Cigarettes - PowerPoint Presentation

Slide1

Cigarettes, very low in nicotine, as a vehicle to significantly reduce smoking: Qualitative studyPreliminary results

Trish Fraser, Dr Anette KiraSlide2

IntroductionIn 1998 American medical association proposed reducing nicotine in cigarettes 1998 AMA.1

In NZ, a mandated very low nicotine policy has been suggested

2

The current study is a repeat of a study conducted

3 in 2002 which found not enough political/policymaker support, concern about compensatory, backlash from smokersHenningfield & Benowitz Walker et al 2014Trish, 2002… Slide3

Methods17 key opinion leaders (telephone interviews) and 21 smokers were interviewed (focus groups)Open-ended semi-structured questions relating to VLNC cigarettes

were asked: policy implementation, obstacles and barriers to implementation; practicalities; regulations required; policy implications; marketing VLNC cigarettes; taste of VLNC cigarettes; other non-combustible nicotine options for smokers; acceptability of VLNC cigarettes; and fit with international tobacco control strategies.

Smokers

were given

some ‘Magic’ very low nicotine content cigarettes to take home to smoke. They will be telephoned over the next week re-interviewed. Slide4
Slide5

ResultsSlide6

Participants

Ethnicity

Gender

Age range

Key opinion leaders (17)Political people

Politicians

2 x NZ EU, 1 X Māori

2 x

F, 1 x M

40

– 60+

Political commentator

NZ EU

M

40 - 49

Government

people

Government

health official

NZ EU

M

50 - 59

Ex-government

health official

NZ EU

M

40 - 49

Ex-treasury

official

NZ

EU

M

40 - 49

Commercial

people

Tobacco industry

British

M

50 - 59

Nicotine industry

British

M

40

- 49

Tobacco retailer

NZ EU

F

40 - 49

E-cigarette retailer

Māori

M

30 - 39

Health

workers

Tobacco control experts

1 Māori/NZ EU, 1 Pacific, 2 NZ EU

2M, 2F

30 – 60+

Smoking

cessation experts

1 Māori, 1 Māori/NZ EU

2F

50 - 59

Smokers (21)

15 Māori, 1

Nuiean

, 1 Samoan, 1 Tongan, 8 NZ EU

16F, 5M

16

– 76+Slide7

Very low nicotine content cigarettes in New Zealand

A number of participants did not think that VLNC cigarettes have a place in NZ.

E-cig retailer: I don’t believe that these cigarettes should be allowed or stocked.

Others were strongly in favour of VLNC cigarettes being available in NZ as an option for smokers.Pol Comm: Absolutely I’ve got no doubt at all that they should be available as one option for consumers of cigarettes.Tobacco retailers would be willing to sell them, if there was a customer demandTob Retailer: I would say that we would have no objection to them being available and would probably say if there’s a customer demand then the product should be available for the customer to purchase.

If VLNCs were available in NZ, participants commented that they should have the same regulations as normal high

nicotine

cigarettes.

Ex-Treasury Advisor

: Well they cause the same harm so they should be subject to the same requirements in terms of age restrictions, product displays, sale in whole packets, advertising controls.

Smok

Cess

Exp

:

Well you could only sell to people over the age of 18, and the Smoke-free Environments Act would have to apply, all of the current FCTC rules and regulations should apply to the product, placement, promotion, marketing, all those things.

Interviewees thought that there were practical issues with VLNC cigarettes.

Tob

Ind

Rep:

I don’t know yet whether there’s ever going to be a possibility of making a very low nicotine cigarette viable… So you’d have to then either recreate what’s been done historically with a decaffeinating plant or you’d have to get to this route to find a way to change the plant and then to be able to reproduce it non-genetically so we’re years away from being able to produce a very low nicotine plant at this stage… Slide8

Opinions – VLNC cigarettes

VLNC cigarettes are still harmful albeit less addictive. Tob

Ind

Rep: these [VLNC] aren’t safer cigarettes. They will have the same risk of lung cancer, heart disease, chronic obstructive pulmonary disease. They may just have less of a risk related to addictionSmok Cess Exp: Combustible tobacco kills, nicotine doesn’t.Mixed views on VLNC as a cessation toolPolitician: Clearly part of the addiction component around tobacco is nicotine addiction and the nicotine content and so if we have cigarettes with less nicotine then they’ll be less addictive and one would expect that that should make quitting significantly easier…

Smok

Cess

Exp

: Each smoker’s level of addiction is kind of personal and we assume that it’s all about the nicotine but it isn’t for a lot of smokers.

