi/fdas-tobacco-stance-faces-test-with-philip-morris-iqos-device-idUSKBN1FB0J2.