tag:theconversation.com,2011:/africa/topics/tobacco-regulation-17966/articlesTobacco regulation – The Conversation2017-12-18T18:33:16Ztag:theconversation.com,2011:article/874212017-12-18T18:33:16Z2017-12-18T18:33:16ZWhy anti-tobacco messages are failing to reach rural Botswana<figure><img src="https://images.theconversation.com/files/198966/original/file-20171213-27555-w2brn4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Twenty-year-old Thuso lives in a small rural farming village in <a href="http://www.statsbots.org.bw/sites/default/files/publications/Kgalagadi%20South%20District.pdf">Kgalagadi South</a> about 500 kilometres outside of Botswana’s capital city of Gaborone. It has a population of about <a href="http://www.statsbots.org.bw/population-census-atlas-2011-botswana">30,000 people</a>. Only one in five households have access to flush toilets and less than half use electricity to light their homes. </p>
<p>Thuso is not employed but he makes some money with “on and off” part-time jobs. Despite this, he smokes a pack of cigarettes a day. And on a good day – by his own admission – he can drink two cases of beer. </p>
<p>His girlfriend Lindah – the mother of his two-year-old child – is also unemployed. She uses snuff three to four times a day. It’s a habit she picked up since she was 12. And her drinking patterns are much the same as Thuso’s. </p>
<p>Both realise that drinking too much could harm them. They have heard about the dangers of alcohol from messages on radio, at school, teachings at community gatherings and even from some family members. But neither have ever really heard that tobacco use could be harmful. In fact snuff was suggested for Lindah by a family member as remedy for her frequent nose bleeds as a child. </p>
<p>Thuso and Lindah are not alone. Across the region’s villages smoking and drinking patterns mirror those of Thuso and Lindah.</p>
<p>I was part of a Ministry of Health and Wellness team that visited the region to talk about living healthily and understanding what challenges people faced doing so. We met with health providers, community members and leaders, and conducted screenings for tobacco and harmful alcohol use, blood pressure, diabetes, obesity, and cervical cancer. Our visit coincided with a debate in Botswana’s Parliament about a new law, the <a href="http://www.mmegi.bw/index.php?aid=70830&dir=2017/august/09">National Tobacco Control Bill</a>. </p>
<p>We found that in each village drinking and smoking rates were much higher than the average in <a href="https://www.cugh.org/events/2018-annual-cugh-global-health-conference">the country</a>. Furthermore, there was more pronounced use of smokeless tobacco such as sniffing or chewing snuff, predominantly by women. </p>
<p>This shows us that there are differences in the smoking patterns of rural and urban communities. Unless these are recognised and included in the in-country tobacco control interventions, efforts to reduce tobacco use will fail.</p>
<p>These were not good signs. Globally, tobacco is the <a href="https://books.google.co.bw/books?hl=en&lr=&id=hrIXDAAAQBAJ&oi=fnd&pg=PP1&dq=World+Health+Organization.+WHO+report+on+the+global+tobacco+epidemic,+2013:+enforcing+bans+on+tobacco+advertising,+promotion+and+sponsorship:+World+Health+Organization%3B+2013.&ots=xk8Wjod5hr&sig=Mbmc90XsWTQNTl3rScwuDtJG7i4&redir_esc=y#v=onepage&q=World%20Health%20Organization.%20WHO%20report%20on%20the%20global%20tobacco%20epidemic%2C%202013%3A%20enforcing%20bans%20on%20tobacco%20advertising%2C%20promotion%20and%20sponsorship%3A%20World%20Health%20Organization%3B%202013.&f=false">leading preventable cause of death</a>. According to the World Health Organisation, currently one billion people smoke and about 6 million die each year due to the <a href="http://www.who.int/bulletin/volumes/95/5/16-175596.pdf?ua=1">effects of tobacco</a>. It’s also among the four major risk factors for non-communicable diseases.</p>
<p>On the continent these diseases have become a major reason for premature deaths. And it’s estimated that there will be about 3.9 million deaths from non-communicable diseases in Africa by 2020.</p>
<p>This is against a backdrop of increasing smoking rates on the continent where about <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132401">14% of men and 2% of women</a> smoke. This rising trend is seen only in <a href="http://www.who.int/gho/tobacco/use/en/">Africa and the Eastern Mediterranean region</a>, while all other regions in he world are experiencing declines in tobacco use.</p>
<h2>A vulnerable choice?</h2>
<p>Tobacco control efforts in Africa have centred on the rising smoking rates among middle-class urban communities. Messages are not in indigenous languages and are primarily distributed through commercial media. </p>
<p>Research shows that tobacco use is more popular in <a href="http://www.tandfonline.com/doi/abs/10.3402/gha.v6i0.19216">urban areas compared to rural areas</a>. But the patterns of tobacco use in rural Botswana tell a different story. There are pockets of the population where rates of tobacco use are far higher. While the national average sits at 18% in Botswana, in Kgalaladi South it jumps to 29%.</p>
