R Street paper urges states to explore new approaches to tobacco control
Co-authored by R Street President Eli Lehrer and Senior Fellow Dr. Joel Nitzkin, a former co-chairman of the Tobacco Control Task Force of the American Association of Public Health Physicians, the paper notes that while smoking bans and prohibitions on the sale of tobacco products to minors have been very effective, roughly 20 percent of American adults, about 46 million people, still smoke and quit rates have leveled off in recent years.
Tobacco taxes, in particular, may be reaching the limits of their effectiveness as a public health measure in many jurisdictions. When a state’s tobacco tax is much higher than neighboring jurisdictions, smuggling and cross-border purchasing become major issues, Lehrer and Nitzkin note.
“Even when outright criminal enterprises do not run cigarette sales, run-of-the-mill gray market tax avoidance—buying cigarettes across state lines or, until recently, on Indian reservations—will almost certainly increase,” the authors note. “In some cases, in some places, raising cigarette taxes may be a good, worthwhile public health measure. But above a certain level, which many states have already surpassed, they may not be the most effective public health measure.”
The introduction of nicotine replacement therapies and smoking cessation drugs hold great promise, but the results of public health studies of the products thus far have been disappointing. Such therapies fail about 90 percent of smokers who use them as directed, when results are measured six to twelve months later, studies have found.
The authors instead encourage more public and private research into tobacco harm reduction strategies, defined as advising current smokers who are unable or unwilling to quit of the differences in risk posed by different tobacco and nicotine products -– such as e-cigarettes and snus — thus enabling and encouraging them to switch to a lower-risk product.
“All tobacco products cause harm and total smoking cessation is certainly the safest and best way to promote public health,” Lehrer and Nitzkin write. “That said, harm reduction strategies that encourage smokers to switch to smoke-free products appear to have practical merit. One large meta-analysis of smokers found that switching from smoked to smokeless tobacco was the most effective, widely available way to quit. Not only did most people stop using cigarettes, but many stopped using tobacco altogether.”
The paper also endorses more public health research into the potential for supported “abrupt cessation” approaches: that is, aiding those engaged in so-called “cold turkey” quitting with web-based educational materials or 1-6 hours of pre-cessation education or counseling. The paper cites research finding that abrupt cessation assisted with a structured health education program, positive in tone, and with self-help materials left in the hands of the participants, results in a one-to-three year success rate of about 40 percent.
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