• electronic nicotine delivery devices
• end game
• harm reduction
• nicotine
• non-cigarette tobacco products

Combustible tobacco products are unique both for the extraordinary harm they cause, and the fact that more than 50 years after these harms became known, they continue to be widely and legally available globally. This ongoing availability is a historical anomaly; any other consumer product that kills up to two-thirds of its long-term users remaining legal is unimaginable. Potent tobacco industry political lobbying, together with the significant prevalence of smoking in many countries, has largely kept ending combustible tobacco sales off the public health agenda.1 2 Even if the political will existed for such a sales ban, until recently no products could match the nicotine delivery efficiency of combustible tobacco with substantially less harm, rendering a sales ban a non-viable option due to the risk of a black market. However, the rapid evolution of the nicotine product marketplace in recent years warrants a reassessment of the viability of phasing out commercial sales of combustible tobacco.

E-cigarettes, and more recently heat-not-burn (HNB) tobacco products, most closely mimic, and therefore have the greatest potential to displace, combustible tobacco. Debate about the potential benefits and risks of e-cigarettes has divided the public health community in recent years. This debate, which now expands to HNB products, centres on the potential for harm reduction, against the potential risk of subverting the declining prevalence of smoking in many countries. An additional concern is the population impact if widespread uptake of these products occurs among people who would otherwise be non-smokers, given the potential for currently unknown harms to emerge with long-term use. Stephens3 and Levy et al 4 provide important contributions to the debate. Stephens3 models and compares the aggregate cancer potencies of carcinogens across four categories of nicotine products, spanning the continuum from most to least harmful (tobacco smoke > HNB > e-cigarettes > nicotine inhalers). Levy et al 4 models the potential deaths that could be averted in the USA by replacing cigarettes with e-cigarettes.

Against the availability of combustible tobacco and its harms, the debate and policy responses to e-cigarette and HNB innovations are currently distorted in several ways. As Levy notes,4 the tobacco industry strategy has been to foster divisions in the public health community around harm reduction. In responding, the tobacco control community may have lost focus on the most deadly form of nicotine delivery. Meanwhile, without consensus about their relative harms and benefits, e-cigarettes have proliferated under a wide variety of regulatory approaches.5 In countries where they are permitted, less caution is exercised in regulation than might otherwise be the case, possibly because their potential harms seem trivial compared with combustible tobacco. E-cigarettes have also largely escaped both taxes and advertising bans.5

Currently, HNB products are available in at least 25 countries and are following a similar market entry pathway as e-cigarettes. Philip Morris International (PMI) has rolled out HNB in markets where it is treated differently to combustible tobacco under existing regulatory and excise frameworks.6 This strategy has allowed it to advertise and engage in intensive one-to-one marketing in the form of ‘coaching’ to switch current smokers to the product,7 activities not permitted under many countries’ tobacco control legislation. At the other end of the regulatory spectrum, in some countries such as Singapore, Australia and Uruguay, current regulations permit combustible tobacco products while banning e-cigarettes and/or HNB, effectively ‘grandfathering’ and providing de facto protection for the most harmful nicotine-containing products.

Neither of the above scenarios is satisfactory. The laissez-faire approach to regulation may incentivise the use of both e-cigarettes and HNB over combustible tobacco; however, it may also assist with ‘normalising’ combustible tobacco products, a strategy explicitly referenced in a 2014 PMI company document.8 The restrictive scenario may condemn the declining proportion of smokers who don’t quit to continued use of the most harmful product when a less harmful alternative exists. Both unnecessarily prolong use of combustible tobacco by preserving it as one end of the continuum of nicotine products.

In July 2017, the US Food and Drug Administration (FDA) announced a comprehensive regulatory plan to reduce nicotine content in tobacco products to below addictive levels, while also encouraging alternative less harmful products.9 A ban on sales of combustibles is not discussed in the plan, and is not permitted under the terms of the FDA’s regulatory authority. However, state and local jurisdictions can ban the sales of specific products in the USA. The underlying principles of the FDA plan are also relevant for countries where regulatory bodies could abolish sales. In August 2017, an action plan for a smoke-free Aotearoa/New Zealand 2025 was launched by a coalition of tobacco control researchers and experts. It incorporates similar principles to the FDA plan, and also includes a range of increasing sales restrictions to achieve smoking prevalence of close to 0% by the end of 2025.10 The argument for abolishing combustible tobacco is not new.11 Legislated measures to achieve such ends have been previously advanced, leveraging less harmful nicotine delivery systems.1 12 Among the factors highlighted for consideration are the risk of tobacco industry subversion and managing tax revenue.

Importantly, a ban on cigarette sales is in line with the rhetoric of PMI, and increasingly other major tobacco companies. The home page of PMI’s website is headlined ‘Designing a smoke-free future’ and asks ‘how long will the world’s leading cigarette company be in the cigarette business?’ The company has acknowledged that a sceptical reception of its claims is both legitimate and justified, given its history. Its duty to shareholders may prevent the company itself from setting a smoke-free date while its combustible market remains both profitable and expanding in some markets. However, there is no such constraint on policy makers.

While combustible tobacco product sales remain legal, the tobacco industry benefits from the looser legislative environment for e-cigarettes and HNB in most countries, remaining free to continue to grow the combustible portion of its business. A policy instituting a rapid phase-out of combustible product sales would shift the tobacco epidemic down the product risk continuum. Although Stephens has advanced the science of assessing harms from e-cigarettes and HNB,3 the evidence base is still limited, particularly in relation to cardiovascular disease.13 However, the health gains modelled by Levy et al 4 show that even in a pessimistic scenario in which HNB and e-cigarettes are more harmful than current knowledge suggests, and with greater uptake by never-users than expected, a rapid phase-out of combustible tobacco is likely to result in significant public health gains.

An important limitation of the Levy et al paper, as with previous research,14 is the enormous range of vaporising products available. Prudent regulation, such as minimum performance standards that limit the potential range and quantity of toxicants in e-cigarette and HNB vapour, is needed. Applying strong regulations to these products, such as substantial taxation, would mitigate potential unintended consequences of as-yet unknown harms and discourage uptake among non-smokers. Differentiated taxation levels could be applied to HNB and e-cigarettes, based on current evidence of the respective products’ risk profiles, with the flexibility to adjust levels as knowledge evolves. A higher tax on HNB would also recognise the culpability of the tobacco industry for the costs of smoking-attributable diseases, and preserve a significant revenue base to meet the ongoing costs of treating these diseases that will occur beyond a phase-out of combustibles, due to the lag in the decline of the disease burden after smoking prevalence has peaked.

A range of arguments can be anticipated against any proposal for ending combustible tobacco product sales, in particular the likelihood of legal challenges. However, the outcomes of several recent tobacco industry challenges show that courts are increasingly ruling in favour of governments’ rights to legislate for public health. Legitimate industries are required to adapt to new regulation, or phase products out entirely, as harms become known and/or safety innovations occur. The new continuum of nicotine products presents an opportunity to end the exceptionalism of combustible tobacco, and allow the most dangerous end of the nicotine product continuum to be rapidly, and completely, phased out.