Life/Health Chief Underwriter, Research & Development, London
More than ever, people
are shunning tobacco. In England, adult smoking prevalence fell to 15.5% in
2016. Although smoking is declining worldwide, it is on the rise in
Eastern Mediterranean and African regions. Despite its dwindling
popularity in many countries, smoking remains the leading preventable cause of
illness and premature death in the world.
Helping people quit
smoking for good is a priority for health services. Tobacco companies, having
taken control of the e-cigarette market, are aligning themselves with the
“smoke free” message. Their centrepiece, however, is composed of new
devices that heat tobacco to extract nicotine without combustion so users
inhale an aerosol infused with nicotine in place of smoke - as opposed to an
e-cigarette that heats a liquid that may or may not contain nicotine. The
manufacturers maintain these new devices play no role in tobacco cessation but
appeal to smokers who don’t want to miss out on nicotine.
Smoking quit rates in
England are at an all-time high with e-cigarettes playing their part. In the UK
around 2.85 million people currently use an e-cigarette, almost all of
whom are smokers or ex-smokers. Around 1.5 million report that they have
quit while 1.3 million remain dual users, switching between an e-cigarette
and tobacco. Small numbers of people vape nicotine-free liquids, and
e-cigarette use among "never smokers" remains very rare, at less
than 1%.
It’s the failure to
completely kick nicotine addiction that remains most troublesome for insurers
seeking to differentiate smokers from non-smokers.
The stated opinion of
Public Health England (PHE) is that e-cigarettes are 95% less harmful than
tobacco.1 They have concluded that heated tobacco devices may
be considerably less harmful than tobacco cigarettes but more harmful than
e-cigarettes. The U.S. Food and Drug Administration (FDA) also remains to
be persuaded that heated tobacco devices are less harmful than e-cigarettes.2 It
wants nicotine in cigarettes reduced to non-addictive levels and has granted no
company the right to specifically claim that their product is less risky than
cigarettes.
Over half the studies
available to PHE were paid for by tobacco companies. Research that is free of
such obvious commercial interest is needed if we are to understand whether or
not heated tobacco products complement or replace cigarettes.
In tests, PHE found
heated tobacco products deliver less nicotine than the tank style e-cigarettes
favoured by 80% of UK vapers, and consistently below the levels drawn from
burned tobacco. Users find them less enjoyable, too. For smokers this is mainly
to do with “throat hit” the sensation of swallowing down smoke. It’s a
problem the manufacturers acknowledge; satisfying committed smokers using a
plastic contraption in place of a real cigarette is not easy.
Changing people’s
behaviour is notoriously hard to achieve, more so when an element of the
behaviour is maintained through addiction. Smoking behaviour is particularly
complex and the industry serving it depends on maintaining that addiction.
There are parallels with the failure of public health initiatives to influence
people to act on healthy eating, exercise and sexual health, use of alcohol,
illicit drugs and tobacco.
While the evidence
presented by the tobacco companies is fulsome and even impressive, questions
will inevitably linger over the validity of evidence sponsored by an industry
which has a track record of making unfounded claims of reduced risk. Insurers
need to see that heated tobacco devices significantly reduce the risk of
disease and not encourage more smoking or delay quitting. Meanwhile, as
nicotine is a core component and doubts remain over dual usage, insurers must
charge users of heated tobacco products the full smoker tariff.
Endnotes
1. McNeill A., Brose
LS., Calder R., et al., Evidence review of e-cigarettes and heated tobacco
products: a report commissioned by Public Health England. London: Stationery
Office, 2018. https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review.
2. Reuters (2018) FDA’s
tobacco stance faces test with Philip Morris iQOS device, 22 January 2018,
available at https://www.reuters.com/article/us-health-tobacco-pmi/fdas-tobacco-stance-faces-test-with-philip-morris-iqos-device-idUSKBN1FB0J2.
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