February 2nd, 2015

Are we in the endgame for smoking?

chessendgame

Now what?

Endgame: noun
1. Chess. the final stage of a game, usually following the exchange of queens and the serious reduction of forces.
2. the late or final stages of any activity: the end game of the negotiations.

There is a thread of discussion in the world of tobacco control devoted to what is known as the ‘endgame’… it is a kind of blue sky thinking about end of tobacco use and the policies needed to bring it about.  It includes a set of policy proposals set out in the May 2013 supplement of the journal Tobacco Control and has become the subject of conferences, journal papers, presentationsop-eds and thought pieces by leading academics and speeches by the Director General of WHO (which actually has some good advice in parts).  But what does the data tell us?

I think it is helpful to know where things stand now.  There was a great data paper published in JAMA last year: Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311: 183–92.

Buried in its supplement is a table with estimates of world cigarette consumption from 1980 to 2012, which I have transcribed into a spreadsheet and made some charts from. Note that while the World Health Organisation talks of the ‘Global Tobacco Epidemic‘, it does not actually do the basic useful job of measuring, monitoring and interpreting it – so academic studies like this are especially valuable, and require knitting together of many data sources. I am taking this paper as the best estimates rather than critiquing it.

Data to inform the ‘endgame’

How much smoking is there now?

First up… the consumption of cigarettes is more than six trillion (6.25 trillion) and still rising globally. That is equivalent to just over three cigarettes per day for every adult alive in 2012.

Actual data 1908-2012

Global smoking prevalence was 18.7% – 31.1% among men, 6.2% among women – down from 25.9% in 1980 (41.2% men, 10.6% women). While smoking prevalence is declining, population and incomes are rising and pushing the other way:  the number of smokers has risen since 1980 from 721 million to 967 million in 2012, and the number of cigarettes consumed has risen from 4.96 trillion to 6.25 trillion. We are not in an endgame: the most we can say is that we may be seeing a slowing of growth.

Now approaching 1 billion daily adult smokers

 Trends

The chart below shows linear trend lines…

Actual data 1980-2012 with linear trend lines projected to 2030 and equations displayed for gradients

The gradients of the trend lines give the average annual change. In round numbers, since 1980, the annual changes have been:

  • Developed countries:   -16.5 billion/year
  • Developing countries:  +53.2 billion/year
  • Net global change:       +36.7 billion per year

The rate of decline even in developed countries is not that fast. If we use geometric rate of change (like compound interest but for an annual decline) the decline in developed countries is just 0.8%/annum on average over 1980-2012 – and at that rate it would take until 2100 to halve consumption in developed countries*. Even at the faster rate of decline in later years (2005-12 = 1.3%) it would still take until 2067 to halve consumption. Of course these rates may change in future, but the history provides valuable perspective.

(Note decline calculated: Ct = Co/(1+r)^t where Co is consumption in a given year, Ct is consumption t years later, r is rate of decline – e.g. 1.3%).

An end to smoking by 2030!

You’ll occasionally hear people saying that we should aim for the end of tobacco by 2030 or some other date in most people’s mental planning horizon – this is not unique to tobacco by the way.  But often these bold sounding aims require implausible changes to deeply rooted trends.  Smoking simply does not change rapidly as there are large numbers of smokers already in the population and history shows it is difficult to stop young people emulating adults, meaning the flow of new smokers changes slowly too – though change it does.  The chart shows a ‘forced curve’ pathway to ‘tobacco free’ by 2030 – these curves uses a steadily increasing decrease so that the gradient changes evenly

Actual data 1980-2012 with curves forced to zero by 2030.

What thing would conceivably cause this? These sort of changes to large scale trends would only be realistic following major human catastrophes, such as global nuclear war, a pandemic, asteroid collision or a rapture. So far no-one in tobacco control has included these ideas in the endgame narrative.

Even if the curve for developed countries looks vaguely plausible (it was drawn to minimise rate of change of gradient), please take some care.  It requires very rapid decline in the late 2020s – far steeper than achieved previously. The decline in developed countries has averaged 25 billion/year in the 8 years 2005-2012, but this curve requires an average decline of 145 billion/year in the 8 years to 2030- more than five times as great.