<p>If passed, the bill being considered by Botswana’s parliament will mark a milestone in the country moving towards fully implementing recommendations by the World Health Organisation. Botswana signed up to them <a href="http://apps.who.int/fctc/implementation/database/parties/Botswana">in 2005</a> and to date has established a Tobacco levy, restricted smoking in public venues (designated smoking areas) and has outlawed direct marketing of tobacco products such as through TV, radio and other media. </p>
<p>The bill would outlaw smoking in all indoor public places and the sale of tobacco to individuals younger than 21. It would further restrict marketing of tobacco products (including indirect advertising) and mandate plain packaging, thus enacting regulatory and policy interventions that have been shown by <a href="http://www.nejm.org/doi/full/10.1056/nejmra1308383#t=article">studies</a> to reduce tobacco use.</p>
<p>The bill also includes strategies to reduce use of smokeless tobacco, which affects key populations such as in Kgalagadi South. </p>
<h2>Multiple interventions</h2>
<p>But the bill won’t be enough on its own. Significant tobacco use takes place in people’s private homes, and ‘passed down’ at an early age from family members who have been using tobacco. Peer pressure significantly affects whether an adolescent will use tobacco, independent of the influence of advertising. </p>
<p>In an analysis of Botswana’s population based national survey (STEPS) on non-communicable disease risk factors that was conducted in 2014, peer pressure was cited as reasons for tobacco use among 20.3% of daily users. We need to find more effective ways to raise awareness and change mindsets of families, of peers, of communities to reduce social acceptability of tobacco use. </p>
<p>In poor, remote communities such as in Kgalagadi South, tobacco is not a ‘new’ trend. It is a slow brewing problem that has been present since colonial times. </p>
<p>In some communities in Botswana, smoking has been seen as a symbol of wealth. Tobacco was once a <a href="https://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=10&cad=rja&uact=8&ved=0ahUKEwjuxM7MioTYAhVBtRoKHcptByEQFghjMAk&url=http%3A%2F%2Fdspace.nwu.ac.za%2Fbitstream%2Fhandle%2F10394%2F2281%2Fpilane_gabaitsiwee(1).pdf%3Fsequence%3D1&usg=AOvVaw1gANk9otLZYM3KfqBiakGx">form of currency</a>. As a result, those growing up in these communities begin to see the practice as not only normal but aspirational.</p>
<p>These traditional beliefs and lack of reach by conventional media makes addressing tobacco use more challenging. </p>
<h2>Targeted messaging</h2>
<p>To reach marginalised communities like in Kgalagadi South, public health messages must take into account everyone who is affected. This means messages need to take into account those whose first language may not be the official language, or who may have less interaction with conventional media. </p>
<p>Beyond having the information, interventions are needed that address culturally entrenched practices and beliefs through grassroots efforts that involve community leaders and school based programmes that impart life skills and prevent regular tobacco use at an early age. Tobacco cessation may sometime require pharmacological treatment for heavy users; we need to ensure that this is available equitable. This is the way to break the vicious patterns of tobacco use.</p>
<p>If these do not take place, Botswana – and many other countries like it – will fail those who are the most vulnerable.</p><img src="https://counter.theconversation.com/content/87421/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neo Tapela does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are differences in the smoking patterns of rural and urban communities. These must be recognised and included in tobacco control interventions to reduce use.Neo Tapela, Senior Research Fellow, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/665452016-10-25T02:32:46Z2016-10-25T02:32:46ZWhy requiring low-nicotine cigarettes is still ill-advised<figure><img src="https://images.theconversation.com/files/142552/original/image-20161020-8849-19ftj5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will a low-nicotine cigarette work for people who love to smoke?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-2583056/stock-photo-close-up-of-an-smoking-man.html?src=Sa25E9j0Dhxhtqh7fy8smw-3-2">From www.shutterstock.com</a></span></figcaption></figure><p>Global policymakers will soon consider a policy of requiring that only reduced-nicotine cigarettes can be manufactured or sold. This may sound good, but as someone who has studied tobacco for decades, I believe it is <a href="http://tobaccocontrol.bmj.com/content/early/2016/07/01/tobaccocontrol-2016-052995.full">premature</a> to deploy this as a tool to improve global health.</p>
<p>The <a href="http://www.who.int/fctc/en/">Framework Convention on Tobacco Control</a> in 2003 was the first international treaty created by the World Health Organization. Some 180 countries have ratified it; the U.S. has not. </p>
