A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Abstract

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

Keywords: ENDS; decision theory; e-cigarettes; heated tobacco products; policy; public health.

Figure 1

Public Health Impact of NVP and HTP Use Among Former Smokers. Notes: HTP = Heated Tobacco Product, NVP = Nicotine Vaping Product. * Based on the counterfactual of whether smoking initiation would have occurred in the absence of both HTPs and NVPs. ** HTPs are a more desirable alternative to NVPs, e.g., tried NVPs and not found desirable or satisfactory. *** Would have otherwise preferred NVPs, but diverted from use due to industry behavior or government policy. Green indicates public health benefit; Red indicates public health loss. Darker shades indicate a greater impact.

Figure 2

Public Health Impact of NVP and HTP Use Among Current Smokers. Notes: HTP = Heated Tobacco Product, NVP = Nicotine Vaping Product. * Based on the counterfactual of whether smoking cessation would have occurred in the absence of both HTPs and NVPs. ** HTPs are a more desirable alternative to NVPs, e.g., tried NVPs and not found desirable or satisfactory. *** Would have otherwise preferred NVPs, but diverted from use due to industry behavior or government policy. Green indicates public health benefit; Red indicates public health loss. Darker shades indicate a greater impact.

Figure 3

Public Health Impact of NVP and HTP Use Among Former Smokers. Notes: HTP = Heated Tobacco Product, NVP = Nicotine Vaping Product. * Based on the counterfactual of whether smoking relapse would have occurred in the absence of both HTPs and NVPs. ** HTPs are a more desirable alternative to NVPs, e.g., tried NVPs and not found desirable or satisfactory. *** Would have otherwise preferred NVPs, but diverted from use due to industry behavior or government policy. Green indicates public health benefit; Red indicates public health loss. Darker shades indicate a greater impact.