Alternative Nicotine Delivery Systems Research Articles

Whether to push or pull? Nicotine reduction and non-combusted alternatives - Two strategies for reducing smoking and improving public health

Combustible cigarettes remain the most harmful and addictive tobacco product, and reducing the prevalence of smoking continues to be a critical public health goal. While nicotine is the constituent primarily responsible for addiction to cigarettes, most of the harm associated with smoking comes from byproducts of tobacco combustion. Recently, two different approaches for reducing the harms of smoking have emerged, both of which focus on breaking the link between the addiction to nicotine and the harms caused by smoking. First, the addictive potential of cigarettes could be minimized by requiring a large reduction in the nicotine content of cigarettes. Evidence for a nicotine reduction policy thus far shows that the use of very low nicotine content cigarettes results in a reduction in the number of cigarettes people smoke per day and a reduction in cigarette dependence. Second, emerging alternative nicotine delivery systems (ANDS) like electronic cigarettes may provide sufficient nicotine to act as substitutes for cigarettes while delivering much lower levels of toxicants. Evidence suggests that the emergence of ANDS has increased the percentage of smokers who are able to quit. The present paper will briefly review the evidence for each of these approaches, and consider what contemporary reinforcement and addiction theories can tell us about their likely success. We argue that the most effective endgame approach is one that pursues both nicotine reduction and alternative nicotine delivery systems as complementary.

Hostage to fortune: an empirical study of the tobacco industry's business strategies since the advent of E-cigarettes

The tobacco market has been transformed by the arrival of e-cigarettes and array of alternative nicotine delivery systems (ANDS). Public health has struggled to cope with these changes and clear divisions are apparent, but less is known about the tobacco industry (TI) response. This first empirical study to examine TI and independent ANDS companies’ business strategies fills this gap. Primary data were collected through 28 elite interviews with senior/influential TI and independent stakeholders, triangulated with a documentary analysis of company reports, investor analyses, market research, and consultation responses (1022 documents). A deliberately emic analysis shows that tobacco multinationals were initially disconcerted by ANDS, but logic provided by the fiduciary imperative is enabling them to turn a potential threat into profitable opportunities. Interviewees argue market changes played to their strengths: customer links, expertise in nicotine, and enormous financial resources. This enabled portfolio diversification in which combustible and ANDS coexist; providing potential to develop robust scientific and regulatory positions and hope of retrieving corporate reputations. The principal threat for major tobacco players comes from the independent sector, which is prepared and able to satisfy bespoke consumer needs. Multinationals by contrast need to turn ANDS into a genuinely mass-market product appealing to its global customers. They are making progress. Given the continued buoyancy of the combustibles market, they have extensive resources to continue their efforts. Disruptive innovations are not unique to tobacco control. Equivalent technological solutions – with concomitant business opportunities − are emerging in obesity and alcohol fields with implications for public health.

Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives.

Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts.

Emotion in the ANDS (alternative nicotine delivery systems) market: Practice-theoretical insight into a volatile market

Purpose The alternative nicotine delivery systems (ANDS) market is complex, with a range of multi-national and multi-sector stakeholders competing for market share but also clashing ideologically as the evidence about the impact and side-effects of ANDS emerges. This empirical study examines the beliefs, goals and emotions at the heart of the practices performed by actors within the organisations behind the controversial commercial explosion of ANDS. Design/methodology/approach The study was designed to explore business strategies from the viewpoints of ANDS business stakeholders. A purposive, snowball sampling strategy was used to recruit ANDS stakeholders and gatekeepers among UK tobacco multinational and independent companies (n = 28). Data were then analysed using a market-as-practices theoretical framework which specifically frames market activities as practices, governed by teleoaffective structures, which seek to establish market procedures and rules, and which contribute to the taste regimes of a consumer practice. Findings Analysis has indicated that the ANDS market is highly contested and volatile, interwoven with competition, emotion and conflicting beliefs. In this context, there are commercial practices routinely undertaken in an attempt to align stakeholdrs' beliefs, which is seen as a core part of the corporate activities required within the marketplace. A key driver of these alignment activities is the profit end-goal, but this is in tension with beliefs, such as about doing 'right' and the objectivity of 'science'. Beliefs across this emergent market vary and are strongly held, and they lead to emotional positions, tying back to why aligning stakeholders is difficult. Analysis illuminates how the projects, end goals, emotions and beliefs which comprise the teleoaffective structures of various corporate practices in the ANDS market might inform the rules and norms of the markey, shaping a taste regime experienced by consumers. Limitations The data and analysis cannot account for the beliefs and emotions of public health bodies, researches, the media, policymakers and other stakeholders, but seek to illuminate how teleoaffectivity is a key part of market practices. Furthermore, the taste regimes of ANDS consumers cannot be observed in the data due to the focus on ANDS commercial actors. Finally, it is possible that conscious or unconscious biases in the interviewing style may have driven interviewees' responses and influenced data interpretation. Implications Tobacco control is one of the greatest success stories of public health; smoking prevalence has been driven down with a combination of popular empowerment and corporate containment. All this depended on a coherent and accepted evidence base. As this evidence base has fractured during the evolution of the ANDS market, so the stories have proliferated and progress has become less certain. The high emotion in the ANDS market indicates a tougher task for behaviour change activity targeting corporate actors. Contribution This paper speaks to the multiple calls in the behaviour change literature to tackle the intractable problems of the day through upstream measures including the restriction of corporate activity. The value is in the unique dataset and in the ambition of the project to unravel behind-the-scenes activities in the ANDS market. A practice-theoretical framework, although conceptually complex, is deployed to capture the complex intertwining of multiple practices and thus attempt to grasp the full significance of teleoaffectivity in the marketplace.