Ex-Treasury Advisor

:

I don’t know of the evidence and I can’t imagine how low nicotine cigarettes would be a more effective strategy than nicotine replacement therapy but I can’t see a reason not to try it.Slide9

Opinions – Would smokers want VLNC?One participant made the statement that VLNC cigarettes had been available in NZ, but had not sold much.Gov

Health Off: They have at various time been marketed in New Zealand and more so internationally but because of the low addictiveness of low nicotine cigarettes they haven’t been very successful in the market placeSlide10

Policy – mandated VLNC cigarettes only

There is a need to consider the cost versus benefit of a VLNC cigarette only mandated policy and how likely such policy is of reducing smoking, compared to other policies.

Politician: The effort that goes into introduction of any particular measure and the political capital that’s used to establish any measure has an opportunity cost because it won’t be used for something else.

Some participants, in particular tobacco control experts, thought that mandating that only

VLNC cigarettes were available was important. Tob Control Exp: The reality is it would only work if it was the only product available… It’s pointless otherwise really. Other participants did not want such a policyEx-treasury Advisor:

I would not support a policy to mandate all cigarettesSlide11

Policy - practical considerations

A number of participants stated that there would be a need for support, in addition to current cessation support, to manage nicotine withdrawal.

Gov

Health Off: A range of options for either getting nicotine alternatively if people were to determined to continue on with their nicotine fix or supporting them with a wide range of mechanisms to manage the withdrawal.

Another point made was that the programme needed to support a VLNC cigarette policy would be expensive. Pol Comm: I think such a programme

would have to come with a lot of carrots attached so it would have to be quite an expensive

programme

of smoke quitting mechanisms Slide12

Policy – Acceptability to policy makersMany participants, across the sections, perceived that there would not much be support for a mandated policy would to policy makers

Gov Health Off: To this Government I think it would be very unpalatable, both from a fiscal perspective but also the whole ‘nanny state’ argument.

Tob

Retailer: To be frank I think the proposal as you’ve put it which is replace all products with a low nicotine content product is pretty audacious… I don’t think the policy in the frame that you’ve put it as ‘all product approach’ would be likely to get much political support The main reasons why participants didn’t think a mandated VLNC cigarette policy would be acceptable was due to lack of public support and scientific evidence. Gov Health Off,: I think it’d really come down to evidence-based and public support… Ideally there’d need to be a ‘proof of concept’ somewhere else I think to make it even on the radar. Maybe test it in a little Pacific country. It would really need to be shown to be an effective intervention somewhere, or somehow, some good testing.

Ex-

Treasury_Advisor

:

If

you had to make a case to cabinet that this is necessary or that it would work I don’t know that that evidence is there.

One participant thought that policymakers would prefer to give smokers a choice

Tob

Control

Exp

:

This Government would probably say

‘we’re

happy to give people a choice’ Slide13

Policy – Acceptability to health professionals A few participants thought that a VLNC mandated policy would be more acceptable to health professionals than to policy makers or smokers

Tob Retailer: I think probably health workers would be more likely [than policy makers] to support it.

Tob

Control

Exp: I think that they would think it’s a good idea. In the National Smokefree Working Group I think there is a place for it, for low nicotine cigarettes. I think Māori communities would like itOthers thought that there would be mixed views about a mandated VLNC cigarette policy, even among health professionalsEx-Treasury Advisor: think there’s two camps of health workers… I don’t think there’s enough of a case yet to be made that would get universal support from the health profession.Pol Comm: Obviously going to have greater appeal to health workers who obviously see the cost and problems with smoking in society today but even in that group some won’t be convinced

Tob

Control

Exp

: There’ll be some tension and there’s still that whole harm

minimisation

and elimination argument ... Slide14

Policy - Consequences

There were a number of participants who expressed a concern for an increase of illicit trade and how to manage a potential increase in illicit trade, whilst others thought that such a risk was low.

Gov

Health Off:

Customs would have to gear up around illicit trade…The illicit trade issue would have to be managed carefully… There would be significant resourcing issues around the compliance side and the illicit trade side. Tob Control Exp: I’m not worried about smuggling and that sort of stuff. There were some concerns expressed around the risk of compensatory smoking. However, one participant stated that research has suggested that compensatory smoking doesn’t take place. There were concerns that

VLNC cigarettes

may seem safer and less addictive and therefore more socially acceptable.

