Hong Kong health authorities are planning to ban alternative smoking products, with the threat of harsh penalties (up to six months in jail) for those who violate the proposed law. International trends in tobacco control play a role in shaping our approach to smoking at home. As part of our global efforts to champion a liberal, harm reduction approach to smoking cessation we submitted evidence to the consultation, drawing on the UK’s world-leading approach in this area.
Banning vaping and heat-not-burn is, to put it bluntly, one of the worst public health policy ideas imaginable. The full submission can be found below (or here on page 171):
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1 Introduction
1.1 This submission was written on behalf of the Adam Smith Institute by Daniel Pryor who works at the Institute as a research economist. The Adam Smith Institute is one of the world’s leading think tanks. Independent, non-profit and non-partisan, we work to promote free market, neoliberal ideas through research, publishing, media outreach, and education. The Institute is today at the forefront of making the case for free markets and a free society in the United Kingdom.
1.2 This submission will focus on the success of the United Kingdom’s tobacco harm reduction strategy, which (in contrast to Hong Kong’s proposed ban) incorporates a liberal approach to reduced-risk products such as e-cigarettes and heated tobacco. We will also argue in the submission that the Hong Kong Government’s stated justifications for the proposed ban are not in line with international evidence. A ban would damage Hong Kong’s international reputation as a standard bearer for evidence-based policy and good governance.
1.3 This submission will be structured as follows:
1.3.1 the United Kingdom’s liberal, harm-reduction approach to smoking cessation has successfully reduced smoking rates
1.3.2 banning e-cigarettes and heated tobacco products in Hong Kong will significantly harm public health
1.3.3 international evidence suggests that reduced-risk nicotine products are not a ‘gateway’ to cigarette smoking
2 The United Kingdom’s liberal, harm-reduction approach to smoking cessation has successfully reduced smoking rates
2.1 The basic premise of tobacco harm reduction is simple; make it as easy as possible for smokers to switch to nicotine products that cause them significantly less harm.
2.2 Since their emergence in the UK, successive governments have largely followed public health authorities in taking a broadly liberal, harm reduction approach to e-cigarettes and heated tobacco products. Our smoking rate is the second lowest in Europe, which is partially due to the rapid market penetration of e-cigarettes.
2.3 The February 2018 evidence review from Public Health England concluded that e-cigarettes are at least 95% safer than conventional cigarettes. Moreover, the latest data available shows that “of the 3.2 million adult e-cigarette users in the UK, more than half have completely stopped smoking. A further 770,000 have given up both smoking and vaping” (Dockrell, 2018). Public health bodies and advocates have repeatedly affirmed their positive impact on smoking cessation, and they are more than 10 times as popular as NHS Stop Smoking services (PHE, 2015).
2.4 There are now more ex-smokers who use e-cigarettes than current smokers (ASH, 2017). The best available evidence, reviewed by Public Health England in February 2018, suggests “an upper bound estimate of around 57,000 additional quitters annually resulting from e-cigarettes (lower bound around 22,000).”
2.5 A 2019 peer-reviewed, independent randomized control trial found that e-cigarettes are almost twice as effective at helping smokers give up tobacco than other alternatives such as nicotine patches or gum (Hajek et. al, 2019). In their February 2018 evidence update, Public Health England stated that “to date there have been no identified health risks of passive vaping to bystanders.”
2.6 Public Health England has also recently summarised the emerging evidence base for heated tobacco products by stating that they “may be considerably less harmful than tobacco cigarettes and more harmful than e-cigarettes.” The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) recently looked at two heat-not-burn products available in the UK and found that compared to conventional cigarettes “there were some HPHCs [harmful and potentially harmful compounds] where the reduction was approximately 50%, but the reduction in a number of other HPHCs was greater than 90%.”
2.7 Since 2014, several heat-not-burn products have been introduced in Japan: Philip Morris’ IQOS in 2014, followed Japan Tobacco’s Ploom Tech in March 2016 and British American Tobacco’s glo later that year. In one year, Heatsticks (the tobacco units used with IQOS) massively increased their market share in Japan from 2.2% to 10% (PMI, 2017). This is likely to have been partially driven by IQOS being featured on a popular Japanese TV entertainment show in April 2016, and the rise in use has been so great that Heatsticks now outsell Marlboro cigarettes (Tabuchi et. al, 2017). The displacement of smokers to heated tobacco in Japan is clearly reflected in significant declines in cigarette sales (Abrams et. al, 2017).
2.8 The draft bill claims that the “public may underestimate the harmful effects of these products”, but in the UK the opposite is true. PHE’s latest February 2018 summary of survey evidence on smokers’ knowledge of the relative risks of e-cigarettes is extremely alarming: “Only half of smokers believe that EC are less harmful than smoking and this decreases to one third among smokers who have never tried EC...In contrast to evidence to date, it appears that a majority of smokers and ex-smokers does not think that complete replacement of cigarettes with EC would lead to major health benefits...Where available, international data show similar misperceptions around nicotine and relative harmfulness of EC and smoking as in England. International data also support the trends of increased harm perception of EC with the exception of one survey in youth in the US.”
3 Banning e-cigarettes and heated tobacco products in Hong Kong will significantly harm public health
3.1 International evidence shows that allowing reduced-risk nicotine products as part of a tobacco control strategy can yield enormous public health gains.
