8. GENERAL DISCUSSION
8.3. Implications for Tobacco Control Policy
8.3.4. Implications for a comprehensive nicotine and tobacco control policy Although the mechanisms by which VLNC cigarettes and e-cigarettes could reduce smoking
behaviour are vastly different, it has been proposed that they could complement one another. If both VLNC cigarettes and e-cigarettes were available alongside regular cigarettes, they could each compete with regular cigarettes and provide smokers with alternative products. VLNC cigarettes could break the association between cigarette smoking and the direct reinforcing effects of nicotine, while e-cigarettes with nicotine could form a new association between the reinforcing properties of nicotine and the alternative and less harmful product. However, if regular cigarettes were still available, smokers may choose not to use these less preferred products, or use them to complement their use of regular cigarettes. Price policy could be used in combination with the available products to encourage switching, however the clear preference for tobacco cigarettes suggest that substantial price differentials may be required.
It has recently been proposed that these strategies could operate together most effectively in a comprehensive, integrated nicotine and tobacco policy where all cigarettes sold are required to contain very low levels of nicotine, and alternative, acceptable forms of nicotine such as e-cigarettes are available (Benowitz et al., 2017; Donny et al., 2016). By mandating substantial reductions in the nicotine content of combustible cigarettes and thus reducing their reinforcing effects, whilst simultaneously making e-cigarettes available, this policy is likely to encourage smokers to make the decision to quit smoking combustible cigarettes. At the same time, mandating nicotine reduction for all combustible cigarettes would be anticipated to reduce dual use, because cigarettes would provide reduced reinforcing effects and thus be less desirable, while e-cigarettes could deliver reinforcing effects and be more satisfying in comparison (Benowitz et al., 2017). Mandatory nicotine reduction would also address some of the controversy surrounding the acceptability of e-
cigarettes within the general public and the tobacco control community (Benowitz et al., 2017). The concern that e-cigarettes could act as a gateway to smoking would be alleviated when the only cigarettes available have low addictive potential, and regulations such as those proposed in New Zealand could limit sale of addictive e-cigarettes to minors and thus
minimise uptake by youth (Ministry of Health, 2017). Additional restrictions for sale to minimise uptake by youth and non-smokers could be to only permit sale at pharmacies, by prescription, or provision from clinicians providing smoking cessation services (Wilson et al., 2015). Although it is important to regulate e-cigarettes for factors such as toxicity, safety, and limiting youth uptake, the studies in this thesis highlight that it is important not to disrupt the features of e-cigarettes that make them viable alternatives to cigarettes, including nicotine and characteristics that produce positive subjective effects (Tucker, Bullen, et al., 2017a, 2017b).
Donny et al. (2016) proposed that potential changes to e-cigarette regulation in New Zealand offer a unique opportunity to implement this novel, integrated policy to decouple the link between nicotine and combusted tobacco and make progress towards the Smokefree 2025 goal. Donny et al. (2016) highlight that New Zealand’s existing comprehensive tobacco control programme and cessation support could facilitate the implementation and evaluation of such a policy, and the policy has the support of tobacco control advocates, smokers and non-smokers, including priority population groups such as Māori and Pacific Island peoples (Li et al., 2016). It would be important to closely monitor and conduct both medical and scientific research, and to use econometric, behavioural economic and psychological methods to understand the impact of these policies in actual communities and for different groups. 8.4. Future Directions
The research in this thesis provides some support for the use of behavioural economic and psychological methods for evaluating tobacco control policy, and has implications for
continuing price policy, making nicotine-containing e-cigarettes available, and promoting VLNC cigarettes to reduce nicotine dependence; and the potential combination of these policies has been discussed. The techniques and measures used to generate simulated demand data are relatively new and changing rapidly, particularly for novel products with different patterns of use and pricing like e-cigarettes (Cassidy et al., 2017). It is important to continue to test modified versions of these tasks in order to determine the optimal framing of a CPT or cross-price task for e-cigarettes for both first-time users and more experienced users. This is also likely to change over time due to the rapidly changing e-cigarette market, and it is important for research to be responsive to these changes. Other developments include the Experimental Tobacco Marketplace (ETM); where participants make hypothetical weekly purchases from an experimental online store displaying information and prices for a number of tobacco products (Quisenberry et al., 2016). This mimics a real-world marketplace, allows the manipulation of prices of all products, and can compare demand for a number of products available concurrently. It could provide a useful, practical and relevant way to evaluate the potential combined impact of making VLNC cigarettes and e-cigarettes available alongside, or instead of, regular cigarettes at a range of prices. It would also be useful to use a broader range of prices to estimate CPE and the Hursh and Roma (2016) equation to fit CPE could provide a more accurate estimate of CPE and provide relevant, practical information about the magnitude of price differentials required to encourage e-cigarette or VLNC cigarette uptake. It would also be informative to evaluate subjective effects, demand and CPE for VLNC cigarettes and e-cigarettes alongside one another in an attempt to inform the potential outcomes of a comprehensive, integrated policy. For example, in order for the two products to end tobacco smoking as per the proposed mechanism outlined in section 8.3.4., more favourable outcomes and increased demand for e-cigarettes relative to VLNC cigarettes would be anticipated, in order to fade out tobacco smoking in favour of e-cigarettes as a