<p>In 2015 WHO’s expert committee published an <a href="http://www.who.int/tobacco/publications/prod_regulation/nicotine-reduction/en/">advisory report</a> that promotes, with caveats, a global consideration of “a policy for limiting the sale of cigarettes to brands with a nicotine content that is not sufficient to lead to the development and/or maintenance of addiction.”</p>
<p>These recommendations will be discussed at the <a href="http://www.who.int/fctc/cop/sessions/cop7/en/">Conference</a> of the Parties (COP7) in India, Nov. 7-12. This event is not well-suited to deal with the many caveats and may instead pick and choose the most politically alluring elements of the strategy.</p>
<p>First, the quality of supporting evidence on the effects of requiring low-nicotine cigarettes is <a href="http://tobaccocontrol.bmj.com/content/early/2016/07/01/tobaccocontrol-2016-052995.full">poor</a>. </p>
<p>Second, there are possible <a href="http://tobaccocontrol.bmj.com/content/early/2016/07/01/tobaccocontrol-2016-052995.full">negative effects of banning traditional</a> cigarettes related to the creation of black markets and ill effects on high-risk users. </p>
<p>Last, before deploying such a requirement, it is now judged to be critical to have satisfying and less-harmful sources of nicotine available. This prior need for alternative nicotine/tobacco products is yet to be fulfilled around the world. Also, it is not appreciated by all proponents of the low-nicotine strategy – especially those who have not followed its evolution. </p>
<p>Safer, alternative nicotine/tobacco products are now part of the strategy as elaborated by the <a href="http://www.who.int/tobacco/publications/prod_regulation/nicotine-reduction/en/">WHO expert committee</a>, which included one of the original authors, and elsewhere by another <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13534/full">original author</a> of the nicotine-reduction strategy. </p>
<h2>A way around an all-out ban</h2>
<p>Since the end of <a href="http://www.ncbi.nlm.nih.gov/pubmed/20331549">alcohol prohibition</a> in the United States, policymakers have avoided outright prohibition of popular recreational drugs. Possible costs in crime, enforcement, punishments, restrictions on adult consumers and black markets have caused many to not favor bans.</p>
<p>In 1994, two prominent researchers, Neal Benowitz and Jack Henningfield, <a href="http://www.nejm.org/doi/full/10.1056/NEJM199407143310212">proposed</a> a novel hypothesis regarding tobacco use. If a nicotine threshold for addiction could be identified – with the further requirement that the nicotine content of all cigarettes be below that threshold – then this would help resolve the smoking and health problem. </p>
<p>Nicotine addiction could thereby be banned, without having to ban cigarettes! Youth who smoked would not become addicted. Even established smokers could not sustain their addiction. The need for supplemental nicotine products was not then mentioned as an issue. </p>
<p>The 1994 low-nicotine strategy included no supplemental nicotine from other products.</p>
<p><a href="http://tobaccocontrol.bmj.com/content/8/1/106.full?ijkey=cb153903df07326836ff1796996c49e8a8c02d97&keytype2=tf_ipsecsha">Other experts</a> <a href="http://www.sciencedirect.com/science/article/pii/S0955395915000432">thought</a> the low-nicotine proposal was ill-advised. The currently recommended low-nicotine cigarette contains “<a href="http://www.cspdailynews.com/category-news/tobacco/articles/22nd-century-files-modified-risk-tobacco-product-application-fda">only trace</a>” levels of nicotine.</p>
<p>Imagine if, by regulation, all beer must only have trace levels of alcohol. Beer drinkers would consider that their preferred product had been banned and think that this regulation struck at the heart of the product. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142553/original/image-20161020-8855-9cpzpd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Would beer be as popular with trace amounts of alcohol?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-407273818/stock-photo-male-group-clinking-glasses-of-dark-and-light-beer-on-brick-wall-background.html?src=PECG09A7POrkrjT7CvD-Dw-1-6">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Authorities have been encouraged by being able to achieve regulations that the industry opposed (e.g., higher taxes, bans on public smoking). The difference here is that none of these measures attack the <a href="http://www.sciencedirect.com/science/article/pii/S0955395915000432">fundamental</a> nature of the <a href="http://tobaccocontrol.bmj.com/content/early/2016/07/01/tobaccocontrol-2016-052995.full">product</a>. While paying more or exiting a bar to smoke, smokers still light up uncompromised cigarettes. </p>
<p>While smokers might “<a href="https://en.wikipedia.org/wiki/Camel_(cigarette)">walk a mile</a>” for cigarettes, smokers might not extend an arm for trace-nicotine cigarettes.</p>
<h2>AMA, FDA support the strategy</h2>
<p>Nonetheless, the low-nicotine cigarette gained influential support. </p>
<p>In the U.S., the American Medical Association and the Food and Drug Administration have both thrown their support behind the strategy of a low-nicotine cigarette. The AMA offered a <a href="http://tobaccocontrol.bmj.com/content/7/3/281.short">formal resolution</a> in 1998, and the 2009 <a href="http://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm246129.htm">law</a> giving the FDA authority over cigarettes included the nicotine-reduction strategy as a centerpiece. Part of the 2009 law said FDA could reduce nicotine, provided levels weren’t taken to zero. </p>
