US E-cigarette Summit: Taming the nicotine industrial complex

I look back to 1997 and simpler time in tobacco control, then look at changes in trade, communications, technology and conclude the market is becoming ungovernable

1. Taming the Nicotine Industrial Complex Tobacco Control 2.0 Clive Bates Counterfactual Consulting London, United Kingdom U.S. E-cigarette Summit Washington D.C. 14 May 2024

2. 1997: a simpler time

3. 36.5% 12th-grade smoking is down by 89%

4. 6. An easy nemesis (lazy, dated, stereotypes)

5. Clarity of goals

6. List of possible tobacco control goals Improve welfare and wellbeing Reduce harms (including policy-induced harms) Reduce serious disease Reduce smoking Reduce tobacco use Reduce nicotine use Reduce substance use Reduce secondhand exposure Protect children or vulnerable groups Secure anti-tobacco legislation Sue the bastards Destroy the tobacco industry Prestige, livelihood, travel, grants… All the above!!

7. Understand nicotine

8. Why is there demand for nicotine?

9. Why is there demand for nicotine?

10. Identify the critical population

11. 3. The focus on youth ignores the main problem Smoking Vaping only Dual use

12. The focus on youth ignores the main problem Smoking Vaping only Dual use Millions Youth (NYTS) Adults (NHIS) Vaping 1.53 7.8 Dual use 0.52 3.3 Smoking only 0.37 25.0 All smoking 0.89 28.3 15 x

13. The focus on youth ignores the main problem Smoking Vaping only Dual use Nearly all the attention goes here The public health problem is here

14. Young adult uptake of nicotine 2014-22 United States Data extraction and graphics: Brad Rodu , Professor of Medicine, University of Louisville, U.S.

15. Young adult uptake of nicotine 2014-22 United States Smoking & vaping prevalence (%) Americans aged 18-24. National Health Interview Survey, 2014-2022 Did not smoke before vaping Vaping former smokers Smoking & vaping Smoking only >70% reduction in smoking, >80% reduction in exclusive smoking Over time, the demand for nicotine is far more robust and resilient than any particular way of taking it. Data extraction and graphics: Brad Rodu , Professor of Medicine, University of Louisville, U.S. Annotations: Clive Bates

16. Is tobacco control losing control?

17. Predictions from 2019 E-cigarette Direct: Vape Predictions 2019: Expert Round Up from Scientists, Industry Leaders, Advocates & More

18. Ungovernable 1: high and rising diversity

19. Measured in millions FDA’s 2016 estimate: 4,050 e-liquids and 747 ENDS devices

20. China since 2017: massive manufacturer and exporter Export value of electronic cigarettes from China from 2017 to 2022 by major destination 9-fold growth U.S. – about half

21. Ungovernable 2: unregulated trade

22. The legal authorised market 23 vaping products FDA Authorized E-Cigarette Products 300,000 vaping products COM(2021) 249 final

23. U.S. vape markets – lost regulatory control Very tightly regulated Not regulated

24. Australia’s vape markets – lost regulatory control Very tightly regulated Not regulated

25. Illegality is an impediment rather than a barrier Past-30-day Daily About 22% About 6%

26. Container volumes through Port of New York and New Jersey Container traffic handled at the Port of New York and New Jersey from 2016 to 2022 (TEU) 26,000 per day

27. Container traffic through all major U.S. ports (January) 86,000 per day

28. The Australian Border Force scans just 1.4 per cent of the 6.3 million containers that arrive in Australia by sea every year. “It’s impossible to stop this at the border” Rohan Pike quoted in the Sydney Morning Herald, It’s a joke: why young vaping addicts say regulations won’t work, 17 June 2023

29. Ungovernable 3: new communications

30. New communications technologies

31. The communications environment has radically changed As of April 2024, 62.6% of the world's population, or 5.07 billion people, use social media. 

32. New forms of commerce

33. New forms of commerce

34. 2. Keep the market legal

35. Ungovernable 4: Innovation

36. Shenzhen e-cigarette innovation eco-system   Xu, Y., Song, X., Li, X., Wang, Z., & Zhang, Y. (2022). Research on the Ecological Deconstruction of E-Cigarette Industrial Clusters in Shenzhen, China, and a Niche Analysis of Related Enterprises. Sustainability , 14 (9), Article 9. https://doi.org/10.3390/su14095606

37. Innovation: or “exploiting loopholes”?

38. Innovation: “Big Puff” vapes

39. Innovation: Do It Yourself

40. Innovation: flavour accessories Havermans , A., Pauwels, C. G. G. M., Hart, I. M. E. B.-’t, Fayokun , R., Nierop, L. E. van, Hellmich , I. M., & Talhout , R. (2024). Across the world availability of flavour accessories for tobacco products. Tobacco Control . https://doi.org/10.1136/tc-2023-058255

41. Tobacco control 2.0 – a system view

42. A complex adaptive system Fiscal Practitioners Communication Regulation

43. A complex adaptive system – interactions drive behaviour change Fiscal Practitioners Communication Regulation Abstinence Behaviour change Illicit sales Workarounds

44. Or maybe the market becomes larger as controls lose their effect Fiscal Practitioners Communication Regulation

45. Tobacco Control 2.0 Accepting the limits of control

46. Tobacco Control 2.0 1. Rethink nicotine and focus on harm

47. Tobacco control 2.0 2. Keep the market legal

48. Tobacco control 2.0 3. Work through consent, not coercion

49. Tobacco control 2.0 4. Regulate for consumer protection, not deterrence

50. Tobacco control 2.0 5. Proportionate approach to youth nicotine use

51. Proportionate approach to youth nicotine use A realistic model of youth risk behaviours Lawful market Age-secure retailing Responsible marketing, including branding and flavour descriptors Truthfulness

52. Tobacco control 2.0 6. Be realists, not idealists

53. Tobacco control 2.0 Rethink nicotine Keep the market legal Work through consent, not coercion Regulate for consumer protection, not deterrence Address concerns about youth Be realists, not idealists