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A Bold U.K. Plan to End the Smoking Epidemic — Meanwhile, the ban on Juul e-cigarettes may hamper U.S. anti-smoking efforts

July 2022
A new report, independently commissioned by the Secretary of State for Health and Social Care of the U.K., provides cutting-edge recommendations with the aim of achieving a "Smokefree 2030." This reflects the U.K. government's ambition to reduce the smoking rate from 13.5% to 5% by the end of this decade. Authored by Javed Khan OBE, MD, and released by the British government on June 9, 2022, the report, "The Khan Review: Making Smoking Obsolete," assesses the impact of the public health policies currently in place and finds that, "without further action, England will miss the smokefree 2030 target by at least 7 years, and the poorest areas in society will not meet it until 2044."
"To have any chance of hitting the smokefree 2030 target," it concludes, "we need to accelerate the rate of decline of people who smoke, by 40%." It's final message: "Smoking kills and ruins lives. But it doesn't have to be like that."
The Khan Review has relevance not only to the U.K. but also to the U.S., as we will explain.
The report offers a series of evidence-based recommendations -- four of them "critical" -- to accelerate progress and save more lives more quickly. They serve both as guideposts for our friends across the Atlantic and as a model for what the U.S. could likewise do more effectively to end the smoking epidemic here.
In both nations, despite historic progress, smoking remains the leading preventable cause of death. There are also staggering inequalities. The poorest and most vulnerable populations are those most likely to continue smoking, making tobacco a leading contributor to significantly increased ill health and reduced life expectancy for those who are most disadvantaged.
The report's "must dos" include:
  1. Increase investment. Comprehensive financial investment is needed for smoking cessation treatment. The report counsels that if the government cannot or will not provide such funding directly, it should "make the polluter pay" by imposing additional levies on cigarette companies to cover the costs.
  2. Increase the age of sale. The government should increase the age of sale from 18, by one year, every year until no one can lawfully buy cigarettes. (The federal minimum age in the U.S. is 21, with no annual increase.)
  3. Promote vaping as a harm reduction approach. The government should also increase its promotion of the use of e-cigarettes to help people quit smoking tobacco. The report says, "We know vapes are not a 'silver bullet' nor are they totally risk-free, but the alternative [of combustible tobacco use, or smoking] is far worse."
  4. Improve prevention in the National Health Service (NHS). Prevention must become a central focus of the NHS's tobacco control efforts. It must offer smokers advice and support to quit in "every interaction they have with health services," including with general practice physicians, hospitals, mental health treatment providers, midwives, pharmacists, dentists, and optometrists.
The report also proposes other evidence-based policies, such as requiring tobacco licenses for retailers, changing the appearance of cigarettes and their packaging to reduce their appeal, expanding smoke-free public places, investing in mass media campaigns, raising taxes on cigarettes, and ending duty-free privileges for tobacco products.
Finally, Khan urges the government to accelerate its plan for healthcare practitioners to prescribe e-cigarettes (in addition to their continued sale as non-medicinal consumer products), especially in deprived communities. This will help make harm reduction approaches acceptable to those who require medical reassurance, and accessible to others who can't easily afford to buy e-cigarettes at retail prices.
These recommendations bear resemblance to New Zealand's ambitious Smokefree Aotearoa 2025 plan, which seeks to end smoking and promotes e-cigarettes as having "the potential to make a contribution to the Smokefree 2025 goal and...disrupt the significant inequities that are present."
In stark contrast with the consensus of government and public health organizations in those nations, the U.S. is mired in a polarized debate pitting concern regarding the risks of e-cigarettes for youth against their potential to help addicted adult smokers stop smoking. The heavy emphasis on protecting youth has, to its credit, succeeded in reducing youth e-cigarette use by over 60%, down to 7.6%, in the past 2 years, at the same time that the youth cigarette smoking rate has plummeted to a historic low of only 1.5% (mitigating the concern that youth vaping might encourage smoking).
Youth vaping is no longer an "epidemic." But these efforts, which too often inaccurately portray the risks of e-cigarettes, have led to significant public misunderstanding regarding the substantially lower health risks of e-cigarettes compared to combustible tobacco products. This, in turn, has impeded the promotion of tobacco harm reduction to the more than 30 million adults who still smoke.
Recently, the FDA announced that it will ban Juul e-cigarettes due to what it described as a couple of unresolved questions related to potential toxicity, although it said it is unaware of any immediate hazard associated with the use of the product. Advocacy groups quickly framed the decision as payback for a product that became popular with kids starting in 2018. Yet, while over 2 million adults have switched from cigarettes to Juul, potentially avoiding over a million deaths from smoking in the coming years, Juul is no longer favored by young people, with only 0.6% of youth reporting having used a Juul product in the last 30 days.
Some experts have noted the irony that an e-cigarette popular with adult smokers trying to quit may be banned while billions of aggressively marketed, and far more hazardous, combustible cigarettes will continue to be sold with relative impunity.
More positively for public health, the FDA continues to promote policies to dramatically reduce the appeal of conventional cigarettes, such as reducing nicotine to nonaddictive levels and eliminating menthol as a characterizing flavor. It has also, in recent months, authorized for sale 23 e-cigarette brands based on the agency's assessment that they are "appropriate for the protection of public health," the standard set forth in its governing statute. Adhering more consistently to this approach based on the "continuum of risk" across different tobacco and nicotine products would align with the progressive approaches now being pursued in the U.K. and New Zealand, and perhaps instill greater confidence that the U.S. can simultaneously support adult smokers while protecting youth.
Let us not forget that the overriding public health objective should be to protect the public from harm, especially grievous harm. The greatest harm to health is overwhelmingly caused by inhaling combustible tobacco smoke, which is responsible for virtually all "tobacco-related" deaths. Millions of adult smokers face imminent harm and even death from their use of combustible cigarettes.
Nicotine causes dependency, but does not itself cause the many diseases resulting from the inhalation of burned tobacco, a fact misunderstood by the majority of physicians. It is our clinical duty to help smokers quit whenever possible, supported by cessation medications and counseling. And for those smokers who cannot or will not use cessation medications, we should encourage them to switch to substantially less harmful sources of nicotine, such as e-cigarettes.
Every day, more than 1,300 Americans lose their lives to smoking. At the same time, to our knowledge, there have been no credibly reported deaths caused by exposure to the aerosol of nicotine-based e-cigarettes. The U.K. and New Zealand are now leading the way in the battle to end the epidemic of smoking-related illness and death. The U.S. can learn from them.
The opinions expressed are the authors' and do not necessarily reflect the views of any organization with which they are affiliated.
Clifford E. Douglas, JD, is the director of the University of Michigan Tobacco Research Network and an adjunct professor at the University of Michigan's School of Public Health. Caitlin Notley, PhD, is professor of addiction sciences and lead of the Addiction Research Group at the Norwich Medical School, University of East Anglia. She is director of the "Citizens Academy," involving patients and the public in research.
Disclosures
Douglas is a co-principal investigator for research conducted through the Center for the Assessment of Tobacco Regulations, which is funded by NIH/FDA. He is also an advisor to the Smoking Cessation Leadership Center at the University of California San Francisco relating to behavioral health and tobacco use. Notley leads a program of work in smoking cessation and relapse prevention, including trials funded by the National Institute for Health Research in the U.K.
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