Update: 13 March 2015. The Lancet has called for phase out of tobacco sales by 2040: What will it take to create a tobacco free world?  Here’s how that would look, just for cigarettes:

Lancet Endgame

Actual data 1980-2012 with curve forced to zero by 2040

 

Of course a phase out of tobacco products is more difficult than a phase out of cigarettes because the former cannot be used to substitute for the latter.

Has enhanced tobacco control forced smoking into a new phase of decline?

Perhaps the recent intensification of global tobacco control efforts through the FCTC means that the past is an unreliable guide to the future? Actually, the annual increase has itself been increasing since the FCTC came into force – it is too early to tell if that is a persistent trend. This chart plots the annual change in consumption in billions.

Annual change in unit cigarette consumption 1980-2012

Annual change in unit cigarette consumption 1980-2012

Using more sophisticated trend lines

What would be a more realistic trend projection? It is sometimes better to use a more sophisticated type of trend line for data like this, in which consumption changes steadily, but also the rate of change of consumption varies too.  Spreadsheets allow different types of curve-fitting – I got the best fit and most plausible trend with a ‘polynomial equation’, in this case a parabola.

Actual data 1980-2012 with parabolic trend projection 2013-2030

Actual data 1980-2012 with parabolic trend projection 2013-2030

Or taking this out to 2053 the developed country curve intercepts with zero… (note this is a projection and not a forecast or prediction, but you can use it as starting point).

Actual data 1980-2012 with parabolic trend projection to 2050

Actual data 1980-2012 with parabolic trend projection to 2050

Why does this matter?

One consequence of a view of an imminent end to smoking can be a kind of impatience with alternatives to smoking or the sense these are an irritating distraction from the teleological certainties of an end of tobacco some date soonish. So I think it is worth looking at what current data and trends reveal.  The current data suggest smoking will persist for several decades.

Visualises total cigarette consumption under current parabolic trend 2010-2030.

The red area can be thought of as a rough proxy for smoking-related harm to health – and it is going to continue.

Introduction of new nicotine delivery technologies

It’s hard to know at present the long term impact of new non-combustible nicotine products like vapour products – or what role existing much safer products, like snus or other form of non-combustible tobacco, could play.  Investment analysts believe vaping products are displacing about 4% of US cigarette consumption (for a sense of proportion, this might be compared to the European Commission’s estimate that its Tobacco Products Directive would reduce consumption by 2% in five years). However, this figure has been achieved despite a massive well-funded relentlessly hostile campaign against these products by many American public health organisations and academics, and comes at the early stage of what is bound to be a prolonged period of innovation.

In fact the future of these products depends on many things other than the products themselves and interplay of manufacturers and consumers. It will particularly depend on the role played by regulators and by the ‘public health establishment’, which has in most cases taken a very hostile approach. However, these products offer a terrific opportunity to change the pattern of consumption of nicotine to less harmful technologies, to disrupt the entrenched cigarette trade, and to reduce risk to health.

An aspirational scenario

So rather than present a projection or forecast (it is too soon for either) let me present an aspiration – what I believe would be a great but realistic public health achievement if everyone involved worked to achieve it instead of obstructing it. This ‘scenario‘ involves rapid growth while the category is small, with a gradually declining growth rate as it advances, with the parameters set to meet 50% of the market by 2030. It is purely illustrative. In reality, achieving this degree of displacement of cigarette use would require continuing innovation to make widely acceptable compelling alternatives to smoking – so by 2030, the low-risk products, like vapour or heat not burn tobacco products, might be very different to those available today.

Slide10

Keeps cigarette-equivalent nicotine consumption as before but introduces a different set of technologies for nicotine delivery. This scenario uses a high initial growth rate for new nicotine (40%) which deflates over time (at 9%pa) to reach 50% of the market by 2030

 

In this case, the red is still the harm, but it is significantly reduced (it is far from clear that any material harm is associated with the green wedge in this diagram – but if there is, it is likely to be 95-100% lower per unit).  If this was achieved by 2030, the prospects for the rest of the century would be very positive – and major inroads would be made into the forecast of 1 billion smoking related deaths in the 21st Century.

