China is ramping up its efforts to control smoking. In 2023, 44 cities introduced or revised regulations, bringing the total number of cities with relevant regulations to 254 nationwide, according to national health authorities.
According to the Xinhua News Agency, 24 regions at the provincial level in China have rolled out smoking regulations, and the proportion of the population protected by comprehensive smoke-free regulations is continuing to increase.
Experts from the National Health Commission (NHC) released the data on Saturday ahead of World No Tobacco Day on May 31.
Meanwhile, as China pledges to protect 80 percent of its population with smoke-free laws by 2030, experts on tobacco control on Sunday called for the country to introduce a national smoking control regulation as soon as possible.
Smoking control, including preventing smoking and encouraging smokers to quit, is a viable approach for both population-wide disease prevention and individual healthcare, according to Wang Lu, a health expert from the NHC.
Curbing smoking doesn’t aim to deprive people of their right to smoke, but to free people from being hurt by secondhand fumes, Zhang Jianshu, a senior expert at the Chinese Association of Tobacco Control, told the Global Times on Sunday.
Innovation in the recreational nicotine market is revolutionizing the tobacco industry and disrupting tobacco control.
By Clive Bates
In his groundbreaking 1997 book, The Innovator’s Dilemma, Clayton Christensen defined the concept of “disruptive innovation.” The term is often used carelessly, but disruptive innovation has several characteristics that apply in today’s tobacco and nicotine market. In essence, it is a theory of how entrants to a market can challenge incumbents by focusing on unmet needs using novel business models exploiting simple enabling technologies.
In the nicotine market, the lithium-ion battery provided a critical enabling technology with sufficient power and energy density to replace combustion with electrical heating to create an inhalable aerosol in a compact and convenient form. Once the concept took off in the early 2010s, the technology rapidly evolved through at least four major generations during the decade. The disruption has never stopped, and the emerging incumbents in the vape industry now face disruption from disposable single-use vape products. It isn’t just technology; the business model has changed and adapted over time, embracing user-driven innovation, new retailing models such as specialized vape shops and international e-commerce, and a pro-health marketing proposition spread through social media.
A new wave of innovation is now breaking with the rapid rise of oral nicotine pouches. This newer trend may prove even more disruptive—a low-tech, low-cost nicotine delivery with negligible health consequences, no intrusion on others and none of the stigma attached to tobacco. Through vaping, consumers have deconflated tobacco and nicotine use and are now primed to adopt this technology.
The regulatory environment also played a critical role, but more for what it didn’t do than what it did. In the United States in 2009, the U.K. in 2010 and the European Union in 2013, there were failed attempts to classify and regulate vaping products as medicines. Several core pharmaceutical regulation concepts are hostile to vaping. Vaping products are not smoking cessation therapies but pleasurable consumer alternatives to smoking that require nicotine delivery equivalent to cigarettes. Medicine regulators are not at ease with pleasure, or what they would call “abuse liability,” yet pleasure is integral to their success as consumer products.
Let’s delve deeper and ask who is disrupted and how.
First, the incumbent tobacco companies. In the standard model of disruptive innovation, these giants would be caught off guard by fast-moving entrants bringing new technology to a vanguard of early adopting consumers, rapidly changing the market dynamics. This would be felt most keenly as a loss of “pricing power” (the ability to raise prices to compensate for declining cigarette volumes) and a squeeze on margins and revenue in the profitable incumbent cigarette business. This should happen as the existing customer base of people who smoke is exposed to a wide range of low-cost alternatives without many downsides. So far, I don’t think this squeeze on the cigarette business has happened to anything to the extent it might have and still could, even though the companies have entered these markets and developed heated-tobacco products. The reason is that regulators are slamming on the brakes in response to activist and political pressure—disrupting the disruption. Regulatory excess has combined with activists and academics working tirelessly to nurture false risk perceptions and reinforce doubt about the wisdom of stopping smoking by switching to a reduced-risk product. The tobacco industry has been protected from the most severe disruption with the unintentional help of the tobacco control mainstream.
