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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Addiction. Author manuscript; available in PMC 2018 January 1.
Published in final edited form as:
PMCID: PMC5396387
NIHMSID: NIHMS842532

The Need for a Comprehensive Framework

Abstract

To facilitate individual and population-level behavior change, we need policies based on science. We must develop coherent policies that explicitly consider the benefits and risks of different classes of nicotine delivery products, rather than continuing the current ad-hoc approach which fails to adequately address the product itself.

Keywords: Cigarette industry, e-cigarettes, framework, public health, tobacco control, vaporized nicotine products

We agree with Dr Freeman [1] that there are many factors other than policies that influence the use and uptake of vaporized nicotine products (VNPs). However, most of the factors that she mentions—curiosity, nicotine addiction, for example—are not readily modifiable. In contrast, the framework that we describe [2] focuses on the role of policies to facilitate individual and population-level behavior change in the same way that tobacco control policies have been used to reduce cigarette consumption. Indeed, this is the premise of the World Health Organization (WHO) Framework Convention on Tobacco Control.

Almost all the advances in tobacco control have been policy initiatives, including increasing cigarette prices via taxation, more prominent health warnings, limiting where cigarettes can be used and sold, restricting marketing [3] and plain packaging law [4]. While modeling studies have found that such policies can reduce smoking prevalence substantially [5,6], the reductions fall short of achieving WHO goals [79]. To be more effective, governments must combine policies that motivate behavior change with those that facilitate behavior change. The widespread interest in e-cigarettes among smokers indicates that they are clearly looking for options to help them to stop smoking, and governments should be implementing policies that will encourage smokers to stop using cigarettes as their source of nicotine.

Evidence shows that the policy environment matters. In countries where policies on VNPs have been less restrictive (United States and United Kingdom) to the year 2015, VNP use is higher, more smokers use VNPs to stop smoking and quitting success is greater compared to countries where policies on VNPs are more restrictive (Canada and Australia, where VNPs with nicotine are not allowed) [10,11]. With large increases in VNP use in recent years we have seen unusually large reductions in smoking prevalence, especially among those aged 18–24 years in the United States [12] and fewer, but still impressive, reductions in England [13].

As Freeman has argued, continued use of VNPs depends upon the relative appeal and marketing of VNPs. These factors will depend upon industry behavior, but that behavior will also be affected by public policies/regulations, such as those that provide accurate information on the relative harms of VNPs and cigarettes [14] and those that increase the substitutability of VNPs for cigarettes while keeping their risks low. Another important policy approach is higher tax rates on the more lethal tobacco products with lower taxes on the less lethal products [15]. By reducing the costs to smokers of switching to reduced risk alternatives, this approach could be especially effective in addressing the central problem of high smoking rates among vulnerable populations (e.g. those of low socioeconomic status), which Gartner [16] has highlighted.

To facilitate individual and population-level behavior change, we need policies based on science, not those based on speculation, fear and bias. Policies have the potential to mitigate the harms of VNPs use (i.e. discouraging uptake by non-smokers) while maximizing potential benefits (i.e. promoting substitution by current cigarette smokers). We must develop coherent policies that consider explicitly the benefits and risks of different classes of nicotine delivery products, rather than continuing the current ad-hoc approach which fails to address adequately the product itself. It has been said: ‘for every complex problem there is a simple solution… and it’s wrong’ [17,18]’. As Brown has argued so eloquently [19], our paper is an attempt to provide an integrated and overarching framework to address the complex patterns of poly-tobacco and nicotine use.

Acknowledgments

K.M.C. has received grant funding from the Pfizer, Inc. to study the impact of a hospital-based tobacco cessation intervention. K.M.C. and R.N. have received funding as expert witnesses in litigation filed against the tobacco industry.

Footnotes

Declaration of interests

No other conflicts of interest are declared.

References

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