The real light and mild scam


Author: John Luik
Article Published: 15/01/2004


For the last few years one of the major strategies of the anti-tobacco activists and their opportunistic friends in the plaintiff’s bar has been to attack the description of tobacco products as “light” and “mild”. The activists have claimed that such descriptors are inherently misleading in that they convince smokers that using these cigarettes is less risky than other cigarettes. For the activists’ legal colleagues the use of light and mild constitutes a novel but massive commercial fraud which the experts in tobacco litigation have been quick to convert into the only thing that really counts in the American tobacco war- multi-billion dollar judgments.

But the public policy battles and the courtroom claims about light and mild, have often distracted attention away from the larger issue of whether light and mild products and more generally what are called safer cigarettes, have a legitimate place in tobacco harm reduction strategies. For those who see the light and mild issue as more than the most recent attempt to bankrupt the tobacco cash cow, the question of harm reduction is central to how tobacco control will proceed in the 21st century.

To many within the tobacco control community the idea of harm reduction represents a fundamental retreat from the driving idea of the anti-tobacco movement- the elimination of smoking, or at least legal smoking. For these pioneers of the tobacco wars, the idea that safer smoking could be a legitimate, even if temporary, step along the way to a smoke-free society is heretical. After all, the rhetorical, as opposed to scientific, strength of the campaign against smoking has always been that there is no such thing as safe smoking, as less risky- let alone “safe” products. The claims of dose-responsiveness have never been part of this credo. Cigarettes are unsafe-period, end of story. All smokers die: ergo all smoking is unsafe. Smokers need to be told only one thing and that is to stop, not reduce their smoking. To compromise on this article of faith, and to accept light and mild cigarettes is to compromise, is to risk the entire religion.

But there have always been other less strident or at least less confident voices within the tobacco control movement which have been uncomfortable with this fundamentalist dogma. Their worries have been of two related kinds: scientific and moral. On the scientific front they have been troubled by a number of epidemiological studies of unquestionable pedigree that have suggested if not conclusively shown that not only does the risk of smoking increase with the number of cigarettes smoked but that certain types of tobacco mortality are proportionate to the tar level of cigarettes. If these studies are correct, then product modifications which produce lower tar levels can be, in the words of the 1988 UK Independent Scientific Committee on Smoking and Health, “beneficial to the health of the public.”  

And here enters the moral worry. If reduced tar cigarettes can be “beneficial to the health of the public”, particularly to that part of the smoking public who either cannot stop smoking or choose not to stop smoking, then surely the government’s tobacco control strategy is more complicated than to simply tell people to stop smoking. Surely government must have some obligation not only to encourage the production of such products but to inform, or at least allow, smokers to be informed about them. This need not mean that the hope of a smoke-free society must be abandoned, it simply means that certain compromises about the mechanics and timing of its implementation need to be accepted.

One doesn’t have to be an expert on the theology of the anti-smoking movement to observe the tension between these competing positions on harm reduction for they turn up frequently on the front page of most newspapers. Take last month’s leading tobacco junk science story, the University of Minnesota “study” published in the respectable mantel of the Journal of the National Cancer Institute that claimed that even though smokers significantly reduced the number of cigarettes smoked, they did not achieve anything more than modest reductions in urinary levels of the allegedly carcinogenic NNK metabolites.

It is equally obvious that those opposed to harm reduction appear to dominant the FCTC process, since Article 11 of the convention calls upon the parties to prevent the use of such terms as low tar, light, ultra light or mild on the grounds that they create the false impression that “a particular tobacco product is less harmful than other tobacco products.”

On the other hand, the advocates of harm reduction within the anti-smoking movement and the public health community can take considerable comfort from the Institute of Medicine’s 2001 report on the scientific basis for harm reduction (Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction). According to the report “filtered cigarettes compared to nonfiltered cigarettes pose a lower risk of lung cancer and possibly other cancers” (p. 164), “for many diseases attributable to tobacco use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible” (p. 5) and harm reduction is a “feasible and justifiable public health policy” provided that it is part of a comprehensive tobacco control policy.