A man before his time: Russell's insights into nicotine, smoking, treatment and curbing the smoking problem.

This narrative review aimed to provide a brief overview of five key research 'classics' produced by the innovative and radical thought leader, Professor Michael Anthony Hamilton Russell (1932-2009), drawing upon his other work wherever feasible. Narrative review. From more than 250 publications, we selected papers we considered seminal texts, published in 1971, 1976, 1978, 1979 and 1991. Russell was among the first researchers to explain that smoking was a dependence disorder caused by the drug nicotine decades before this was recognized formally. He therefore saw quickly the importance of delivering nicotine in a less harmful format as a way of controlling nicotine withdrawal when stopping smoking, first studying nicotine gum. In addition to pharmacotherapies, Russell's research also explored the role of behavioural support, particularly the role of general practitioners (GPs), alone as well as supported by specialist clinics; this research underpinned initiatives in England to reimburse doctors for giving advice to smokers, and to provide a national network of smoking cessation services. Research on nicotine uptake from other delivery systems and routes led Russell to theorize that the speed and dose of delivery impacted upon the effectiveness of a product to act as a substitute for smoking. He commented on the addictiveness of the high nicotine boli delivered in quick succession when smoking cigarettes and argued that alternative recreational nicotine delivery systems would need to be promoted actively to smokers in order for them to compete with cigarettes, a forerunner for contemporary debates on electronic cigarettes. The legacy of Russell's landmark research is seen in present-day nicotine science, policy and discourse.

Obsolete tobacco control themes can be hazardous to public health: the need for updating views on absolute product risks and harm reduction

BackgroundLeading themes have guided tobacco control efforts, and these themes have changed over the decades. When questions arose about health risks of tobacco, they focused on two key themes: 1) how bad is the problem (i.e., absolute risk) and 2) what can be done to reduce the risk without cessation (i.e., prospects for harm reduction). Using the United States since 1964 as an example, we outline the leading themes that have arisen in response to these two questions. Initially, there was the recognition that “cigarettes are hazardous to health” and an acceptance of safer alternative tobacco products (cigars, pipes, light/lower-tar cigarettes). In the 1980s there was the creation of the seminal theme that “Cigarettes are lethal when used as intended and kill more people than heroin, cocaine, alcohol, AIDS, fires, homicide, suicide, and automobile crashes combined.” By around 2000, support for a less-dangerous light/lower tar cigarette was gone, and harm reduction claims were avoided for products like cigars and even for smokeless tobacco which were summarized as “unsafe” or “not a safe alternative to cigarettes.”DiscussionThe Surgeon General in 2014 concluded that by far the greatest danger to public health was from cigarettes and other combusted products. At the same time the evidence base for smokeless tobacco and alternative nicotine delivery systems (ANDS) had grown. Product innovation and tobacco/nicotine bio-behavioral, epidemiological and public health sciences demonstrate that low nitrosamine smokeless tobacco (e.g., Swedish snus), and ANDS have substantially lower harms than cigarettes. Going forward, it is important to sharpen themes and key messages of tobacco control, while continuing to emphasize the extreme lethality of the inhaled smoke from cigarettes or from use of any combusting tobacco product.SummaryImplications of updating the leading themes for regulation, policymaking and advocacy in tobacco control are proposed as an important next step. A new reframing can align action plans to more powerfully and rapidly achieve population-level benefit and minimize harm to eliminate in our lifetime the use of the most deadly combustible tobacco products and thus prevent the premature deaths of 1 billion people projected to occur worldwide by 2100.

The Moment Study: protocol for a mixed method observational cohort study of the Alternative Nicotine Delivery Systems (ANDS) initiation process among adult cigarette smokers

IntroductionAlternative Nicotine Delivery Systems (ANDS) such as e-cigarettes are battery-powered devices that aerosolize nicotine and other substances to simulate smoking without using tobacco. Little is known about the ANDS initiation...

Smoking, vaping and public health: Time to be creative.

The development of policies on vaping in health care organizations (HCOs) needs to be based on a solid understanding of science and a recognition of individual rights. It should also be seen in the broader public health context of innovative alternative nicotine delivery systems playing a key role in ending the immense devastation of combustible cigarettes. Opposition to vaping based on inaccurate and incomplete information, or fear of unlikely and avoidable hypothetical unintended consequences, will invariably cause great harm to individuals, impede rather than assist the attainment of public health objectives, and unnecessarily prolong the epidemic of cigarette-caused diseases.