<p>For research, the FDA contracted for trace-nicotine cigarettes that were genetically engineered using a patented process. It has invested tens of millions of dollars on research on the <a href="http://www.sciencedirect.com/science/article/pii/S0955395915000432">cigarette</a>.</p>
<p>The law also requires that any regulation considers negative effects from contraband markets. Also, it should be noted that, although the FDA law explicitly allows for graphic-warning labels on all cigarettes, legal action has derailed such labels. This was influenced by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345832/">FDA’s own cost/benefit analyses</a>.</p>
<p>A closer look at the complex law, which was supported by <a href="http://www.forbes.com/2009/06/11/fda-smoking-cigarettes-business-healthcare-tobacco.html">Altria®</a>, raises doubt about whether mandatory trace-nicotine cigarettes are <a href="http://www.sciencedirect.com/science/article/pii/S0955395915000432">practicable</a>. </p>
<h2>Research not convincing</h2>
<p>The most extensive <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1502403#t=article">study</a> to date produced only “preliminary short-term data…suggesting” some changes in nicotine exposure and dependence. The study participants had no severe mental illnesses or alcohol or other substance issues, except for marijuana. Other <a href="https://www.ncbi.nlm.nih.gov/pubmed/27714427">research</a> on the effects of these cigarettes in high-risk groups was limited by very small samples (for example, only six individuals with affective disorders) and “no assessment of chronic exposure” to only these cigarettes.</p>
<p>This is <a href="http://tobaccocontrol.bmj.com/content/25/3/261.full?sid=785854f2-1edc-4214-84dc-810a8d0f4296">important</a> because smoking is much <a href="http://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm">more common</a> among substance users and mentally ill individuals than in the general population. And the nicotine may provide a kind of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1763976/">self-medication</a>. </p>
<p>A subsequent <a href="http://www.ncbi.nlm.nih.gov/pubmed/27367436">paper</a> from this project makes it clear that dissatisfaction with these cigarettes was the major predictor of cheating by smoking conventional cigarettes, and this was found in the large majority (78 percent) of participants. </p>
<p>Indeed the dissatisfaction with very low-nicotine cigarettes is central to the <a href="http://sphhp.buffalo.edu/community-health-and-health-behavior/faculty-and-staff/faculty-directory/lk22.third.html">problem</a>.</p>
<h2>The trace-nicotine model no longer a ‘nicotine’ end-game strategy</h2>
<p>While initially in 1994 the nicotine-reduction strategy said nothing about supplemental nicotine, the model in the hands of its leading scientific proponents (<a href="http://www.who.int/tobacco/publications/prod_regulation/nicotine-reduction/en/">and</a> <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13534/full">creators</a>) has evolved to require that less-harmful nicotine sources be provided:</p>
<p>“The key to successful cigarette nicotine reduction is likely to lie with providing readily available, consumer-acceptable non-combusted forms of nicotine to support shifting the source of nicotine from cigarettes to a non-combusted product…We recommend that regulations regarding e-cigarettes and other ANDS [alternative nicotine delivery systems] focus on toxicity, safety and limiting youth uptake, but do not disrupt features that make them viable alternative to cigarette <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13534/full">smoking</a>.”</p>
<p>The evolved approach should spur the AMA, FDA and WHO to advance safer, satisfying forms of nicotine products before, if ever, trying to ban traditional cigarettes. </p>
<h2>Countries confused over safer tobacco/nicotine products</h2>
<p>The WHO conference in India will also discuss <a href="http://www.who.int/tobacco/industry/product_regulation/eletronic-cigarettes-report-cop7/en/">vape</a>, and their inclinations have not been nearly as supportive as those of <a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">others</a>. The world is in <a href="http://www.who.int/bulletin/volumes/92/12/14-031214/en/">chaos</a> <a href="http://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm394909.htm">concerning</a> regulations and support for less-harmful, satisfying forms of nicotine/tobacco. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142555/original/image-20161020-8869-1e3a4qc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Snus, or smokeless, manufactured tobacco.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-407273818/stock-photo-male-group-clinking-glasses-of-dark-and-light-beer-on-brick-wall-background.html?src=PECG09A7POrkrjT7CvD-Dw-1-6">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Although the evidence is clear that <a href="http://www.karger.com/article/FullText/360220">manufactured smokeless tobacco</a> in the U.S. or Sweden is much less harmful to health than cigarettes, authorities have shown reluctance to <a href="http://www.ijdp.org/article/S0955-3959(16)30092-5/fulltext">provide this information</a> to American consumers. </p>