In many senses, the IOM report, with its scientific acknowledgement of the harm reduction properties of lower tar cigarettes and its frank acceptance of a policy framework that includes safer smoking products, is a return to a policy perspective and scientific effort of over thirty years ago. During the late 1960’s both in the US and the UK, the government, convinced that the risk of smoking was proportionate to tar levels, began a program to produce lower tar cigarettes. What made the effort unique, at least from the perspective of  today’s adversarial relationship between the government and tobacco industry, was that the program was a cooperative one between the respective governments, the public health community and the tobacco industry. In the US the effort was run through the National Cancer Institute’s Smoking and Health program and called the Tobacco Working Group. The group’s membership went far beyond the NCI including representatives from the National Heart, Lung and Blood Institute, the National Institute of Environmental Health Sciences, the Department of Agriculture and the Secretary of Health, Education and Welfare, along with the research directors from the major US tobacco companies. 

From 1968-1977 the Tobacco Working Group produced and tested four sets of experimental cigarettes. As the former director of the program, Dr. Gio Gori noted, this involved about 150 modifications of the “various aspects of cigarette design, tobacco varieties and … additives, reconstituted tobacco, and tobacco substitutes.” (Gori, Virtually Safe Cigarettes, 2000) Perhaps the most important work done by the group was the development of modifications that could reduce tar yields by as much as 95%.

In the UK under a series of voluntary agreements beginning in 1973, a similar program began with the tobacco industry supplying  some 7 million pounds through the Tobacco Products Research Trust to support 25 research projects on the modification of cigarettes.  As in the US the scientific assumption which underpinned these efforts was that the health risks in tobacco were not to be found in the nicotine but rather in the tar and that a reduction in the tar consumed by smokers could result in significant reductions in mortality. As the former chair of the UK’s Independent Scientific Committee on Smoking and Health Sir Peter Froggatt observed

“Absorbing (harmful) tar constituents is in fact an unwanted by-product of absorbing useful (harmless) nicotine.” 

Beginning in 1973 the UK government also undertook measurements of tar and nicotine yields and biannually ranked brands by tar yield. Additionally, as part of the voluntary agreements between the industry and the government Sales Weighted Average Tar yields were established. In Canada a similar approach of tar reduction was undertaken by the industry at the government’s request. In 1979 the Canadian government released a table of tar, nicotine and carbon monoxide levels of cigarettes sold in Canada and advised smokers to choose light and mild products.  

By the mid seventies, harm reduction, chiefly through the gradual reduction in tar yield (gradual so as not to lead smokers to switch to higher tar brands), was the prevailing tobacco control strategy on both sides of the Atlantic. In all three countries- the UK, the US and Canada- the commitment to harm reduction was based on a pragmatic assumption that a good number of smokers would continue to smoke, even in the face of a growing consensus about the risks of smoking and regardless of how vigorous a public education campaign was mounted.  It was also based on the scientific evidence which suggested that reductions in smoking generally and reductions in smoking cigarettes with high tar levels in particular could reduce tobacco related diseases.

But all of this was, unfortunately, to change. In the US the Carter Administration and its Secretary of Health, Education and Welfare were opposed to harm reduction, both in principle and practice, favoring a much more aggressive combination of education and regulation to eliminate smoking. By the end of 1979 all of the Smoking and Health Program activities had come to an end. Though the research and the stepped reductions in tar levels would continue for a time in the UK, the growing anti-smoking movement, both in the UK and in North America, with its commitment to total cessation was increasingly critical of harm reduction strategies. For this brave new world of tobacco control the future was to be found not in making cigarettes safer and by implication more acceptable, but in the exclusive emphasis of their dangers, even to the point of distorting what science knew, in the interests of a world free of tobacco by 2000.

With the end of the US government’s Smoking and Health program, the official voices that had championed tar reduction and argued for light and mild products were silenced and those in the public health community who had championed harm reduction were left alone to face the new orthodoxy of the anti-smoking fundamentalists. This fundamentalism was based on three articles of faith.