Ex-Treasury Advisor: One might think you’re creating another possible way of making smoking more socially acceptable. ‘These aren’t the addictive ones, it’s okay if I smoke them in various environments’.

There were a number of concerns expressed about potential retaliation from the tobacco industry, such as trade disputes or withdrawing tobacco from NZ completely.

Tob

Control

Exp

: I think there have been some people who have said ‘No the industry won’t let us do that, the TPPA won’t let us do that’ ‘it’s too extreme’. The perceived risks are of course being sued by Big Tobacco.Slide15

Other options for harm reduction

The tobacco industry representative stated that in order to reduce harm, the better option would be to increase nicotine and reduce toxins.

We’ve

tended to go the other

way, more nicotine to tar to get people to reduce the amount of toxins they’re taking in. Others stated that other, less harmful options such as snus or e-cigarettes, would be preferable over VLNC cigarettes. E-cig Retailer: I don’t believe that we need to be creating other forms of poisons particularly we have other alternatives that people can turn to that give a very similar effect and … we’re taking out the relatively harmless product in cigarettes but we’re still continuing to feed people carcinogens and tars and other poisons.Gov

Health Officer:

More

broadly reduced harm products e-cigarettes and snus

etc

whether better to go down that route rather than low nicotine.Slide16

Other options - Are other support tools more attractive and/or effective?

There

were a number of people who suggested that other forms of cessation support, in particular e-cigarettes, may be more effective and attractive than VLNC cigarettes.

Nic

Ind Rep: The most recent data on electronic cigarettes in the UK shows that the e-cigarettes that are the best at delivering nicotine, are the most effective in helping smokers move away from tobacco. So it seems easier for people to give up the smoke than it is for them to give up the nicotine…Technology is moving at such a pace. We just need to stay current with that because very clearly smokers are staying current with it…. I think predominantly my perspective is around e-cigarettes and the prominence of the role that they play. I think whatever approach is taken New Zealand should look to what’s actually happening globally

Tob

Control

Exp

:

I

would be inclined at that point to try a few other more likely scenarios such as electronic cigarettes. Electronic cigarettes have got a large section of the public behind them, so from a point of view of policymaking I don’t think reduced nicotine cigarettes would be as quite as popular.

Tob

Control

Exp

:

I would be inclined to try a few other more likely scenarios such as electronic cigarettes – let people have a go at them.

Tob

Ind

Rep: We’re

trying as fast as possible to create acceptable electronic cigarettes, acceptable tobacco heating products with a much lower toxin profile than the cigarettes and smokeless… I’d rather we’ve gone the other way which is trying to get rid of all the tar and keep the nicotine in e-cigarettes Slide17

Other options - Alternative policies

Another suggestion was that rather than mandate

VLNC cigarettes

only make prices on

VLNC cigarettes lower and hence more attractive. Smok Cess Exp: The only way you could drive people to use the denicotinised ones would be to make them 1/10th of the price of the current one and then you might just encourage smoking more to get your nicotine. Tob Control

Exp

:

I’m just thinking from a Pacific person and the mentality we would have would be why would I pay the same price that has less of something. So they either need to be cheaper than the normal brand

One way for making the price lower would be to have a lower tax on

VLNC cigarettes

compared to

high nicotine

cigarettes.

Gov

Health Off:

Some people have suggested a differentiated tobacco excise tax levied on nicotine content rather than on tobacco content

Pol

Comm

:

I wouldn’t say subsidy but reduced tax rate on them.

Tob

Control

Exp

:

They would have to be sold at a price that made them attractive. That means reduced excise for these cigarettes.

Gov

Health Off:

Have a graduated taxation base or tax the hell out of high nicotine cigarettes to the exclusion of low nicotine cigarettes and e-cigarettes for a period.

One

participant suggested to encourage more competition for producing NRT, leading to a more competitive and desirable product being developed.

Tob

Ind

Rep:

[government] wanted to encourage a bit more competitiveness in the NRT space so they really wanted people to come forward with product that could seriously compete [with tobacco cigarettes]

One participant thought that other policies, such as plain packaging and

smokefree

cars were priority.

Politician:

We need to take the steps to making plain packaging part of our legislation and then we also need to go to the

smokefree

cars where children are present that would be the next move and then the low nicotine. Slide18

Preliminary take home messagesOpinions about VLNC mixedstill harmful but not addictive

VLNC cigarettes only policy unattractive Low evidence Low perceived public support

Alternative policies would

probably have more

tractionE-cigarettes with nicotineVLNC available but not mandatedTobacco industry could be difficult