Investigating the Drivers of Smoking Cessation: A Role of Alternative Nicotine Delivery Systems?

Abstract

Since 2010, several nations with impressive histories of smoking cessation have witnessed the proliferation of Alternative Nicotine Delivery Systems (ANDS). Advocates suggest that ANDS offer an effective and safer substitute for combustible tobacco. Critics fear that ANDS could expose consumers to novel harms, discourage smoking cessation and may even renormalize tobacco use. Different nations have adopted radically different regulatory strategies ranging from outright bans to active encouragement of ANDS-led smoking cessation. Economic, social and political factors also influence rates of smoking and uptake of ANDS. An investigation into the national-specific context for smoking cessation; including the role of ANDS in reducing cigarette consumption, is likely of value to regulators around the world hoping to reduce smoking-related morbidity and mortality in their own communities.

Five case studies were conducted to review the evidence from Australia, Canada, Japan, South Korea and the UK, drawing on an interdisciplinary framework for investigation combining sociological, ethnographic, policy analytic and econometric disciplinary approaches into a schema for studying the drivers of smoking cessation at the individual, micro, meso and macro levels. Data on smoking, and cessation from four decades was combined with more recent data on ANDS use, to investigate the relationship between tobacco control policies, ANDS use and smoking cessation, as well as other salient aspects of the national tobacco control landscape. Each case study developed specific recommendations for policy makers and the research agenda. This report summarizes the findings of those studies.

Taxation and Stop Smoking Services (SSS) were among the most effective cessation drivers. Smoke-free laws were also found to be of value, though the evidence for their efficacy in reducing smoking prevalence is mixed. Other policies that sought to reduce the appeal or opportunity to smoke such as plain pack legislation and health warnings, etc. were less associated with short term reductions in smoking prevalence, though these may yet reduce national smoking rates by discouraging uptake among future generations. Tobacco use continues to be concentrated in socially and economically disadvantaged groups. Where regulations allowed, ANDS (e-cigarettes and heated tobacco in particular) were associated with smoking cessation. Moreover, instances of tobacco use declining even as e-cigarette use increased suggests that e-cigarettes do not necessarily re-normalize tobacco use as feared. The results demonstrate how policy decisions affect ANDS use and the latter’s value as a cessation mechanism.

The authors recommend that regulators continue to increase tobacco taxes carefully and study how to integrate ANDS with well-funded SSS provision. Regulators should also seek policies that differentiate among nicotine products with respect to their harms profiles. Future cessation programs should target socially and economically disadvantaged groups where tobacco harms continue to be concentrated. This research highlights the need for high quality open-access data collection and analysis, especially regarding use of ANDS.

Keywords: Tobacco, Smoking, Smoking Cessation, Cigarettes, ANDS, ENDS, E-Cigarettes, Vaping, Tobacco Control, Harm Reduction