Over the years, the major companies have faced endless law suits on the basis that they both lied about the dangers of their products while also withholding information they knew would prove the cases against them. Eventually in the USA, the companies settled through the Tobacco Master Settlement Agreement which means they will be paying forever. Although product liability must have been an important part of the litigation, manufacturing, selling and promoting cigarettes was not a crime. So key to the issue was the companies’ responsibilities to their consumers, in other words, issues of morality, ethics and rights.
Now what if you could turn this on its head and argue that by publicly lying about the dangers of safer nicotine products this has resulted in smokers not switching away and so suffering all the consequential damage? Or that by denying the independent science, politicians have been persuaded to pass laws making it difficult if not impossible for smokers to enjoy the best possible health while still consuming nicotine.
The third report of the Swedish Snus Commission published in 2017 calculated that if snus had not been banned in the EU, then over 300,000 lives could have been saved. Even if they followed correct procedures, could the EU Commissioners who voted for the ban be guilty of what in English law is called gross negligence manslaughter where the defendant commits a lawful act in such a way as to render the actions criminal, but importantly can also can be committed simply by omission. There might only need to be one successful test case of a person who died or became seriously ill as a result of being persuaded not to switch or through legal means was denied access to safer nicotine products for the flood gates to open. Who would you indict?
Well, dear readers, I’m about to break a promise. I said no more mentions of the Axis of Evil, but I cannot let this pass. Simon Chapman has publicly apologised for near-libellous comments about the qualifications of Dr Joe Kosterich to give the Michael Russell Oration at the recent GFN conference in Warsaw. I doubt that the e-meritus professor had an e-piphany about e-cigarettes (OK, enough Harry) more likely a word from a legal eagle. And it was a ‘blink and you miss it’ tweet, but in the interests of posterity, here is that tweet in full.
This is a key paragraph from the comment to the FDA on regulating or banning flavours in tobacco/nicotine products by Iowa Attorney General Tom Miller, David Abrams, Ray Niaura, David Sweanor and Clive Bates.
“If flavors increase the appeal of harm reduction transitions and pathways, then intervening to reduce flavor-related appeal may cause harm. We do not believe that, at this point, FDA can reliably distinguish between harms and benefits that arise from flavors in non-combustible nicotine products or provide assurance that its interventions would not cause more harm than good. This applies to both adult and youth populations. We see no ethical or legal rationale to exclude harm reduction benefits to young people from policy analysis simply because we would prefer them not to use nicotine products at all”
And moving from flavour bans to reducing nicotine in cigarettes, this excellent editorial in The Lancet by John Britton from the UK Centre for Tobacco and Alcohol Studies who questions whether such a strategy can work beyond clinical trials.
“The FDA argues that taking nicotine out of cigarettes will prevent young people who experiment with tobacco from becoming regular smokers. From first principles this seems rational since in the absence of nicotine, the main addictive constituent of tobacco smoke, progression from experimentation to regular smoking is less likely. However, the FDA's suggestion that reducing the addictiveness of cigarettes will help established smokers to quit seems rather less rational. Conventional wisdom holds that smokers self-titrate nicotine intake to avoid withdrawal symptoms, and if presented with cigarettes that deliver less nicotine in each puff of smoke will compensate by smoking more intensely, thereby increasing their intake of tobacco smoke toxins and, hence, potentially sustaining even greater harm. The available clinical trial evidence… confirms that this is the case for reduced nicotine cigarettes unless nicotine content is reduced by more than 95%, which makes compensation virtually impossible to achieve. In clinical trial settings, smokers allocated to cigarettes containing such low levels of nicotine show reduced tobacco consumption, reduced intake of toxins, and increased motivation to quit. It is this trial evidence, along with results from a modelling exercise that underpins the FDA proposal.
The unanswered question is whether these trial findings will translate to the general population of smokers if denicotinisation is mandated and conventional cigarettes, to practical purposes, are prohibited. Adult smokers who take part in trials of very low nicotine cigarettes do so by choice and are by definition motivated to try them. They also know that they are opting into a finite period of use, during which they are free to withdraw and revert to smoking conventional cigarettes at any time, are provided with denicotinised cigarettes free of charge, and in some cases receive a financial reward on trial completion.These smoker characteristics and incentives to participate are far removed from the wider world in which mandatory denicotinisation is hoped to succeed.