Switching nicotine delivery technologies is more ‘tractable’ than rapidly reducing nicotine use, because it doesn’t require people to give up things they like or may be dependent on.

The idea is that changes to the boundaries within nicotine-using technologies (the inner boundary) are more tractable than changes to the total nicotine-using envelope (the outer edge). The reason for that is that they require much less of the consumers – people who wish to use nicotine or are dependent on it. It also does not require highly coercive policy measure that force radical cultural or behavioural changes, which are either unlikely to work politically or legally, or would violate dearly held values. Not in this scenario, the upper boundary matters little for health, it is the easier more tractable lower boundary that counts.

Coming shortly…

In a second posting on ‘the endgame’, I will examine some of the endgame policy proposals that are under discussion by tobacco control experts. Some believe that the sea of red in the charts above justifies a ‘force majeure’ approach to policy. But somehow I doubt it will be that simple… à bientôt!

Appendix – graphics on Slideshare

22 comments to Are we in the endgame for smoking?

  • […] tobacco control would dearly love to extol the virtues of vaping as a means of reaching the ‘End Game‘ for tobacco. Others view vaping as the second coming of the tobacco industry and seek to […]

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  • […] [2] Bates C. A billion lives? The Counterfactual, November 2015 [link] and Bates C. Are we in the endgame for smoking? The Counterfactual, February 2015 [link] […]

  • […] tobacco control would dearly love to extol the virtues of vaping as a means of reaching the ‘End Game‘ for tobacco. Others view vaping as the second coming of the tobacco industry and seek to […]

  • […] The first World Health Organisation report on Second Hand Smoke was buried because it showed advantages to SHS but it is extant and can still be found online. Smokers were told their lungs were black. All diseased lungs are black. But healthy smokers lungs are the same as anyone else’s. Nicotine was demonised and all sorts of untruths about it were put about. But it seems embarrassingly, they were not true. Smokefree’s adverts offered here in the UK every year are a disgusting form of twisted science inducing fear into everyone who sees them – even children. Anti Tobacco has caused real suffering in families torn apart by their propaganda, people my age, and older people, prisoners, psychiatric patients, hospital patients and families, visitors, workers, holiday makers, pubs and the hospitality industry. No amount of rubbish science can show that we are happier, or better off because of it. Tobacco Control has been a vicious harmer of people in a world that was already smoking less in the West. Yet still we smoke despite them. […]

  • festus

    The only benefit from tobacco is the monetary benefits of a farmer other than this it is truly harmful to your health. Even if they write on the packets NO 1 EVER READS THIS!!!!

  • […] This is the second of two pieces on the ‘tobacco endgame’.  In the first, (Are we in the endgame for smoking?) I presented some data on global cigarette use to show that we are not in an endgame, at least […]

  • Bill Godshall

    Ever since I first heard the term “endgame” used by tobacco controllers (in 1999 when Dick Daynard began using the term to refer to banning cigarettes and the cigarette industry), the term’s meaning (by those who advocate it) has evolved to include the banning of ALL tobacco products, companies and use(rs), including e-cigs since 2008/09.

    While cigarette prohibition might be a viable public health policy option (if/when the smoking rate declines to 1%), there is no public health justification for banning smokefree tobacco/nicotine products (or even cigars or pipe tobacco).

    Even worse, tobacco controllers in the US who advocate an “endgame” removed cigarette prohibition from their legislative and regulatory agenda more than a decade ago when CTFK, ACS, AHA, ALA and GSK’s Mitch Zeller negotiated and agreed with Philip Morris (when endorsing the FSPTCA) to prohibit the FDA from banning cigarettes and from even banning cigarette sales to 12th grade high school students.

    So the tobacco controllers “endgame” in the US has become a turned into a counterproductive campaign to protect cigarette markets by banning (and/or e-cigs, dissolvables, new snus products, other new smokefree tobacco/nicotine alternatives and flavorings, and/or regulating and taxing the least hazardous tobacco/nicotine products the same as lethal cigarettes.