The first was the claim that the risks associated with smoking were immutable, that cigarettes were inherently dangerous in their design and that there was no threshold of safety in smoking. The second was that the only proper response to this knowledge was to use not only all available but indeed all conceivable measures to eliminate tobacco use. The goal of tobacco control policies was not simply to reduce smoking but to eliminate smoking. Anything that served to justify the continuation of smoking was unacceptable. The third was that the main way in which to change behavior was through knowledge. The more that individuals knew about the dangers of smoking, the more likely they would be to stop. Knowledge about the dangers of smoking, even if the extent of those dangers were exaggerated, not low tar, safer cigarettes, was the answer to the smoking problem.

This fundamentalist faith found official expression in a new report issued by  the National Cancer Institute, once the home of harm reduction,  (Monograph 13) at the end of 2001 in which it argued that ; 1) the epidemiological evidence did not show a benefit from reduced tar cigarettes; 2) smokers compensate for reduced tar by more intensive smoking, thus defeating the purposes of light and mild products; and 3)  lower tar cigarettes “promote initiation and impede cessation” through misleading smokers into thinking that they are using less risky products.

While the language of the NCI was in some ways carefully academic, that of the anti-smoking fundamentalists was not. ASH, for instance, declared that the low tar efforts of the last 30 years had been nothing more than a tobacco industry conspiracy. The Royal College of Physicians recommended that the tar and nicotine yields on tobacco packages should be removed, and the Canadian government ran an advertising campaign showing three corpses in a morgue: one had a tag saying Full Flavor smoker, another saying Lights smoker and a third saying Ultra-Lights smoker. In the most extreme action against low tar products to date, a group of  Canadian “health and legal experts” filed a complaint last June under the Canadian Competition Act claiming that the use of such terms as light and mild was fraudulent and asking that such brands be prohibited.   

This campaign against light and mild in particular and harm reduction in general continues as an editorial in last month’s Journal of the National Cancer Institute (January, 2004) criticized  “those who suggest that now is the time to implement ‘harm reduction’ approaches”. According to the writer “there are major challenges to demonstrating a public health benefit of a ‘harm reduction’ approach, and certainly insufficient data to support the practice of encouraging smokers to pursue reduced smoking as a harm reduction strategy.”

This, however, is not the truth. Indeed, the position of the NCI and the anti-smoking fundamentalists is deeply flawed in three senses: it is false, it is incoherent and it is unethical.  It is false in its claims about the health effects of lower tar products. Despite the NCI’s claim, there is clear evidence to “support the practice of encouraging smokers to pursue reduced smoking”. Stellman and Garfinkel (1989), using the American Cancer Society database of a million men, demonstrated that there is a dose-response relationship between tar intake and lung cancer. Sir Richard Doll, in examining the mortality rates from smoking-related diseases in the UK from 1950-1984, noted that the decline in death rates was not due to less smoking but to changes in the constituents of the cigarettes- e.g. lower tar levels. In a similar vein the UK’s Independent Scientific Committee on Smoking and Health concluded that “past reductions in the yields of tar and associated cigarette smoke components have reduced the risk of lung cancer and possibly of chronic obstructive airways disease…. (1988)

In its efforts to demonstrate a link between ETS and lung cancer, the US EPA’s 1993 report noted that in eight major studies there was a “gradient of increasing risk for lung cancer mortality with increasing number of cigarettes smoked per day…” And just last year, Geoffrey Kabat, after looking at fifty years of evidence about low tar cigarettes concluded that the “studies indicate a reduction of risk [of lung cancer] on the order of 20-30% for smokers of lower tar … as opposed to higher tar… cigarettes. He further noted that some of the better studies also indicated a reduced risk (10%) of heart disease for low tar smokers. Of the seven studies that examined total mortality “five show a statistically significant reduction on the order of 10-20% among smokers of lower tar cigarettes.” (Inhalation Toxicology, 2003) All of which shows how irrelevant the issue of smoker compensation really is. Whether or not smokers compensate for lower tar cigarettes, such tobacco products still present less risk to their health than the high tar cigarettes of the 1950’s and 60’s.

