By Carolyn M. Dresler, MD, MPA
Posted: March 1, 2019
It is common knowledge that the number one cause of preventable deaths in the world is from tobacco use—overwhelmingly from cigarettes.1 Most of the deaths from tobacco use, particularly from smoking, are from cardiovascular disease, followed by cancer, and then chronic obstructive pulmonary disease (COPD).2 The most common cause of cancer deaths in advanced economies is smoking-related lung cancer. Approximately 25% of deaths from cardiovascular disease are from smoking, and approximately 80% of COPD deaths are from smoking.3 Therefore, if we are looking at general public health, we must turn our attention to the vector that is causing most of the top three causes of death.
The Current ENDs Market
Since the turn of the 1900s, this vector has been the cigarette. However, the cigarette industry is under significant challenge from other nicotine-delivery products. Most notably, the electronic cigarette, or electronic nicotine delivery systems (ENDS), has been a market disrupter for the past decade. ENDS come in a variety of forms such as e-hookahs, vaporizer pens, and tank systems. ENDS are different from cigarettes in that they use a battery to create an aerosol that contains nicotine, which is then inhaled. This aerosol is a liquid mixture of a variety of chemicals created from propylene glycol (PG), vegetable glycerin (VG), flavors, and nicotine. The ratio of the PG to the VG is important to the user, particularly if they want the big “vape cloud,” in which case they would use a higher proportion of VG.
Initially, ENDS were created by innumerable small manufacturers, which proved quite variable with respect to quality control and equally variable with respect to their capacity to deliver nicotine to the lungs. Over time, a few market leaders have grown more prominent. An initial market leader in the United States was NJOY, which was not affiliated with a tobacco industry. Then, Vuse became a market leader; this was initially an R.J. Reynolds Tobacco Company product that was subsequently purchased in the United States by British American Tobacco, which already had the ENDS product Vype. Altria (a U.S. company that had split off from Philip Morris but still sells Marlboro, which is the global market leader of cigarettes) sells MarkTen® as their ENDS product. Lorillard Tobacco Company had the ENDS product Blu, but it was sold to Imperial Tobacco when R.J. Reynolds Tobacco Company bought Lorillard Tobacco Company. Therefore, multiple companies, each with their roots in the sales of traditional combustible tobacco, are prominent in the marketing of ENDS. Additionally, there is Juul—at approximately 70% market share in July 20184 and growing, there will surely be more on this product in a future article.
HTPs: An Answer for Higher- Income Countries?
Heated tobacco products (HTPs) are another cigarette alternative. Purportedly, HTPs do not combust tobacco, but rather they simply heat tobacco in order to put nicotine into an aerosol. For users of ENDS and HTPs, it is all about the nicotine delivery and the resolution of withdrawal or cravings for nicotine. Unlike with ENDS manufacturers, the largest marketers of HTPs are the usual tobacco companies that have been known for decades. iQOS (or “I quit ordinary smoking”) by Philip Morris International, Ploom TECH by Japan Tobacco International, and glo™ by British American Tobacco are the most common now, but this market is growing.
Ostensibly, by heating the tobacco rather than burning or combusting it, there are fewer carcinogens and, hopefully, fewer other harmful or potentially harmful constituents. Right now, these large, multinational tobacco industries are trying to position their HTPs to become market leaders. The CEO of Philip Morris has declared that his company wants to stop selling cigarettes in the United Kingdom and have them replaced by people smoking iQOS. In the United Kingdom, the United States, Canada, Australia, France, Japan, and many other developed economies with effective tobacco control programs, smoking of cigarettes continues to decrease. These multinational companies should stop selling their cigarettes in lower-income countries where there are still high rates of use and, thus, high rates of related morbidity and mortality.
Will New Products Result in Fewer Deaths?
It is true that both ENDS and HTPs seem to have fewer carcinogens, so their use should, theoretically, cause fewer cancers, particularly lung cancers. However, there is more controversy about other health effects, and there is great variability among various countries as to how they are perceived. ENDS are forbidden in many countries, particularly if they deliver nicotine. However, countries such as the United Kingdom are strongly encouraging adults to switch to ENDS as a cigarette smoking-cessation tool because ENDS are believed to be less hazardous than cigarettes. A recent report from the United Kingdom states that it is plausible that the nationwide decrease in smoking prevalence is due to the availability of ENDS as cigarette smoking–cessation tools. Other countries fall elsewhere on the continuum of perceived risk/benefit, although a common shared belief is that ENDS are less deadly than cigarettes. The big question that is confounding many countries is the uptake of ENDS by youth and the unknowns that result from this uptake. For example, what are we to think about JUUL, an innovative ENDS in the United States that has approximately 70% of the market share and has created havoc in schools with its increasing prevalence of use? Even less is known about HTPs, particularly what they will mean for the market, whether they will be less harmful in long-term use than cigarettes, and whether youth and young adults will start using them.
The various regulatory options that governments might implement are another factor that must be considered. For example, the U.S. Food and Drug Administration is considering a rule that would significantly decrease the amount of nicotine that could be delivered by a cigarette. It is unclear, however, whether this would result in a decrease in the percentage of youth who start smoking or an increase in the number of adults who quit smoking. Equally unclear are the effects on rates of users of ENDS or HTPs and the ultimate public health outcome.
Additionally, there has been a worldwide movement to restrict flavors in tobacco products, particularly combusted products, to help stop smoking initiation by youth. However, this is tricky because adults also prefer flavored tobacco products, and such flavorings may be the attraction that aids adults in their transition from combusted products such as cigarettes with low nicotine delivery, to ENDS or HTPs.
We can only hope that these recent changes will be effective in decreasing the deaths from tobacco. ✦
About the Author: Dr. Dresler is in IASLC member and an international tobacco control expert.
1. WHO: Smoking Remains Major Cause of Death, Disease. VOA News website. https://www.voanews.com/a/who-smoking-remains-majorcause-of-death-disease/4416902.html. Published May 30, 2018. Accessed September 9, 2018.
2. Deaths. The Tobacco Atlas website. tobaccoatlas.org/topic/deaths. Accessed September 9, 2018.
3. Tobacco Products. Th e U.S. Food and Drug Administration website. www.fda.gov/tobaccoproducts/publichealtheducation/healthinformation/default.htm. Accessed September 9, 2018.
4. Brodwin E. The wildly popular e-cig startup Juul is valued at $15 billion, but it faces a growing backlash of lawsuits and invesigations. Business Insider website. businessinsider.com/juul-e-cig-booms-amid-backlash-lawsuits-investigations-2018-7. Published July 28, 2018. Accessed September 9, 2018.
5. McNeill A, Brose LS, Calder R, Bauld L, Robson D. Evidence review of e-cigarettes and heated tobacco products 2018 A report commissioned by Public Health England. Public Health England website. https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_ heated_tobacco_products_2018.pdf. Published February 2018. Accessed September 9, 2018.