As the FDA intends, many adult smokers may welcome denicotinisation as a stimulus to quit or to migrate to less harmful nicotine products, including e-cigarettes, as an alternative to smoking
However, smokers who find these options unacceptable, or simply object to the principle of denicotinisation, might look elsewhere for the cigarettes they crave. Among the motivated smokers who took part in randomised trials of denicotinised cigarettes, rates of attrition and self-reported non-compliant use of regular cigarettes were as high as 40%. Among the wider population of nearly 40 million current smokers in the USA, the proportion seeking to obtain tobacco cigarettes will inevitably be higher and likely to generate demand for illicit tobacco. The FDA appears confident that this risk can be managed, and the hearts and minds of smokers sufficiently captured, for the benefits of denicotinisation to outweigh the risks. Time will tell.
A further question is whether, if successful in the USA, this policy to reduce nicotine in combustible cigarettes to minimally or non-addictive levels can work elsewhere. In part through its geography, the illicit tobacco market in the USA primarily involves bootlegging tobacco products from low to high tax areas, with little of the large-scale criminal smuggling of products ostensibly manufactured for the licit market, of so-called cheap white branded cigarettes manufactured for the illicit market, or of the counterfeit products that plague so many other countries. There is no guarantee that success in preventing a surge in illicit supply after mandatory denicotinisation, even if achieved in the USA, would translate easily to countries with more porous borders.
The FDA also recognises that, despite reservations over the safety of e-cigarettes, success for denicotinisation while minimising illicit tobacco use depends on ensuring the availability of effective alternative nicotine products. It is concerning, therefore, that WHO is considering denicotinisation as a global tobacco control strategy while discouraging the availability of alternative nicotine products.
The global public health community has been rocked by the news that there is no such thing as ‘less harm’. This startling revelation was made by Dr Pierre Chan, a member of the Hong Kong Legislative Council during a debate about e-cigarettes. The Council CEO observed.
“But as far as a complete ban is concerned, Hong Kong does have to recognize her trade obligations in an international environment, because if conventional cigarettes are even more harmful but they are allowed to be sold in Hong Kong under certain regulation, to go into a total ban of another form of tobacco product, which is less harmful medically, would raise many challenges, So, we really have to strike a balance”.
To which Dr Chan replied:
“The “less harmful” wording is wrong. This is… there is no such thing (as) “less harmful”; it’s “harmful”.
The global impact has been dramatic; just in the first few hours, safer drinking guidelines were being ripped up as seat belts were torn out of cars, bikers threw away their helmets, while sales of Diet Coke and salad plummeted. There is now a world shortage of doughnuts.
Nice coverage of advocacy action in the Asia-Pacific region https://asia.nikkei.com/Politics/Asian-consumers-push-for-right-to-use-smoking-alternatives and more good news from New Zealand. This from the Ministry of Health;
E-cigarettes: an option to help smokers to quit
Although the best thing smokers can do for their health is to quit smoking completely, the Ministry of Health considers that e-cigarettes have the potential to contribute to the Smokefree 2025 goal and could disrupt the significant inequities that are present. How much e-cigarettes can help improve public health depends on the extent to which they are a route out of smoking for New Zealand’s 529,000 daily smokers, without providing a route into smoking for youth and non-smokers.
Expert opinion is that e-cigarettes are significantly less harmful than smoking tobacco but not completely harmless. A range of toxicants have been found in e-cigarette vapour, including some cancer-causing agents. In general, levels of these toxicants are much lower than they are in tobacco smoke or are unlikely to cause harm. Smokers switching to e-cigarettes are highly likely to reduce their health risks and that of those around them.
Where smokers want to use e-cigarettes to quit smoking, the Ministry of Health encourages them to seek the support of local stop-smoking services. Local stop-smoking services provide smokers with the best chance of quitting successfully and should support smokers who want to quit with the help of e-cigarettes.
The government has also decided not to challenge the decision to allow IQOS sales. The importance of the ruling (like the ruling in Kentucky) was the recognition of relative harm and the benefit to existing smokers of allowing reduced harm nicotine products to be readily available. Over to you Australia.
It is a sad fact of life at least in the UK, that children don’t play outside like they used to. Video games and other electronic diversions are blamed, but also the increased reporting of young people coming to harm out there. Well, time to lock up the kids again as a new menace hoves into view. Them damn Yankees are sending us JUUL. You can write the headlines now. https://www.cnbc.com/2018/07/16/juul-e-cigarette-expands-to-england-scotland-eyes-asia.html
It has been reported that vaping causes blood clots in mice. I blame those bastard e cig manufacturers targeting mice with their cheesy flavoured e liquids, like Cosmic Cheddar, A Galaxy of Gouda and Emmental Ecstasy. Wont somebody think about the rodents? https://medicalxpress.com/news/2018-07-vaping-tied-blood-clotsin-mice.html
And finally, it has often been written that as a way of consuming nicotine, smoking cigarettes belongs to the Stone Age. Well here is the proof from a TV commercial banned in 1961