Second, disruption has wrong-footed regulators and legislators. In response to rapid changes in the market, regulators and legislators have blundered in without first understanding (or perhaps without caring about) the complex adaptive system in which their rules would be applied. Because the new products function as economic substitutes for cigarettes, we expect three primary responses to excessive regulation: more smoking than there otherwise would be, more illicit trade in the new products, and consumers adopting risky workarounds, such as mixing their own flavored e-liquids. For example, limiting nicotine strength in the European Union made it harder to bring to market the pod devices that have been successful in reducing smoking in the United States. Flavor bans in the United States made vapes less appealing and caused more people to smoke, in some cases including young people. The prescription-only availability of vapes in Australia has led to a chaotic, lawless mess, with more than 90 percent supplied via informal, illegal channels. With their mission to protect the young from vaping, regulators forgot that in a world without vaping, many young people would smoke and, therefore, are benefiting from vaping.
Third, the rise of the confident consumer. Consumers are the primary beneficiaries of the radical reduction in health and welfare detriments of smoke-free products. We are used to smokers burdened with regret, challenged with stigma and punished by anti-smoking policies. But all of that is driven by the health implications of smoking and the policy response that started in the early 1960s. How does the recreational nicotine consumer change if they are no longer troubled by the health and welfare implications of nicotine use and related policies? Simple economic theory suggests that if the costs and nonmonetary detriments of nicotine use fall, then demand will rise. It is likely, in my view, that there will be new users of nicotine who would never have become smokers in the absence of much safer products. For some, that is profoundly disturbing. For me, it is almost an inevitable consequence of having far lower risks and there being a latent demand for the real or perceived hedonistic, functional and therapeutic benefits of nicotine. Public morality may be shocked, but more people (of any age) using much safer products should not cause a public health crisis—we would be moving to substance use more like drinking coffee.
Fourth, the existential threat to the tobacco control complex. The public discussion of the emerging landscape of low-risk consumer products seldom focuses on the interest group that is most vulnerable to disruption: the mainstream of tobacco control. It is a complex of interests comprising nonprofit activists, academics, medical and health societies, major institutions (such as the World Health Organization or the U.S. Food and Drug Administration), philanthropists and research-funding bodies. The problem for the mainstream of tobacco control is that without serious harm, the whole movement loses its purpose and its reason to exist. When it comes to low-risk alternatives to smoking, this complex is profoundly confronted by the threat of having nothing to control, no case for intervention and no reason to be. It is a powerful incumbent interest group challenged by new technology, new suppliers and new consumer confidence.
As a result, the mainstream of this interest group has rejected tobacco harm reduction as a strategy for addressing its own notional goals of reducing death and disease from tobacco use. Instead, it has mounted a rear-guard defense based on a range of strategies, including the following:
Falsely implying that noncombustible products are no less risky than cigarettes, that data is too uncertain or short-term, or asserting that reduced risk is no more than a marketing claim of tobacco companies.
Asserting that harm reduction is merely a commercial strategy of tobacco companies. The aim here is to attach the reputational baggage of “Big Tobacco” to these new developments. Yet, many independent experts support tobacco harm reduction, and it is good if tobacco companies adopt a business model aligned with reducing health impacts.
Excluding or stigmatizing contrarian opinions and creating sealed bubbles open to groupthink. The WHO Framework Convention on Tobacco Control has taken this to new extremes.
Shifting emphasis to problematize nicotine rather than the “tar” of cigarette smoke that is the cause of nearly all tobacco-related disease. We are hearing more about “addiction” and less about cancer. Yet, a dependence only meets the definition of addiction if there is serious net harm to the user.
A relentless focus on the supposed interests of children without recognizing that would-be smokers among adolescents also benefit from low-risk products and that the demand for nicotine has persisted across generations for hundreds of years. Young people have an interest in the health of the significant adults in their lives as carers, breadwinners and role models.
Pressing for prohibitions or equivalent regulation to cigarettes, often with manipulation of language to imply equivalent risk, for example, by stating that heated-tobacco products produce “smoke” or that all tobacco products should be treated the same even though they have very different risks.