<p>A product that produces no lung cancer or other respiratory disease, which accounts for the majority of smoking deaths, has been estimated to be at least <a href="https://www.karger.com/Article/FullText/360220">90 percent less dangerous</a> than cigarettes. </p>
<p>Swedish smokeless tobacco, or snus, is <a href="http://tobaccocontrol.bmj.com/content/12/4/360.full">banned</a> in the European Union (except for Sweden). A national U.S. survey <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-015-0055-0">found</a> that only 9 percent appreciated that smokeless tobacco was safer than cigarettes. </p>
<p>Other countries have banned e-cigarettes (Australia) or nicotine in e-cigarettes (Canada), while others have been clear in supporting the constructiveness of <a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">vaping</a>. New FDA <a href="http://www.fda.gov/TobaccoProducts/Labeling/RulesRegulationsGuidance/ucm394909.htm">regulations</a> constrain the development of e-cigarettes. </p>
<p>One manufacturer (NJOY) has declared <a href="http://nypost.com/2016/09/19/e-cigarette-maker-files-for-bankruptcy/">bankruptcy</a>, citing pressures arising from FDA legislation. Sound, public <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3079-9">health-promoting regulations</a> need to be in place globally to support safer, <a href="http://www.ncbi.nlm.nih.gov/pubmed/26704429">satisfying</a> alternatives to cigarettes, before, if ever, taking any further steps to banning traditional cigarettes.</p>
<p>Optional very low-nicotine cigarettes have been promoted in the past, but were commercial <a href="http://www.webcitation.org/6iI6OhpHj">failures</a>. We need more experience in motivated smokers using such cigarettes in <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13515/full">open markets</a>. What <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13515/full">patterns of longer-term multiple-product use</a> might develop alongside trace-nicotine cigarettes (which are fully toxic)?</p>
<h2>Comprehensive policies</h2>
<p>Modern efforts can decrease smoking to historic <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC472137">lows</a>. Mandatory trace-nicotine cigarettes might never <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.02129.x/full">be needed or even desirable</a>, especially if comprehensive efforts continue to decrease smoking. The availability of less-harmful products has been associated with drops in smoking and not <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3079-9">increases</a>.</p>
<p><a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3079-9">Comprehensive tobacco control</a> programs should discourage the use of <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">combustible products</a> and maximize use of less harmful products such as smokeless tobacco products or vape by those who are not prevented from or able to quit using all of these products.</p>
<p>It may take a while for those who imprinted on the purity of the 1994 nicotine reduction model (with no place for additional nicotine) to accept that the evolved model now requires a vibrant availability of less-harmful, consumer-satisfying, noncombusted products. </p>
<p>Without these changes, the model unarguably is a cigarette prohibition and ill-advised. AMA, FDA and WHO should now tackle first things first.</p><img src="https://counter.theconversation.com/content/66545/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynn T Kozlowski receives funding from the National Institutes of Health, but not on the issue of low-nicotine cigarettes. </span></em></p>Requiring low-nicotine cigarettes sounds good, but it’s not the answer. Policy makers instead should speed up the support of safer, satisfying forms of nicotine and tobacco.Lynn T. Kozlowski, Professor, Department of Community Health and Health Behavior, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/549132016-05-31T10:41:23Z2016-05-31T10:41:23ZHow smoking bans could lead to the death of the tobacco industry<figure><img src="https://images.theconversation.com/files/124581/original/image-20160531-1923-134oaud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stubbed out.</span> <span class="attribution"><span class="source">shutterstock.com</span></span></figcaption></figure><p>Smoking bans have been introduced in numerous countries around the world, following the incontrovertible link that’s been made between smoking and cancer. The World Health Organisation <a href="http://www.who.int/mediacentre/factsheets/fs339/en/">estimates</a> that over 6m people a year will die from smoking related illnesses each year and thousands more suffer from the effects of secondhand smoke. This has led to more than 170 countries signing the <a href="http://www.who.int/fctc/en/">World Health Organization’s Framework Convention on Tobacco Control</a>, a treaty that commits them to introduce comprehensive smoking bans. </p>
