Search tips
Search criteria 


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

The Need for a Comprehensive Framework


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.


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.


Declaration of interests

No other conflicts of interest are declared.


1. Freeman B. Is public health regulation the biggest factor influencing the use and uptake of vaporized nicotine products? Addiction. 2017;112:19–21. [PubMed]
2. Levy DT, Cummings KM, Villanti AC, Niaura R, Abrams DB, Fong GT, et al. A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products. Addiction. 2017;112:8–17. [PMC free article] [PubMed]
3. Sweanor D, Yach D. Looking for the next breakthrough in tobacco control and health. S Afr Med J. 2013;103:810–1. [PubMed]
4. Freeman B, Chapman S, Rimmer M. The case for the plain packaging of tobacco products. Addiction. 2008;103:580–90. [PubMed]
5. Levy D, Benjakul S, Ross H, Ritthiphakdee B. The role of tobacco control policies in reducing smoking and deaths in a middle income nation: results from the Thailand SimSmoke simulation model. Tob Control. 2008;17:53–9. [PubMed]
6. Levy D, de Almeida LM, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLOS MED. 2012;9:e1001336. [PMC free article] [PubMed]
7. Gartner CE, Barendregt JJ, Hall WD. Predicting the future prevalence of cigarette smoking in Australia: how low can we go and by when? Tob Control. 2009;18:183–9. [PubMed]
8. Levy D, Currie L, Clancy L. SimSmokeFinn: how far can tobacco control policies move Finland toward tobacco-free 2040 goals? Scand J Public Health. 2012;40:544–52. [PubMed]
9. Tobias MI, Cavana RY, Bloomfield A. Application of a system dynamics model to inform investment in smoking cessation services in New Zealand. Am J Public Health. 2010;100:1274–81. [PubMed]
10. Yong HH, Borland R, Balmford J, McNeill A, Hitchman S, Driezen P, et al. Does the regulatory environment for e-cigarettes influence the effectiveness of e-cigarettes for smoking cessation? Longitudinal findings from the ITC Four Country Survey. Paper presented at Society for Research on Nicotine and Tobacco, 2016 Annual Meeting; Chicago, Illinois. [PubMed]
11. Yong HH, Borland R, Balmford J, McNeill A, Hitchman S, Driezen P, et al. Trends in E-cigarette awareness, trial, and use under the different regulatory environments of Australia and the United Kingdom. Nicotine Tob Res. 2015;17:1203–11. [PMC free article] [PubMed]
12. Centers for Disease Control and Prevention, National Center for Health Statistics. Early Release of Selected Estimates Based on Data From the National Health Interview Survey, 2015. 2016 Available at: (accessed 8 August 2016) (Archived at
13. Public Health England. Smoking Prevalence—Annual Population Survey (APS) 2016 Available at: (accessed 8 August 2016) (Archived at
14. Kozlowski LT, Sweanor D. Withholding differential risk information on legal consumer nicotine/tobacco products: the public health ethics of health information quarantines. Int J Drug Policy. 2016;32:17–23. [PubMed]
15. Chaloupka FJ, Sweanor D, Warner KE. Differential taxes for differential risks—toward reduced harm from nicotine-yielding products. N Engl J Med. 2015;373:594–7. [PubMed]
16. Gartner CE. The potential impact of vaporized nicotine products on vulnerable subpopulations. Addiction. 2017;112:18–9. [PubMed]
17. Mabry PL, Olster DH, Morgan GD, Abrams DB. Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am J Prev Med. 2008;35:S211–24. [PMC free article] [PubMed]
18. Marcus SE, Leischow SJ, Mabry PL, Clark PI. Lessons learned from the application of systems science to tobacco control at the National Cancer Institute. Am J Public Health. 2010;100:1163–5. [PubMed]
19. Brown J. A gateway to more productive research on e-cigarettes? Commentary on a comprehensive framework for evaluating public health impact. Addiction. 2017;112:21–2. [PMC free article] [PubMed]