Tobacco Control or Eradication: Are ENDS part of an endgame?

Is the tobacco epidemic more like smallpox or HIV? It’s an important question. If it is like smallpox, then we can pursue strategies to eradicate tobacco as a risk to human health. However, if it is like HIV, we instead need to be thinking in terms of controlling and managing the epidemic. I have tended to favor the idea of eradication. But this “World No Tobacco Day,” I find myself reconsidering.

I aired some of these thoughts in a CGD podcast with David Sweanor, a long-time veteran of the war on smoking, and Rajesh Mirchandani, where we discussed the promise and misgivings associated with encouraging people to switch from cigarettes to Electronic Nicotine-Delivery Systems (ENDS, commonly known as e-cigarettes). This strategy of harm reduction could be extremely effective at reducing premature deaths, but it would mean accepting that nicotine addiction, like unsafe sex, is something that won’t be eliminated anytime soon.

Eradicating deaths from smoking is not necessarily a pipe dream

It was possible to eradicate smallpox because human beings were its only host, transmission didn’t involve another reservoir for infection, and an effective vaccine existed to prevent infection and interrupt transmission. Smoking cigarettes shares many of these factors. If human beings stopped growing tobacco, manufacturing cigarettes, and selling them, then the prevalence of associated diseases—such as lung cancer—would plummet. This idea of moving beyond tobacco “control” to something like a “tobacco-free future,” in which smoking is no longer a major health threat, is known as an “endgame proposal.”

Most strategies today for reducing death and disease from tobacco are compatible with endgame proposals but are essentially efforts to manage, constrain, and reduce the scope of the epidemic. This year, WHO is prominently discussing the effectiveness of plain packaging, which limits the ability of companies to entice new smokers and undercuts profitability by increasing competition. Other control measures include tobacco taxes (which I’ve argued are the single best health policy in the world) and measures to ban smoking in public places, restrict sales to minors, prohibit advertising and sports sponsorships, and limit cigarette company access to policymakers. These control measures are responsible for remarkable progress against smoking in the last few decades; yet the number of smokers has continued to rise.

When I’m feeling optimistic, I envision that these control efforts will reduce demand enough to make cigarette manufacturing unprofitable, marketing efforts weaker, and interference with regulation unlikely. But the process is slow (another 30 million people start smoking every year), the number of deaths during the transition is enormous (rising to 10 million per year in 2030), and the context is constantly changing. Cigarette manufacturers have demonstrated incredible ingenuity at outsmarting taxes, advertising prohibitions, and other regulations. In countries with the largest smoking populations, multinationals aren’t even necessarily the main drivers of the epidemic. China has a large state tobacco monopoly. In India, high-toxin chewing tobacco and hand-rolled bidis are a major threat. Tobacco consumption in Indonesia is diverse and it is the only large country that failed to muster political support to sign the Framework Convention on Tobacco Control.

Electronic Nicotine-Delivery Systems are changing the game

The Royal College of Physicians (RCP) concluded that using ENDS is substantially less hazardous than smoking cigarettes. This creates an alternative for those currently addicted to nicotine and who have been unable to quit. By regulating and taxing ENDS less stringently than cigarettes, it could be possible to accelerate progress against smoking-related diseases. Furthermore, as David Sweanor argues in our podcast:

• žENDS producers could force cigarette companies to face more competition, lowering their profitability (so long as regulators don’t constrain the ENDS market); and
• plaintiffs’ attorneys could sue combustible cigarette manufacturers for selling unreasonably dangerous nicotine-delivery devices (because of a safer alternative in the market).

While I find these points convincing, I still have misgivings. My biggest worry is that cigarette manufacturers will co-opt ENDS so as to encourage nicotine-dependence and move users to combustible cigarettes (a concern also raised in the RCP report). I also wonder if ENDS will become a way to renormalize the social behavior of “puffing” in public and roll back what little gain we’ve made in de-glamorizing smoking.

More importantly, does using ENDS as a harm-reduction strategy mean giving up on the idea of an endgame? As Clive Bates asks, what exactly are we trying to eradicate: death and disease or nicotine-addiction? The two issues are quite different.

I’m not willing to give up on the idea of a world free of tobacco-related illnesses. As with smallpox, the “reservoir” of this epidemic is exclusive to our species. The associated diseases could be eradicated if we were to eliminate the political, social and economic mechanisms which support “transmission.” If this is simply infeasible because of the genetics and behavioral aspects of nicotine use, then we need ENDS for the endgame. It requires the right public health policies to regulate and tax ENDS in a way that discourages nicotine addiction; offers current smokers a safer alternative; and disrupts the cigarette market. If successful, this methodology would be a way to help people live with nicotine rather than die from smoking.

I’d like to thank David Sweanor and Prabhat Jha for comments on an earlier draft.