Effects of a Fact Sheet on beliefs about the harmfulness of alternative nicotine delivery systems compared with cigarettes.

BackgroundThis study explored the value of providing information in a Fact Sheet to correct misperceptions about the relative harmfulness of nicotine replacement products (NRT) and smokeless tobacco (ST), when compared to cigarette smoking.MethodsFour convenience samples from different countries (Australia, UK, Sweden and USA) were surveyed concerning their beliefs about the relative harmfulness of smokeless tobacco and NRT. Study participants were given the Fact Sheet that explained that nicotine, as used by consumers, is not particularly harmful and explained why. They were resurveyed one week later regarding their beliefs about the relative harmfulness of smokeless tobacco and NRT and future intentions to use the products.ResultsIn all four samples knowledge increased by similar amounts and beliefs regarding the lower harmfulness of smokeless tobacco increased. However, misconceptions remained common and responses to belief measures were not always consistent. Likelihood of use of ST increased in all four samples after exposure to the Fact Sheet, but interest in NRT use only increased in the US sample.ConclusionsA Fact Sheet such as this one can help address misconceptions about NRT and smokeless tobacco, at least in the short term. However, as is true of most educational interventions, exposure to a single educational session is not sufficient to overcome misperceptions that smokers have about the relative harmfulness of oral versus combustible forms of nicotine delivery.

Regulatory imbalance between medicinal and non-medicinal nicotine.

Cigarettes are very efficient, but exceedingly 'dirty', nicotine delivery systems. Although nicotine creates dependency, it is the contaminated delivery system that causes tobacco-related harm. With an annual global tobacco market > USD$300 billion, and a large proportion of the > 1 billion tobacco users seeking to avoid the 50% risk of death, there should be a huge market for alternative nicotine delivery systems. A move towards risk reduction could significantly benefit public health, provide consumer choice and allow free market forces to combat the leading cause of preventable death. However, market forces are currently prevented from providing consumers with the risk-reducing products they want because of existing regulatory systems. Tobacco products have been exempted from consumer protection laws, but there are no such exemptions for other nicotine delivery products, e.g. NRT. This has resulted in an exceedingly uneven playing field for nicotine products, with the most harmful products subject to little regulation while the least hazardous products are stringently regulated. In effect the world is upside-down, and nicotine regulatory systems should be reformed in order to maximize the reduction in risk. In addition, regulatory bodies need to: develop nicotine- and tobacco-specific expertise, rapidly evaluate which products should be permitted and decide how these products should be marketed. Appropriate regulatory structures could harness the power of free enterprise in global efforts to control the tobacco epidemic. This can be done through the development of regulatory processes designed to ensure that all nicotine delivery products are considered in relative terms (regardless of source), and ensuring that all regulatory action strives for the greatest practical reductions in risk.

Regulatory imbalance between medicinal and non‐medicinal nicotine

Cigarettes are very efficient, but exceedingly 'dirty', nicotine delivery systems. Although nicotine creates dependency, it is the contaminated delivery system that causes tobacco‐related harm. With an annual global tobacco market > USD$300 billion, and a large proportion of the > 1 billion tobacco users seeking to avoid the 50% risk of death, there should be a huge market for alternative nicotine delivery systems. A move towards risk reduction could significantly benefit public health, provide consumer choice and allow free market forces to combat the leading cause of preventable death. However, market forces are currently prevented from providing consumers with the risk‐reducing products they want because of existing regulatory systems. Tobacco products have been exempted from consumer protection laws, but there are no such exemptions for other nicotine delivery products, e.g. NRT. This has resulted in an exceedingly uneven playing field for nicotine products, with the most harmful products subject to little regulation while the least hazardous products are stringently regulated. In effect the world is upside‐down, and nicotine regulatory systems should be reformed in order to maximize the reduction in risk. In addition, regulatory bodies need to: develop nicotine‐ and tobacco‐specific expertise, rapidly evaluate which products should be permitted and decide how these products should be marketed. Appropriate regulatory structures could harness the power of free enterprise in global efforts to control the tobacco epidemic. This can be done through the development of regulatory processes designed to ensure that all nicotine delivery products are considered in relative terms (regardless of source), and ensuring that all regulatory action strives for the greatest practical reductions in risk.

Policy Options to Reduce Tobacco-Caused Mortality

Tobacco-related death and disease place significant health and economic burdens on society. In an attempt to reduce these, support is growing for the use of alternative nicotine delivery systems in smokers who are unable to break their addiction to nicotine. However, as increasing numbers of alternative nicotine delivery systems are developed, by pharmaceutical companies, the tobacco industry and other manufacturers, the need for a comprehensive regulatory policy governing all such products becomes even more important. This article reviews the existing legislation surrounding tobacco and nicotine, the politics of nicotine delivery, and current scientific knowledge surrounding nicotine, and assesses the various policy options to minimize tobacco-related harm. Segmentation of the nicotine market, according to different smokers' needs, and research and philosophical issues are also considered.

Prevention of Lung Cancer by Long-term Use of Alternative Nicotine Delivery Systems?

Prevention of Lung Cancer by Long-term Use of Alternative Nicotine Delivery Systems?