3.2 The Adam Smith Institute's 2018 report “1 Million Years of Life: How harm reduction in tobacco policy can save lives” uses World Health Organisation estimates of additional life expectancy from quitting smoking at different ages and Public Health England estimates of e-cigarette relative risk to estimate that 1,036,640 years of life could be saved if young women vaped at the same rate as young men. While 8.9% of British young men vape, for British women it is just 2.6%. Women are however continuing to smoke with nearly 16% of women aged 16-24 smoking.
3.3 Previous estimates of positive public health impacts from increased e-cigarette adoption amongst smokers have come to varied conclusions but are all indicative of significant gains. For example, recent modelling of e-cigarette adoption’s potential effects on premature deaths and life years saved in the United States has yielded pessimistic estimates that “1.6 million premature deaths are averted with 20.8 million fewer life years lost” (Levy et. al, 2018).
3.3 Survey evidence suggests that the most common reason for UK smokers who have tried e-cigarettes no longer using them is that the product does not imitate smoking closely enough (ASH, 2017).
3.4 Evidently, different smokers have different preferences and the more variety of reduced-risk products on the market (including those that may imitate the experience of cigarettes more closely), the more likely it is that smokers will switch.
3.5 A robust harm reduction approach should ensure that heat-not-burn devices and hybrid products (such as those that pass e-cigarette vapour through tobacco for flavour purposes) are treated according to their relative risk profiles under the law.
4 International evidence suggests that reduced-risk nicotine products are not a ‘gateway’ to cigarette smoking
4.1 Contrary to media reports, the available international evidence shows that reduced-risk products do not attract young never-smokers to regular use at a significant level.
4.2 Young people who initiate e-cigarette use are likely to have taken up smoking anyway.
4.3 Public Health England’s February 2018 evidence review concluded that “despite some experimentation with these e-cigarettes among never smokers, e-cigarettes are attracting very few young people who have never smoked into regular use...The ‘common liability’ hypothesis seems a plausible explanation for the relationship between e-cigarettes and smoking implementation.”
4.4 Even if never-smokers were attracted to reduced-risk products on the margin, the public health costs of a ban (i.e. far more cigarette smokers) would far outweigh the marginal gains from preventing such uptake.
4.5 Youth uptake of heated tobacco devices is extremely unlikely to be significant, given the comparatively high price point of heat-not-burn devices (especially when compared to cigarette prices).
4.6 Appropriate enforcement of age restrictions on reduced-risk products and responsible marketing practices are the best policy approach from a public health perspective.
5 Conclusion
5.1 The Hong Kong Government’s proposed ban on reduced-risk products is contrary to international best practice on smoking cessation and harm reduction.
5.2 Such a ban would create large public health costs with no identifiable benefits.
5.3 Fears of a ‘gateway effect’ from reduced-risk products to cigarettes are unfounded.
5.4 Hong Kong policymakers should consult public health authorities in the United Kingdom on best practice in tobacco harm reduction policy.
28 March 2019
Bibliography
McNeill A, Brose LS, Calder R, Bauld L & Robson D (2018). “Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England.” London: Public Health England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf
Martin Dockrell, "Clearing up some myths around e-cigarettes" (20 February 2018), Public health matters (PHE). Available at: https://publichealthmatters.blog.gov.uk/2018/02/20/clearing-up-some-myths-around-e-cigarettes/
Public Health England, "E-cigarettes: an emerging public health consensus" (15 September 2015). Available at: https://www.gov.uk/government/news/e-cigarettes-an-emerging-public-health-consensus
Action on Smoking and Health, "Use of e-cigarettes (vapourisers) among adults in Great Britain" (May 2017). Available at: http://ash.org.uk/download/use-of-e-cigarettes-among-adults-in-great-britain-2017/
Hajek P et. al, “A randomized trial of e-cigarettes versus nicotine-replacement therapy.” N Engl J Med 2019 Jan 30; [e-pub]. Available at: https://doi.org/10.1056/NEJMoa1808779
COT, COC and COM, "Statement on the toxicological evaluation of novel heat not-burn tobacco products" (December 2017). Available at: https://cot.food.gov.uk/sites/default/files/heat_not_burn_tobacco_statement.pdf
PMI, Philip Morris International Inc. (PMI) Report 2017 Second-Quarter Results. Available at: https://www.google.com/url?q=http://phx.corporate-ir.net/External.File?item%3DUGFyZW50SUQ9Njc1NTk5fENoaWxkSUQ9MzgzNzUzfFR5cGU9MQ%3D%3D%26t%3D1&sa=D&ust=1528209502769000&usg=AFQjCNFojdIok45FMqLL8UIRKGNFWI8AsA
Tabuchi T, Gallus S, Shinozaki T, et. al, “Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol” Tobacco Control. Published Online First: 16 December 2017. doi: 10.1136/tobaccocontrol-2017-053947
Abrams et. al, “Submission to Tobacco Products Scientific Advisory Committee” (14 December 2017). Available at: https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM593125.pdf
Daniel Pryor, “1 Million Years of Life: How harm reduction in tobacco policy can save lives” Adam Smith Institute (21 June 2018). Available at: https://static1.squarespace.com/static/56eddde762cd9413e151ac92/t/5b2a58eaf950b7e84b9a4a20/1529501933343/1+Million+Lives+Paper+-+Daniel+Pryor.pdf
Levy DT, Borland R, Lindblom EN, et al “Potential deaths averted in USA by replacing cigarettes with e-cigarettes” Tobacco Control 2018; 27:18-25.