    So to answer Clive’s question “Are we in the endgame for smoking?” is most definately NO since the “endgame” as deployed by tobacco controllers has really been an “endgame” to unethically protect cigarette markets from competition by far less hazardous smokefree alternatives, and to inhumanely impose “quit or die” policies on all smokers.

  • Clive Bates

    Mathew Donnelly asks in a tweet whether when tobacco control talks of an ‘endgame’ is it trying to immanentize the eschaton? What can he mean?

    • Chris Price

      Possibly: imminent-ise (neologism?) the eschaton (‘final event’). A misspelt neologism and an obscure reference, perhaps, meaning to bring forward the final event.

  • Absolutely critical and important analysis, Clive. Thank for compiling all of this so thoughtfully.

    I would welcome your reactions to the notion that when you couple one’s answer to the question of whether “are we winning the war on tobacco?” with loss aversion (http://en.wikipedia.org/wiki/Loss_aversion), you might have a further contributing explanation for the range of reactions to ecigs. I would posit that if you think you’re winning, then anything that is different/new is automatically going to be viewed as a threat.

    And if you agree, can we use that understanding to improve the discourse and progress?

    • Dodderer

      This raises a related issue as to which figures on prevalence to believe.Our annual smoking survey by the Office of National Statistics produced figures of 21% for 2007-2009 inc and 20% for 2010-2012 inc before falling to 19% in 2013(last available).

      Tobacco Control’s “in-house” surveys – the Smoking Toolkit Study – shows a decline from 24.2% in 2007 to 18.5% in 2014.What is noticeable is the steady annual 0.7% fall in each of the last 4 years culminating,coincidentally,at our government’s target for 2015 set at the start of their period of office.

      Admittedly,the ONS survey covers Scotland and Wales as well as England but their figures are similar and account for only 15% of the total.Two different trends with two different stories – ecigs are crucial to further falls in prevalence or ecigs have made no real difference to successful TC policies

    • Clive Bates

      Yes – inclined to agree. I think this argument is most strongly evident in Australis, where talking up about tobacco control success is combined with dismissal of vapour as justifiably illegal and irrelevant, even though surveys show it has a significant impact even though technically outlawed through pharma and poisons regulation.

  • A few technical points:

    -Nice job laying out the graphs. Do you have the data to break it down further, adding sticks-per-adult figures and breaking it out by region. (I am curious.)

    -You cite rising population and rising income as countering the decrease in the prevalence fraction. But it is only rising population. Rising incomes will tend to cause the fraction to increase (when they rise from dirt-poor to enough to afford cigarettes), so they are part of it. Also there is a bit of ambiguity in the word “prevalence” in this context — absolute vs relative — which is why I added “fraction” above.

    -As I note in the posts I link to in my previous comment, keep in mind that an endgame in chess occurs only if no one is clearly winning. The game can be won at any stage. This misuse of the term by tobacco control is quite telling. I would recommend avoiding phrases like “we are not in an endgame” in favor of the accurate “we are no closer to eliminating smoking than we ever were”.

    -You fall into the tobacco control “demonic possession” myth by implying that the motive for someone to take up smoking is to emulate adults. People take up smoking because they like smoking. I suppose if it did not exist at all, they might not invent it widely, but it is not emulation that makes it attractive — not anymore anyway.

    -I am amused by the rapture reference. Implication: after the good people are called up, those left behind will not smoke because so many of them are “public health” people?

    -You should probably explicitly note that your quadratic “projection” starts with the *assumption* that we are at the peak right now and then fits the curve. There is, of course, no reason to believe this is the case. You are presenting what might be called the best (by their goals) plausible case scenario.

    -Re your point about tobacco control efforts: As I note in my posts from two years ago, the biggest cause of smoking prevalence fraction reduction is basic education about the risks. THR is a solid second (but outside of Sweden, a distant second). Taxes matter a bit. Nothing else matters at all. So it is no surprise that FCTC type efforts do not show up in the trend. But this does bring up one critical question: how educated are the consumers in places where there are sharp increases in consumption. I honestly do not know how much they really “get it” — they are subject to the same propaganda, of course, but that is different. That is probably actually a bigger issue, in terms of predicting trends over one or two decades, than THR promotion efforts.

