Ann McNeill is Professor of Tobacco Addiction and co-director of the NIHR-funded Policy Research Unit in Addictions. Ahead of her Society Lecture at the 2024 Annual Conference, Professor McNeill spoke to the SSA’s Rob Calder about her career and expertise in tobacco harm reduction. Read edited excerpts of the interview below or listen to the interview on the Addictions Edited podcast.
People are very distrustful of this whole idea that you can reduce the harmfulness of smoking.
On the origins of harm reduction in tobacco control…
Tobacco harm reduction has been around quite a long time, and there are two aspects to it: reducing harm to people around a smoker; and then reducing harm to the smokers themselves. Reducing harm to people around people who smoke isn’t controversial. That’s what smoke-free policies are predicated on. So that’s all been accepted. Where it’s more controversial is around reducing the harmfulness of someone’s own tobacco use or own smoking behaviour. And that goes right back to the 1960s.
Around that time, the tobacco industry was keen to reassure smokers that their smoking wasn’t that harmful to them by doing a number of things. And one of those things was reducing the tar in cigarettes. So, they did that and they heavily and aggressively marketed those to smokers. But what the epidemiological evidence revealed was that it didn’t actually have the desired impact. And that was because, for example, they would put filters on cigarettes and put little pin prick holes in the filters, which wouldn’t be covered when a machine smoked them, so they would then appear to be low tar. But actually, when a smoker smoked them, they covered the little holes in the filters, and therefore they didn’t make any difference to what the smokers were consuming. They were an ‘industry con’. And I mention that because really, that’s caused a lot of the controversy. People are very distrustful of this whole idea that you can reduce the harmfulness of smoking.
However, in the 1970s, Professor Mike Russell started to develop clean nicotine delivery systems. These were predicated on the fact that nicotine is what causes people to smoke by and large. But it isn’t the nicotine that kills. It’s the other 7,000 odd constituents that come along in cigarette smoke. So, if you can get alternative nicotine delivery systems which aren’t burned, those would be useful to help people to stop smoking by first dealing with the kind of behavioural aspects of smoking. And then they could come off the nicotine.
And then in about 1991, I think he said that because lots of smokers hadn’t moved to use these products, what we really needed was nicotine delivery products that competed with cigarettes on the open market and these would be products that were attractive to smokers. Sadly, he died just as e-cigarettes were emerging, which did all of those things. They were competing with cigarettes on the open market.
On changing her mind about tobacco harm reduction…
US tobacco wanted to build a Skoal Bandits factory in Scotland, supported by the UK Government. That’s a type of smokeless tobacco product, which, at the time, they were very heavily promoting to young men in the US. And they were commonly used by sports people – baseball players. But there were also signs that they were causing oral cancer. So, there was a real concern that having this factory built with the support of the UK Government wasn’t a good thing, and we would end up having a very similar situation here, where they would be aggressively marketed to young people, and young people would take up these Skoal Bandits.
I wrote an editorial called ‘Bandits on the run: the oral snuff debate’ that was supportive of the fact that this shouldn’t be built. But then I thought it was prudent to study the evidence – look at these products and look at what we knew about them in terms of their health effects. And that’s what drew me to also studying what was going on in Sweden. So, we actually had some smokeless tobacco products tested here in the UK. And in fact, news came out very similar to the nicotine replacement product. So, that made me realise that whilst we wouldn’t want the aggressive marketing of US tobacco, having people use such products instead of smoking could have been beneficial. And that’s when I really started to think that there was potential benefit from including tobacco harm reduction alongside cessation and prevention in our tobacco control armoury.
On the influence of the tobacco industry…
One of the biggest problems is that we are up against an industry whose sole objective is to make a profit and sell these products as widely as possible. And to do that, they have to make them attractive, make them accessible, et cetera, et cetera.
I think it’s particularly galling for the tobacco industry to present themselves as the proponents of tobacco harm reduction – you know, that they’re interested in public health after so many decades of doing the opposite and obfuscating about the dangers of tobacco smoking. But also aggressively undermining every policy that we’ve ever tried to introduce. So, things like plain packaging of tobacco products, removing tobacco from the point-of-sale displays. All of those they’ve very aggressively campaigned against and taken legal action.
It’s very hard to work out how best to regulate the industry so that it plays ball. And I don’t think we’ve got the answer to that yet. But there are some good suggestions as how best to do that, certainly in terms of ensuring that they reduce the supply of the combustible tobacco, which is the main killer. But managing how they supply and promote these alternative nicotine products is much more difficult.
On the challenges of researching a rapidly-changing market…
The first e-cigarette I bought cost about £70. I remember showing it to my students at the time, saying, you know, ‘This is a product that obviously won’t take off, but I brought it out here to show you alongside a number of others’. And, of course, within a matter of years, that changed. And they became much cheaper and more accessible to smokers.
It is hard to keep abreast of what’s going on. The problem also when you do a systematic review, is that it is often two years out of date before you publish it and there’s a lot of other papers that come out in the interim. I think probably the way that those reviews need to move is towards being a living systematic review, like the Cochrane reviews, where the evidence is updated on a month-by-month basis.
One of the fears is that by diluting our message about abstinence – you know, stopping smoking being the goal – we might then be encouraging some smokers to carry on.
On how to balance adult cessation and youth prevention goals…
We know that exposure to second-hand smoke causes around 5,000 hospitalisations of children every year. So, reducing adult smoking, and particularly adult smoking in disadvantaged groups, will drive down and improve the health of young people as well. So, it’s not a strict divide between adult cessation and youth prevention. But, and I think that’s what we’re all struggling with at the moment, how do we promote products like e-cigarettes to help people to stop without them being taken up by young people who have never smoked?
When we were studying this for many years, it was all going in the right direction. Adults were stopping smoking by using e-cigarettes, whereas young people weren’t taking them up. And then what changed was the advent of new disposable products like Elf Bar, Lost Mary. These products that were bright and jazzy and looked very good, very cheap, very accessible. And that’s when we saw an uptick in youth vaping.
Lynn Kozlowski did some very elegant work a few decades ago, where he looked to see what would happen if the whole population used a clean nicotine product like a nicotine replacement therapy – so, I’m not talking about vapes. And he basically concluded that even if the whole population took up one of these products, we’d still be better off than 15–20% of people smoking in a population. Now, obviously, that’s not something we would aspire to at all. But I think it puts in context the extraordinary deadliness of and the unique deadliness of cigarettes. So that that’s the sort of equation.
But I think these dilemmas are common in other fields as well, because one of the fears is that by diluting our message about abstinence – you know, stopping smoking being the goal – we might then be encouraging some smokers to carry on.
edited by Natalie Davies
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