<p>A natural consequence of smoking bans has been a decline in smoking in countries implementing them. Within one year of a ban on smoking in all enclosed work places being introduced in the UK, for example, <a href="http://news.bbc.co.uk/1/hi/health/7480856.stm">400,000 people quit smoking</a>. But these kinds of bans have also had a surprising consequence for the tobacco industry. </p>
<p>It has long been believed that tobacco firms based in countries with smoking bans would start targeting markets without bans. By and large these are poorer countries, which also provide new markets for big Western tobacco companies. But our <a href="http://onlinelibrary.wiley.com/doi/10.1111/1467-8551.12161/abstract">recent research</a> shows that this is not the case. </p>
<p>In fact, smoking ban legislation has led to a decline in the way that tobacco firms expand internationally. We studied 141 companies across 20 countries over a ten-year period, seeking to explain patterns of foreign direct investment (FDI). We found that FDI in the tobacco industry is widespread, and that 53 tobacco companies engaged in FDI, with 26 investing in countries with some form of smoking ban. Many of their new target countries were among the poorest.</p>
<p>However, we also found that smoking bans at home reduce the likelihood of companies internationalising. Not only did bans affect their cash flow, and therefore reduce their funds for international expansion, there was another reason at play, too.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=816&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=816&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124582/original/image-20160531-1931-14hani6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=816&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Increasingly common.</span>
<span class="attribution"><span class="source">shutterstock.com</span></span>
</figcaption>
</figure>
<p>It seems that tobacco companies are sensitive to their public profiles and, as they seek new working relationships with governments and battles over issues such as plain packaging and intellectual property, do not want to be seen to be exploiting the poorest countries. Smoking bans often reflect a negative political mood within their home country toward tobacco and so investing in poorer countries to make up for <a href="http://www.telegraph.co.uk/finance/newsbysector/retailandconsumer/leisure/11656836/Is-smoking-finally-on-its-way-to-being-stamped-out.html">dwindling sales at home</a> may seem exploitative and would be bad for their PR. </p>
<h2>Swelling tide</h2>
<p>Those that have tried to increase their FDI, however, have sometimes struggled against the swelling tide of legislation against smoking. India, for example, has <a href="http://www.business-standard.com/article/economy-policy/govt-bans-fdi-in-cigarette-manufacturing-110040900076_1.html">banned foreign direct investment in cigarette manufacturing</a>, with its government contending that, as a signatory to the Framework Convention on Tobacco Control, it had the responsibility to reduce consumption. </p>
<p>Instead of investing overseas, tobacco companies seem to be diversifying into new products. FDI in the tobacco processing sector requires a lot of capital, operating at large scale. As such, a decline in revenues seriously adversely affects their ability to invest. </p>
<p>As a result, the field has been cleared for companies who don’t have bans where they are based. Their internationalisation will not be so critically appraised at home and they have the resources to fund expansion. We saw signs of this in our study, which raises the prospect of the sector being dominated by a few countries who don’t have bans or public opprobrium toward smoking.</p>
<p>China, for example, has recently introduced a smoking ban in public spaces, but the ban has <a href="http://www.scmp.com/news/china/policies-politics/article/1959676/china-back-pedals-tough-national-smoke-free-law">numerous exemptions</a>, including restaurants, bars, hotels and airports. Historically, it has seen growth in domestic sales of <a href="http://www.bloomberg.com/news/articles/2014-12-12/the-chinese-government-is-getting-rich-selling-cigarettes">more than 4% a year</a>, along with <a href="http://www.tobaccoreporter.com/2013/12/chinas-cigarette-output-soars-despite-tobacco-control/">increased internationalisation of its tobacco industry</a>, particularly in Asia <a href="http://www.tobaccoreporter.com/2013/04/china-hongyunhonghe-launches-cigarette-processing-unit-in-africa/">and Africa</a>. </p>
<p>Equally, tobacco companies from EU countries with only limited bans, or where bans have less impact due to weather, such as <a href="http://ec.europa.eu/eurostat/statistics-explained/index.php/Archive:Tobacco_processing_statistics_-_NACE_Rev._1.1">France and Italy</a>, continue to see internationalisation of their tobacco firms.</p>