    • Clive Bates

      Thanks Carl – comments much appreciated.

      1. There is a great deal of data in the JAMA supplement – aggregates, time series and country breakdowns.

      2. I thought rising incomes had a positive impact on consumption per user – from World Bank

      3. I lazily used a chess board as a graphic – I don’t want to make anything of it as a metaphor. Might change it…

      4. If no >18s smoked in a society, smoking would be v marginal among <18s. I'm pretty sure that parental smoking is a big 'risk factor' for smoking. I think the flow is determined partly by the stock, and by the fact that people do like it - just as politics or religious belief are handed on. I don't buy the 'demonic possession' theory either.

      5. The quadratic projection is of course a better fit than the linear and it does show a sort of plausible future that won't be too paradigm busting. However, a cubic equation is an even better fit (obviously) - but try it and see... it produces a wildly rising function. So yes - the quadratic is the one that looks most like what people might expect.

      6. I tend to agree about tobacco control measures. It reminds me of the WHO presentation to the European Parliament in 2013 billed as "Review of the scientific evidence on effectiveness of key measures to reduce smoking, with special reference to the revision of the Tobacco Products Directive" - my critique of that is here

  • More on this in a two-part series I did a couple of years ago, in response to a step in the same process that inspired this. Notice that there is pretty much nothing extant or being discussed now that was not already the case then. http://antithrlies.com/2013/04/20/more-on-endgame/

  • vapingpoint

    Very interesting post. Shows how Tobacco Control has NOT been successful. Every worker working in the “industry” has made a living for themselves promoting The Emperors New Clothes.

    The “industry” have made smokers so ashamed to smoke in the West, that I think finding out who smokes, would produce unreliable figures full of “deniers”. So we don’t actually know how many smokers there are.

    As for knowing how many people smoking actually kills, that is a total guess. I fail to see how anyone, scientist or not, could possibly know.

    Watching how Tobacco Control Groups are mashing figures and facts about vaping just exposes how corrupt they really are.

    There are some people in the “industry” I really like. It is so sad they have been co-opted into promoting the Emperor.

    • Jude

      This is something I’ve often thought about myself. In Australia we have “tobacco control” claiming that the rate of adult smokers is at about 13%, also claiming this is due to their policies of demonisation, taxation, and silly things like plain packaging, (the incidence of teenagers taking up smoking rose after plain packaging came in).

      They make these claims even though the sale of cigarettes and tobacco are steadily rising. It makes no logical sense, unless you assume that many smokers are simply not admitting to being a smoker.

      With the amount of discrimination in the workplace, in insurance policies, in housing, (many smokers find it hard to rent a house or flat), etc etc, it would hardly be surprising that smokers simply don’t admit to smoking. As smoking is pretty much banned everywhere public, its entirely possible that the numbers put out by tobacco control are as fictional as their claims that vaping doesn’t help people quit smoking.

      We may not be seeing their “endgame” but they are known liars, so may be seeing the illusion of this rather than reality.

  • @Maek M
    Tobacco control policies have zero or close to zero effect if the 20% Prevalence Rule operates. For example, the number of smokers in the UK rose by about half a million between 2008 and 2013.

    The NHS should have all the useless £200m removed that is spent on smoking cessation services unless they can show substantial changes toward replacing their proven worthless methods with a bias toward something that actually works, such as THR. Of course, for multiple reasons, that will never happen.

  • Chris Price

    Tremendous work, needs to be seen far more widely than it might be here. It would make a useful and realistic paper in a medical journal, compared to the usual fantasy and propaganda.

  • Maek Magenis

    As tobacco controls efforts make only small percentage changes, then perhaps we could make better use of their funding. The NHS has very real and immediate issues that would be a far better use of scarce tax payer resources.

  • The tobacco endgame looks like a CRUISADE, based on irrationnal dogma. Thanks for pointing this criminal dream.

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