A blunt refusal to face trade-offs (for example, between the interests of youth and adults) or unintended consequences (for example, increases in smoking) arising from favored policy positions.
I have watched on in horror as the leadership in tobacco control, albeit with many honorable exceptions, has dogmatically denied and suppressed the opportunity to radically reshape the recreational nicotine market to cause vastly reduced harm and avoid hundreds of millions of premature deaths. It looks like a nervous breakdown is developing in tobacco control in response to profound disruptive innovation. I doubt they will survive it.
Clive Bates is the director of Counterfactual Consulting and the former director of Action on Smoking and Health (U.K.).
Ghana’s government has developed a five-year National Tobacco Control Strategy (NTCS) with a goal of decreasing the consumption rate of tobacco in the country, reports The Ghanaian Times. The end goal of the NTCS is to eradicate all tobacco usage.
The Ministry of Health, the Food and Drugs Authority (FDA), the World Health Organization and the United Nations Development Program put the strategy plan together along with advocate policymakers on tobacco control.
According to Baffour Awuah, acting director of the Technical Coordination Directorate of the Ministry of Health, cardiovascular disease rates due to increased smoking are rising.
“The strategy we are launching today is the climax of extensive collaboration, research and commitment by various stakeholders, experts and civil society,” Awuah said. “Its purpose is to guide us in combatting the devastating effects of tobacco use, both in terms of health and the economy.
“It aims to ensure effective coordination among agencies involved in tobacco control, setting clear goals and adopting strategic timelines.”
Awuah encouraged stakeholders to actively engage in discussions to help transform the document into tangible action.
Olivia Boateng, director in charge of tobacco and substance abuse at the FDA, stated that illicit trade in tobacco products has made them more accessible at lower prices. The country has made progress in tobacco control policies, but the illicit trade has “amplified the tobacco epidemic,” according to Boateng.
Stakeholders will be trained on the protocol to eliminate illicit trade in tobacco products in the country once the NTCS is implemented, according to Boateng.
It is time to confront the fundamental confusion about the public health aims for tobacco and nicotine policy.
By Clive Bates
In 2013, the journal Tobacco Control published a supplement, “The Tobacco Endgame,” setting out various ways in which various experts thought a tobacco-free society could be attained. Ideas included annually increasing age limits, a cap and trade system, outright prohibition, taking control of the industry and making it put itself out of business, and removing most of the nicotine from cigarettes. In the intervening seven years, most of these ideas have not progressed at all. And rightly so, as I argued in a detailed critique, these policies are mostly impractical or excessively coercive and would fail if tried. The only one that attracted any real interest was the idea of lowering nicotine concentrations in cigarettes to make the product subaddictive (i.e., to eliminate the main reason people smoke). But even this de facto prohibition has not fared well. After backing the idea in 2017, the U.S. Food and Drug Administration (FDA) dropped the reduced nicotine rule from its regulatory plan in 2019. The most senior researchers engaged in the idea recently acknowledged that its viability would depend on the availability of credible safer alternatives to smoking.
So, all this begs the question, where is the endgame now? Or maybe the more interesting prior question is: endgame for what? What will end and what, if anything, will continue? Does the endgame mean the end of tobacco and nicotine use? Or is the endgame, as I believe, the final stages of a transition—a shift from an unsustainable to a sustainable nicotine market?
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At the heart of this question is a fundamental confusion about the public health aims for tobacco and nicotine policy. This dispute is rarely surfaced and never resolved but confronting it has now become unavoidable. At least five objectives can be identified in tobacco control: (1) reducing disease and premature death; (2) eliminating smoking and smoke exposure; (3) eliminating tobacco; (4) destroying the tobacco industry; and (5) achieving the nicotine-free society or “ending nicotine addiction.” When the consumer nicotine market was supplied almost exclusively by cigarettes, it was possible for activists to say, “all of the above.” Activists could get away without having to declare or even recognize their underlying aims or to face the trade-offs and tensions between them.
No longer.