<p>So the flip side of the decline of some big tobacco companies is that it does leave the field open to firms based in countries without a ban. This could be more detrimental to their citizens’ health. Big firms in the UK and US, for example, have <a href="http://www.bat.com/group/sites/uk__9d9kcy.nsf/vwPagesWebLive/DO9GFM88">argued</a> that such firms are less regulated and produce lower quality products, which exacerbates the health effects of smoking. In Indonesia, local products are a mixture of tobacco and cloves, which many people locally believe to be more healthy, though typically this simply leads to them smoking more. </p>
<p>Ultimately, smoking bans reflect society’s attitude toward smoking. The decline in FDI by firms that are based in countries with a ban shows how they are influenced by changing norms. As they are enforced with growing conviction around the world, this may ultimately lead to the death of the industry. Until then, the companies in countries that do not have effective bans will see their profits rise.</p><img src="https://counter.theconversation.com/content/54913/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nigel Driffield most gratefully received funding for this research through a Leverhulme Fellowship. He has held 4 ESRC awards on the issue of foreign investment, as well as funding from OECD, European Commission and the World Bank to study the impacts of foreign investment.</span></em></p><p class="fine-print"><em><span>I have received funding from the British Academy.</span></em></p><p class="fine-print"><em><span>Jo Crotty does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research shows how tobacco companies are feeling the effects of smoking bans across the world.Nigel Driffield, Professor of international business, Warwick Business School, University of WarwickChris Jones, Senior Lecturer in Economics, Aston UniversityJo Crotty, Professor of Management, Aberystwyth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/589412016-05-05T13:06:48Z2016-05-05T13:06:48ZWhat the EU has done to take on Big Tobacco<figure><img src="https://images.theconversation.com/files/121356/original/image-20160505-19858-1c89olq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Africa Studio</span></span></figcaption></figure><p>Three landmark cases in the EU Court of Justice have dealt an important blow in the long-running campaign by Big Tobacco to use legal challenges to avoid regulation. The big question at stake is about how effective is the EU at taking on the might of the multinationals – the huge and well-funded companies in the tobacco industry – in the name of health protection. </p>
<p>The decisions, which unequivocally support the EU’s latest package of tobacco regulation, will be warmly greeted by pro-Europe campaigners in the UK’s referendum – such as <a href="http://scientistsforeu.uk/">Scientists for EU</a> – who argue that on balance, staying in the EU is better for health.</p>
<p>One <a href="http://curia.europa.eu/juris/document/document.jsf?text=&docid=177721&pageIndex=0&doclang=EN&mode=req&dir=&occ=first&part=1&cid=518658">case</a> was brought by the Polish government and the others were referred by the English High Court, which asked the EU court to interpret EU law. Based on this judgment, the English court will now decide claims brought by <a href="http://curia.europa.eu/juris/document/document.jsf?text=&docid=177724&pageIndex=0&doclang=EN&mode=req&dir=&occ=first&part=1&cid=518658">tobacco companies, or suppliers to the industry</a> and a <a href="http://curia.europa.eu/juris/document/document.jsf?text=&docid=177723&pageIndex=0&doclang=EN&mode=req&dir=&occ=first&part=1&cid=518658">retailer of e-cigarettes</a>.</p>
<p>The EU began to regulate tobacco in the late 1980s, as information about the dangers of tobacco came to greater public awareness and the EU’s competence to regulate in its market expanded. Of course, the world knew about the dangers of tobacco well before that – see, for instance, the <a href="http://www.surgeongeneral.gov/library/reports/">US Surgeon General’s Report</a> of 1964 and earlier research such as the work of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2038856/pdf/brmedj03566-0003.pdf">Doll and Hill</a> in Oxford in the 1950s.</p>
<p>But it is notoriously difficult for governments or international organisations to control the tobacco industry. Tactics include <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673600020985/abstract">undermining anti-tobacco cancer research</a>, relying on ideas such as <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127662/">freedom or human rights</a>, appealing to social norms or drawing shocking historical parallels – which have included calling anti-smoking campaigners “<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736555/">Nicotine Nazis</a>”. </p>
<p>Then factor in the level of lobbying and persuasion of law and policy-makers, which is considerable. And the power of these companies to engage in expensive litigation tactics, which – in the case of tobacco – include <a href="http://eulaw.typepad.com/eulawblog/2006/12/tobacco_adverti.html">repeatedly</a> making the legal argument that the EU has exceeded its powers.</p>
<h2>Setting the rules</h2>
