A response to ‘Stubbing Out Cigarettes for Good’
Earlier this month, the New York Times published and op-ed penned by Richard Daynard of Northeastern University titled “Stubbing out Cigarettes for Good.” Professor Daynard is president of Northeastern Law’s Public Health Advocacy Institute, and a prominent anti-tobacco crusader. I wrote the following response, and sent it to the Times, but they declined to print it. I also shared copies with Daynard and Mark Gottlieb, his colleague at the Public Health Advocacy Institute.
In reply, Gottlieb shared some research findings relative to the “light” cigarettes, noting that they contained the same amount of nicotine as full-flavored cigarettes, but were designed to hide nicotine content from the then-prevalent “FTC method” machines used to measure tar and nicotine content. Smokers could access the additional nicotine by inhaling longer and more deeply. His proposal for a low-nicotine cigarette would, per their limited studies, result in minimal compensatory behavior by smokers since such compensatory behavior would not yield more nicotine.
He acknowledged the legitimacy of the other points I made, but disagreed that, if implemented, they would likely do more harm than good. He also acknowledged the potential value of adding a tobacco harm reduction initiative to current tobacco control programming, and correctly noted that the initiatives Daynard recommended and tobacco harm reduction are not mutually exclusive.
****************
The first of his two proposals – reducing the nicotine in cigarettes to non-addictive levels — ignores what we have learned over the past 30 years about light and low-tar cigarettes. These cigarettes dramatically lowered both tar and nicotine. Their message was so effective that such cigarettes now account for more than 99% of American cigarette sales. They have done nothing to reduce the prevalence of smoking in the United States and appear to present a risk of lung cancer greater than the full-flavor cigarettes they replaced. In order to securing the desired dose of nicotine, smokers appear to have inhaled the smoke deeper and held it longer within the lung.
Reducing nicotine to a level that will no longer satisfy current smokers seems more likely to drive these smokers to contraband cigarettes than to quit smoking or to switch to other tobacco/nicotine products. Contraband cigarettes are already a major problem in jurisdictions with high cigarette taxes. Making regulated cigarettes unpalatable to smokers would likely increase the demand for contraband products.
The second of Professor Daynard’s two proposals — to ban sales of cigarettes to persons born after the year 2000 — is and has been in place for many years throughout the United States. Every state now bans cigarette sales to persons under 18 years of age. This has not been effective in preventing 15% to 20% of teens from initiating cigarette use.
New thinking will be required within both the U.S. Food and Drug Administration and the larger tobacco control community if we are to substantially reduce tobacco-related illness and reduce nicotine addiction in the United States.
The first element of this new thinking should be to recognize that we have two separate tobacco-related problems. The first relates to current adult smokers. The second relates to teens at risk of initiating tobacco use.
The 8 million Americans likely to die of a tobacco-attributable illness in the United States over the next 20 years (400,000 per year x 20 years) are current adult cigarette smokers over 35 years of age. The smokeless products that have been on the American market since the 1980s — chewing tobacco, snus, and other snuff products — present a risk of potentially fatal tobacco-attributable illness less than 2% the risk posed by cigarettes. E-cigarettes, strips, sticks and orbs probably present even less risk. Simply informing current smokers of this difference in risk would likely induce large numbers of smokers to switch to one of these lower risk products.
This approach, known as tobacco harm reduction, is currently opposed by the tobacco control community. They refuse to consider use of any non-pharmaceutical tobacco/nicotine product in the context of a public health initiative. In addition, the FDA tobacco law imposes nearly insurmountable barriers to tobacco harm reduction and requires continuation of misleading and technically inaccurate warnings on American smokeless tobacco products: warnings based on hazards posed by tobacco products that are not available in the American market.
Tobacco harm reduction could be added to current tobacco control programming. It would rely on market forces to achieve reductions in tobacco-attributable illness and death not likely achievable in any other way. It would do so in a way that would not increase demand for contraband products.
Experience with e-cigarettes and other bits of scientific evidence suggest that these smokeless tobacco products may be less attractive to teens and easier to quit than cigarettes. This flies in the face of the conventional wisdom in the tobacco control community that informing the public that such products are lower in risk than cigarettes would dramatically increase the number of teens initiating tobacco/nicotine use.
The time has come to seriously consider tobacco harm reduction as a new addition to current tobacco control programming.