Even in the 1990s, splits in tobacco control were already emerging over snus, an obscure Scandinavian oral tobacco product. The faction interested in reducing disease was intrigued by Sweden’s abnormally low smoking rate. Toxicology and epidemiology suggested that substantially lower rates of disease in Swedish men were due to use of snus as an alternative to smoking. For that group, the harm reduction potential of snus had great potential. However, the faction interested in the end of tobacco saw the European Union’s ban on snus (other than in Sweden) as a win and incremental progress toward their goal of the tobacco-free society. Thirty years later, snus remains banned in the European Union despite undeniable evidence that snus reduces smoking and by doing so, reduces individual and population harm. This willingness to forego major public health benefits should tell us something fundamental: The dominant tobacco control faction is engaged in a war-on-drugs mission and not, as often assumed, a public health crusade. It is trying to forge a path toward a nicotine-free society with little concern for the collateral damage inflicted to health on the way to meeting its goal.
However, the rise of vapor and heated-tobacco products in the last 10 years means this is no longer a localized conflict. The harm reduction “proof of concept” of snus can now be generalized to an experience much closer to smoking in every respect other than harm to health. Add in the recent developments in oral nicotine pouches, which will make snus-like products more acceptable to a much larger population, and the diverse portfolio of smoke-free alternatives to smoking is starting to look quite formidable. The products available to nicotine users have changed beyond recognition in the last 10 years. If we project forward through another 10 years or 20 years of innovation in these new categories, imagine how the market could look in 2030 or 2040.
This is the opening phase of the technology disruption now roiling the industry. But it is also disrupting the tobacco control community by surfacing the tensions between its objectives. In particular, we are seeing the goal of the “nicotine-free society” coming to the fore, with an increasing stress on nicotine and the inclusion of goals to end nicotine use or “nicotine addiction” where there was previously an aim to pursue the end of smoking or to prevent disease.
Even many public health supporters of “tobacco harm reduction” see the smoke-free products as an expedient and effective way of helping to stop smoking—a sort of pimped-up nicotine-replacement therapy. And that is a good argument, as far as it goes. But it doesn’t really settle the question of our collective attitude to nicotine over the longer term.
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To look ahead, let’s consider the situation in Norway where daily smoking among 16-year-old to 24-year-old women has fallen from 15 percent to only 1 percent in just 10 years, according to 2019 data from Statistics Norway. Have they stopped using nicotine? No, they have been using snus from the outset. By 2019, daily snus use was at 14 percent in this group. That group is now using nicotine without ever starting to smoke, and they probably never will. Harm reduction supporters argue that this is “a win” for public health because without the use of snus, many of these young women would otherwise be smoking. But how will that argument look in 10 years or 20 years when cigarette smoking may be well on the way to obsolescence?
Here we need to confront the deeper question about nicotine that goes beyond harm reduction in which the cigarette is the reference point for harm. The concept of harm reduction feels unsatisfactory in this context—what if no one uses a harmful product to start with? If there is going to be a long-term market for nicotine, the question becomes how to regulate a recreational nicotine market based on consumer-appealing products with risks that are within our normal appetites for risk? I believe the product portfolio is now evolving toward how it could look over the longer term—smokeless and electrically heated tobacco and nicotine products. I don’t expect the combustible products to disappear but to become a niche interest—like vinyl records in a world dominated by digital music streaming.
For some in tobacco control, this is a nightmare vision. This is not the nicotine-free society that has been their ultimate endgame. But if the harms are not particularly large and the drug is popular, why should governments stop people using it? Drug use is pervasive in human society and throughout history, perhaps started by our hominid ancestors millions of years ago. Nicotine, a relative newcomer, was domesticated between 6,000 years and 8,000 years ago. To say that a drug should be legal and available in relatively safe form is not to endorse its use or somehow to recommend it but to acknowledge that some people may wish to use it, and there isn’t a good reason to stop them by force of law. That idea has both philosophical and practical underpinnings. The philosophical foundation recognizes adult autonomy and the right to indulge in risky behaviors that do not harm others. The practical experience of prohibitions is that they do not work (a new supply chain is established by criminals) and cause serious harms to the individual and to wider society.
