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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. |
