A recent report  from the Core Team on Tobacco Control drew 120 eminent signatories from the tobacco control community to endorse the proposition that it is possible to end adult cigarette use within a generation. But to achieve that commendable goal, federal public-health agencies and lawmakers will need to change their tune on tobacco harm reduction.
The Core Team report urges policymakers to amend current tobacco-control policy to encourage smokers to switch to lower-risk products that would reduce their risk of potentially fatal tobacco-related illness. It finds, as I long have advocated, that tobacco harm reduction needs to be incorporated into tax policy and other tobacco control policies. This should also mean informing smokers and the public at large that e-cigarettes and smokeless products carry far less risk of illness and death than cigarettes.
In fact, I strongly support two-and-a-half of the three action items the report recommends. I endorse its recommendations that tax policy be crafted to encourage shifting to lower-risk products; that public health authorities promote smoking cessation; and that we generally need more rational regulation of tobacco-related products to promote innovation and lower-risk products. The one place the report falls short is its endorsement of U.S. Preventive Services Task Force policy guidelines that limit smoking-cessation programming to pharmaceutical protocols — mostly notably, gums, patches and lozenges — that fail more than 90 percent of smokers who use them, when results are measured at six to 12 months.
Tobacco kills an estimated 480,000 Americans each year and costs more than $170 billion in annual medical expenses. Essentially all of these deaths and healthcare costs stem from a single tobacco product — the machine-made cigarette. In the U.S., deaths from all other tobacco products combined are so few in number that they are not tracked or routinely estimated by any federal or voluntary agency.
Cigarettes are highly addictive, likely to attract teens who try them and are exceedingly difficult to quit. E-cigarettes and other low-risk products, by contrast, are also less addictive, less likely to attract teens to nicotine addiction, and are easier to quit.
Of course, none of these products is totally risk-free. The best approach is never to start using any tobacco-related product. The next best approach is to quit as early as possible. But for those who are unable or unwilling to quit, and for teens inclined to experiment with hazardous substances, informing the public of these differences in risk likely will secure public health benefits that wouldn’t be readily achievable by any other means.
To make these benefits a reality, the major federal agencies will need to change their messaging on tobacco harm reduction. The surgeon general’s 2016 report on e-cigarettes noted in its narrative that e-cigs are very likely lower in risk than cigarettes, but then recommended that tax and tobacco-control policies treat them as equivalent. The Centers for Disease Control and Prevention regularly rails against all tobacco-related products, as if they present equal risks of addictiveness and death, without mentioning tobacco harm reduction or any objective comparison of addictiveness and risk.
Worst of all has been the Food and Drug Administration. To date, the agency’s interpretation and implementation of the Family Smoking Prevention and Tobacco Control Act of 2009 has placed huge regulatory burdens on novel and lower-risk products, while giving the major brand cigarette products a free pass, eschewing new restrictions on combustible cigarettes that would be any more stringent than those already in place before the law.
The FDA even continues to mandate misleading warnings on smokeless tobacco products, denying consumers the guidance that these products are far lower-risk than cigarettes and ignoring that the most common smokeless products on the American market pose no risk of mouth cancer.
Congress could help address these issues, in the short term, by passing the FDA Deeming Authority Clarification Act , legislation introduced by Reps. Tom Cole, R-Okla., and Sanford Bishop, D-Ga., that would prevent the pending elimination of e-cigarettes from the market. Over the longer term, what we need is a major rewrite of tobacco-control policy in ways that would sensibly regulate e-cigarettes and other lower-risk products, while recognizing the crucial role they can play in ending adult cigarette use within a generation.
Image by John Abbate 
- “A recent report”: http://www.tobaccoreform.org/wp-content/uploads/2017/03/Executive-Summary-Report-Ending-Cigarette-Use-by-Adults.pdf
- “FDA Deeming Authority Clarification Act”: https://cole.house.gov/media-center/press-releases/cole-and-bishop-introduce-fda-deeming-authority-clarification-act-2017
- “John Abbate”: https://www.shutterstock.com/g/DrAbbate