Prohibition does not even protect adolescents. Despite federal prohibition, past-30-day use of cannabis among U.S. 12th graders has been over 20 percent for at least a decade. The recent U.S. lung injury outbreak that hospitalized 2,800 and killed 689 was largely a consequence of reckless criminal behavior in the illicit supply of cannabis (THC) vapor products.
As a drug, nicotine is relatively innocuous—it doesn’t cause serious disease, intoxication, overdose, violence, road accidents, sexual vulnerability, incapacitation or family breakdown. Perversely, this relative safety becomes a serious tactical problem for the war-on-drugs tendency in tobacco control. If the prospects of cancer, lung disease and heart disease are greatly diminished, why should people fear nicotine? It is even possible that more people will take up nicotine if the consequences of using it are much less dreadful—that would be the economist’s assumption. Harm (from smoking) is the most persuasive reason not to use nicotine, and that reason is going up in a puff of vapor. In a weirdly inverted way, the greatest threat to the nicotine-free society is the availability of relatively safe nicotine products. I think that explains why so much strenuous, even desperate, effort is going into finding serious harms in smoke-free products though, beyond reasonable doubt, there are none.
The theme of this year’s online GTNF 2020 is “Sustainable change through innovation and regulation.” It will be a great opportunity to discuss the future of nicotine in greater depth.
Clive Bates is the director of Counterfactual Consulting and the former director of Action on Smoking and Health (U.K.).
In 2013-14, governments around the world together spent less than 0.4 percent of their tobacco excise receipts on tobacco control, according to estimates made by the World Health Organization.
The conclusion states that policies and programs that work to reduce the demand for tobacco products are highly cost-effective.
‘Significant tobacco tax and price increases, comprehensive bans on tobacco industry marketing activities, and prominent pictorial health warning labels are generally the least costly tobacco control interventions, followed by the implementation and enforcement of smoke-free policies and the provision of population-wide tobacco cessation programs,’ the report states.
‘Significant tobacco tax and price increases are the most cost-effective of these interventions.’
However, the report goes on to say that despite the considerable revenues generated by tobacco taxes, few governments are investing more than a fraction of these revenues in tobacco control or in other health programs.
‘WHO estimated that in 2013–2014, global tobacco excise taxes generated nearly 269 billion US dollars (US$) in government revenues, but governments spent a combined total of less than US$ 1 billion on tobacco control,’ it said.
Other major conclusions listed in the report’s executive summary are:
* The global health and economic burden of tobacco use is enormous and is increasingly borne by low- and middle-income countries.
* Failures in the markets for tobacco products provide an economic rationale for governments to intervene in these markets.
* Effective policy and programmatic interventions are available to reduce the demand for tobacco products and the death, disease, and economic costs that result from their use, but these interventions are underutilized.
* Control of illicit trade in tobacco products, now the subject of its own international treaty, is the key supply-side policy to reduce tobacco use and its health and economic consequences.
* The market power of tobacco companies has increased in recent years, creating new challenges for tobacco control efforts.
* Tobacco control does not harm economies.
* Tobacco control reduces the disproportionate burden that tobacco use imposes on the poor.
* Progress is now being made in controlling the global tobacco epidemic, but concerted efforts will be required to ensure that progress is maintained or accelerated.
China’s cigarette production has soared over the past decade, despite efforts to curtail tobacco use, according to a new study, reported by China Daily.
Annual cigarette production in the world’s most populous country has increased 50 percent over the past 10 years, according to the report Tobacco Control in China from a Civil Society Perspective 2013. In the 12 months to October, Chinese tobacco companies produced 2.175 trillion cigarettes.
The latest finding echoed a similar recent assessment by the World Health Organization (WHO), which rates China as a poor performer among countries that have joined the Framework Convention on Tobacco Control.
The WHO assessment awarded China two of a possible 16 points on public smoking control, and zero points on tobacco advertising control. Moreover, the country’s tobacco tax rate, at 43.4 percent, is still below the world average, the assessment noted.