It is also false in its assumption that increased knowledge about the dangers of smoking will change an individual’s risk-taking inclination. The risks associated with tobacco use are universally understood, yet it is clear that a certain percentage of the population remains willing to assume them. The assumption that smoker education obviates the need for harm reduction is simply not true. Education about the risks of smoking, even for young people, will not produce a smoke-free society.

Finally, the anti-smoking fundamentalists are wrong in their claim that low tar cigarettes “impede cessation” through misleading consumers about the risks of smoking. A study done for the Canadian government indicated that overwhelming majority of smokers believed that low tar cigarettes were both as harmful and as addictive as other cigarettes.

But the position of NCI and the anti-smoking fundamentalists is also incoherent in at least two senses. First, while opposing harm reduction in principle, it has pressed for equal reductions in tar and nicotine, on the grounds that reducing nicotine was necessary to reduce the risk of addiction. This goes against what we know about the role of nicotine in smoking. Smokers are carefully consistent in their nicotine intake. This means that reductions in nicotine beyond a certain level will result in increased smoking and increased tar intake, thus eliminating the very benefit that low tar cigarettes promise. As most experts have suggested, nicotine levels should be maintained at rates high enough to reduce compensatory smoking, while tar levels are reduced as much as possible.

Second, it is incoherent in that its consistent push for higher cigarettes taxes actually works to negate not only the health advantage of lower tar cigarettes but undermines the rationale for such taxes, namely that they encourage quitting. Using data from a large longitudinal study sponsored by the NCI, researchers( Farrelly et al, Health Economics, 2003) found that higher cigarette prices encouraged compensating behavior in smokers of all ages: they reduced the number of cigarettes consumed but moved to cigarettes with higher levels of tar. Because cigarettes became more expensive and they wished to maintain a consistent dose of nicotine, they turned to cigarettes that delivered a higher tar and nicotine content but were cheaper. So rather than encouraging quitting, higher taxes actually drove these smokers to assume greater risks.

And with this indifference to the ways in which their policies damage smoker’s welfare we come to the third problem with the crusade against low-tar cigarettes and harm reduction in general, its unethical character.

By distorting the history of low tar products, denying that the risks of smoking are dose dependent, misrepresenting the epidemiological evidence about their health benefits and demonizing the tobacco industry for promoting them, the anti-smoking fundamentalists sacrifice the health of smokers who choose to continue to smoke to the mistaken belief that a smoke-free society is the only legitimate and possible goal of tobacco control policy. At the end of the day, lower tar products are opposed not because they fail to offer health benefits- the scientific evidence simply does support this claim- but because they are believed to threaten the elimination of smoking. In this immoral calculus, the lives of smokers who wish to continue to smoke and could do so with a reduced risk by using lower tar cigarettes, are judged to be of less importance than the elimination of smoking. Indeed, these smokers are so little valued that they can be lied to about the possible health benefits of lower tar cigarettes. 

If, for example, we take Kabat’s lower estimate of a 20% reduction in lung cancer risk from low tar cigarettes and consider this in the context of the world’s one billion smokers, it is obvious that a substantial reduction in premature smoking-related mortality can be achieved. After three decades in which the smoke-free society has always been just around the next policy corner, it is now clear that whatever people know about the risks associated with smoking, substantial numbers of smokers will continue to smoke. This means that equally as important as the issue of how to prevent people from beginning to smoke is the question of what can be done to protect the health of those who continue to smoke. There is no compelling evidence that these goals must be incompatible, just as there is no compelling evidence that banning such terms as light or mild will bring any significant health benefits.

On the other hand there is ample evidence both that lower tar products can reduce smoker’s risk and that the real dishonesty over lower tar tobacco products lies with the anti-smoking fundamentalists.

 

John Luik - Published by Tobacco Reporter, January 2004

 




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