Predicting the Future of Smoking in a Rapidly Evolving Nicotine Marketplace

The nicotine product market is global and rapidly evolving (1). Factory-made cigarettes still dominate the market accounting for nearly 90% of overall sales. However, overall cigarette sales globally have been steadily dropping by about 2% annually. In some parts of the world cigarettes have been displaced by less harmful forms of nicotine delivery. For example, in Sweden, oral snus has largely displaced cigarettes as the predominant form of tobacco consumed with corresponding reductions in the incidence of smoking caused cancers, heart disease, and respiratory diseases (2–3). The eventual demise of the conventional cigarettes has long been anticipated and planned for by cigarette companies. As one R.J. Reynolds’ executive observed, “if the exit gate from our market should suddenly open, we could be out of business almost overnight” (4).

As early as the 1960s, cigarette manufacturers were patenting nicotine vaping devices that could be used by smokers as substitutes for cigarettes, if and when competition emerged to threaten the conventional cigarette market (5–6). In the late 1990s and early 2000s, market forces against cigarettes began to shift radically. Manufacturers were forced to admit that their cigarettes were deadly and addictive (7). Governments adopted more effective policies to reduce cigarette demand (i.e., excise taxes, public smoking bans, product and marketing regulations, graphic health warnings and mass media campaigns), and technologies emerged that allowed non-cigarette vaping manufacturers to market their products directly to consumers over the internet bypassing the marketing controls that had long allowed cigarette manufacturers to operate without real competition (8–9). In United States (US) and England (EN) nicotine vaping products (NVPs) have displaced stop smoking medications approved by regulatory bodies as the most popular stop smoking aid used by adult smokers (10–11).

Vaping nicotine is not harmless, but it is much less harmful than smoking (12–13). However, it is too early to know for sure what the long-term health risks and/or benefits of nicotine vaping will be since those risks are not only influenced by the types of products used, but also by how the products are used and by whom. Vaping behavior is complex and not as easily quantified as is smoking behavior. The motivations for vaping are also more varied than they are for smoking and the products themselves differ widely in their nicotine delivery compared to cigarettes. Further complicating matters is the lack of consensus from public health officials about how best to regulate the evolving nicotine product marketplace. Some jurisdictions have taken a cautious approach towards vaping products relying on conventional smoking control policies to reduce smoking while erecting barriers limiting consumer access to NVPs (14). For example, Australia (AU) has among the strongest anti-smoking policies in the world, but has taken a cautious approach to nicotine vaping making it illegal to possess nicotine e-liquid without a doctor’s prescription.

Canada (CA), another country with very strong anti-smoking laws, also up until recently restricted the sale of NVPs in retail establishments absent government approval. However, unlike AU, health authorities in CA were less strict about enforcing the retail sales ban on vaping products allowing vape shops to proliferate in many areas of the country (15). Previous studies have documented that the restrictions on vaping products in AU and CA have suppressed vaping prevalence and influenced where vapers report getting their vaping products (i.e., primarily online for AU vapers, and vape shops and online sources for CA vapers) (14). Beginning in May 2018, CA began allowing the marketing and sale of vaping products in retail stores similar to what has been allowed in EN and the US.

Over the last two decades, EN has adopted many of the same strong anti-smoking policies that have been implemented in AU and CA, but unlike AU has encouraged smokers to switch to NVPs. On a national level, the anti-smoking policies in the US are not as strong as are in AU, CA, and EN, choosing instead to allow states and localities to lead tobacco control efforts, which has created regional disparities in smoking rates.

The US is currently the largest vaping market in the world (1). In 2016, the US Food and Drug Administration (FDA) was granted authority to regulate nicotine vaping industry, but up until recently has resisted efforts to aggressively regulate vaping products. However, that situation may be changing as public health groups, have raised concerned about the risks of vaping and about the increased rates of youth vaping, pressuring FDA to implement strict and costly approval criteria for product licensing which would effectively slow the growth of the vaping industry in the US (16).

These four countries illustrate the complex relationships between smoking, vaping, and the regulatory environments that help to shape the nicotine markets in each jurisdiction. The diversity of these approaches taken by these four countries constitutes a unique natural experiment for measuring and understanding the impact of different regulatory environments.

Thus, it is challenging to predict what the future impact that the evolving nicotine marketplace may have on population health in any given jurisdiction. However, that is precisely the challenge that investigators involved with the International Tobacco Control Policy Evaluation Project (ITC) have taken on as reported in this special issue of Addiction. This issue contains 13 different papers spanning a wide range of topics from broad descriptions of NVPs and usage patterns, motivations for using vaping products, beliefs and attitudes about nicotine vaping, and the impact of various policies on vaping and smoking behaviors, and the likely impact they will have on population health outcomes (17–29)

These 13 papers point out some of limitations of the data available on vaping, smoking-vaping transitions, and health risks and highlight the challenges in predicting how the evolving nicotine delivery market in different jurisdictions might impact population health. The answer to this question may depend on where one lives. In markets such as the US and EN, where the nicotine vaping industry has flourished, cigarette sales are declining at what appears to be an accelerating rate. By the same token, cigarette consumption is also falling in AU, where public health officials have adopted policies suppressing the nicotine vaping market.

The similarity in the basic trend of falling cigarette consumption in AU vs. US and EN suggests that it is necessary to consider the impact of both policies designed to reduce smoking and policies that are relevant to vaping products (some of which are more restrictive and some of which are less restrictive). Perhaps, access to NVPs is less critical in places with strong smoking control policies already in places and where the smoking epidemic is on the wane. On the other hand, the opposite might also be true as the benefits to be gained from conventional smoking control measures appears to diminish overtime, so adding access to lower risk alternative nicotine products may actually represent a way to maintain and accelerate momentum to reduce smoking. Indeed, the diminishing reductions in smoking prevalence in recent years has been a central argument for why NVPs should be permitted and regulated in ways that encourage smokers to switch to them (30).

It is also difficult to predict the possible impact of NVPs in jurisdictions where smoking rates are still increasing. In such countries, the impact of NVPs may depend on the additive and interactive effects of a number of factors including commitment to FCTC implementation. As Yogi Berra is attributed to have said, “Prediction is difficult, especially about the future” (31).