Endgame proposals and a wake-up call to the tobacco-control community
The recent endgame review by Patricia McDaniel and her team in the Aug. 28 edition of Tobacco Control demonstrates a major flaw in thinking within the tobacco-control community.
The McDaniel paper lists 16 endgame proposals, 14 of which consist of partial or total bans on aspects of the manufacture or sale of non-pharmaceutical nicotine delivery products. Only two – one referencing e-cigarettes and another “advantage cleaner nicotine products over combustibles” – make any reference to tobacco-industry participation in pursuit of tobacco-control objectives. Both are discouraged as unproven and impractical, despite substantial scientific evidence to the contrary.
The flaw in thinking within the tobacco-control community is its attitude toward the “tobacco industry.” This can also be seen in the 2013 Tobacco Control editorial by Ruth Malone justifying that journal’s refusal to consider papers written by authors with connection to the tobacco industry.
This flaw in thinking has two major components. One is dismissing industry-supported investigators by considering them dishonest until proven otherwise. The other is the perception that the tobacco industry is dominated by the executives and attorneys of the “big tobacco” cigarette companies. In real life, nothing could be further from the truth. The real-life tobacco industry is an intensely competitive, highly fragmented group of companies and individuals.
There are a number of companies and individuals in tobacco-related companies who are ready, willing and able to partner with public-health colleagues in pursuit of public-health objectives, if given the opportunity to do so. Most prominent among them are smokeless tobacco firms and those affiliated with the vape shop component of the e-cigarette industry.
This situation has been drawn to our attention by the skyrocketing popularity of e-cigarettes. This surge has been simultaneous with accelerated reductions in the prevalence of smoking. Despite this experience, tobacco-control leaders refuse to consider the possibility that some of this reduction in smoking may be due to large numbers of smokers switching to e-cigarettes. The response of the tobacco-control community has been to do everything in its power to reduce e-cigarette use by portraying them to be as dangerous as tobacco cigarettes, as ineffective to reduce smoking and as a gimmick to recruit teens to nicotine addiction.
The real-life impact of the negative public-health response has been to protect cigarette companies from competition from these far less hazardous and less addictive products.
Nicotine is relatively non-addictive. Cigarette addiction stems from a combination of nicotine and other substances in cigarette smoke. Thus, counterintuitive as it may seem, encouraging smokers to switch likely would reduce, rather than increase, nicotine dependency.
Nicotine delivery products differ substantially in risk. Cigarettes are the most hazardous and most addictive. Nicotine-only products – such as pharmaceutical nicotine replacement therapy (NRT) products and e-cigarettes –are probably least hazardous and least addictive. None are totally risk free. As best we can tell, the risk posed by e-cigarettes is under 5 percent of the risk posed by cigarettes.
Vapor devices stand as a truly disruptive technology with the potential to transform the tobacco industry and reduce tobacco-related harms from a major to a trivial set of public-health issues. They differ from NRT products in their ability to satisfy the urge to smoke and by offering low-cost, low-risk nonmedical alternatives to cigarettes.
Tobacco harm reduction (THR), in this context, means informing physicians and the general public about these differences in risk to encourage smokers to switch. By presenting e-cigarettes as an alternative consumer product, health-care and public-health systems would not have to pick up the cost of the vapor devices.
Achieving this public-health benefit will require correcting these flaws in the tobacco-control community’s thinking. It will require collaborating with all who are willing and able to work with the public-health community to pursue shared public-health objectives.
The time has come for the public-health community to engage in dialogue with stakeholders within tobacco-related industries. The purpose of this dialogue would be to consider how a THR component could be added to current tobacco-control programming to substantially reduce tobacco-related illness and death.
Experience to date with e-cigarettes gives us grounds for optimism that this could be done easily without recruiting teens and other non-users to nicotine.
A world in which tobacco-related addiction, illness and death have been reduced to trivial public-health problems could be achieved within our lifetimes. Achieving this goal will require reorienting tobacco control from a crusade against all things “tobacco” to a public-health initiative that considers all options to prevent addiction, illness and death. This is a goal not likely achievable by any other means. A seemingly small change in the wording of our tobacco-control goal from “a tobacco-free society” to “a smoke-free society” will get us most of the way there.