<p>The question in these recent cases was whether the EU is competent to adopt the latest <a href="http://ec.europa.eu/health/tobacco/products/revision/index_en.htm">Tobacco Products Directive</a> of 2014, which must be implemented in national law by May 20 2016. That directive revises and <a href="http://www.bbc.co.uk/news/business-36200778">tightens up</a> existing EU rules about cigarette packaging, prohibits vouchers and discounts, and strengthens health warnings. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121352/original/image-20160505-19860-1x3fffq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Candy cigarettes – whose idea was that?</span>
<span class="attribution"><span class="source">Craig Pennington</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The directive also prevents misleading words on cigarette packaging (such as “natural”, “slim” or “light”) and regulates the size of packages, banning what have been called “lipstick-style” packs of fewer than 20 cigarettes which are targeted at women and young people. It also sets rules about flavourings and additives such as menthol or cinnamon, which are used to make cigarettes more palatable – especially for young people when they first try them – and regulates e-cigarettes and other novel tobacco products.</p>
<p>The EU’s court has ruled that the EU’s powers allow it to adopt the directive. The judgment stressed that the EU must secure high levels of health protection in all its policies, including its trade law. It rejected arguments that relevant EU laws are a disproportionate paternalistic incursion on autonomy, by emphasising that the rules seek especially to protect young people. </p>
<p>The court confirmed that EU law may adopt a precautionary approach when the dangers associated with new products, such as e-cigarettes, are still <a href="http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf">being explored</a>. It also rejected arguments based on freedom of expression, including the freedom of companies to advertise, saying that these entitlements are outweighed by the “proven harmfulness of tobacco consumption”.</p>
<p>The EU court confirms that the directive does leave discretion to member states. In the UK there has been discussion about whether this includes power to adopt plain packaging (as in Australia), or standardised packaging – which was called for in the <a href="http://www.kcl.ac.uk/health/10035-tso-2901853-chantler-review-accessible.pdf">independent report</a> by Sir Cyril Chantler, and adopted by the <a href="http://www.legislation.gov.uk/ukpga/2014/6/section/94">Children and Families Act 2014</a>. </p>
<p>Note that the current UK government <a href="http://www.ft.com/cms/s/0/d44ff478-b2ff-11e2-b5a5-00144feabdc0.html#axzz47jAOoUd7">does not intend</a> to adopt plain packaging, and the question of whether it could lawfully do so was debated only as a theoretical or hypothetical one in the legal hearing.</p>
<h2>Taking on the smoking guns</h2>
<p>The EU’s track record on tobacco regulation is far from perfect from a health point of view. The imbalances of lobbying power are legendary: the WHO noted that some 20 people advocated the health policy aspects of this directive, whereas more than 160 lobbyists represented the industry. </p>
<p>In October 2012, the EU health commissioner John Dalli resigned amid allegations uncovered by the <a href="http://europa.eu/rapid/press-release_MEMO-12-788_en.htm">European Anti-Fraud Office</a> regarding links between Dalli and the tobacco industry. Dalli was unsuccessful in <a href="http://curia.europa.eu/juris/document/document.jsf?text=&docid=176865&pageIndex=0&doclang=EN&mode=lst&dir=&occ=first&part=1&cid=521888">subsequent legal claims</a> about the nature of the resignation process and the European Union’s ombudsman has <a href="http://www.ombudsman.europa.eu/en/cases/decision.faces/en/55558/html.bookmark">recommended</a> release of all pertinent documents after the conclusion of those proceedings.</p>
<p>The EU’s tobacco law has been <a href="https://books.google.co.uk/books?id=ek22CgAAQBAJ&pg=PA535&dq=Hervey+McHale+EU+Health+Law&hl=en&sa=X&ved=0ahUKEwiY9vfUn8HMAhVJCcAKHZ7LC-8Q6AEIIzAB#v=onepage&q=Hervey%20McHale%20EU%20Health%20Law&f=false">hailed</a> as a public health success story – and perhaps with some justification. From a position in which several EU countries <a href="http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/tobacco_fr_en.pdf">had no effective tobacco regulation at all</a>, by the early 1990s the EU had adopted a suite of laws on tobacco product regulation, labelling and packaging, and taxation. </p>
<p>From the 1990s onwards, EU anti-tobacco law has proceeded at a slower pace, involving a “<a href="https://books.google.co.uk/books?id=WKCsJ8-FXJUC&printsec=frontcover&dq=greer+kurzer+European+Union+public+health+policy&hl=en&sa=X&ved=0ahUKEwi5g4G3n8HMAhWIWSwKHSMmDVgQ6AEIHTAA#v=onepage&q=greer%20kurzer%20European%20Union%20public%20health%20policy&f=fal">nudging</a>” approach focused mainly on young people. There is undoubtedly more that the EU could do to stop Big Tobacco, especially as it develops new products. But the EU has been more effective than its member states acting alone. And its transparency rules mean citizens have greater abilities to track industry influence on policy than in many of its member states.</p>
<p>The example of EU tobacco regulation is important for the UK referendum. There are understandable concerns about the impacts of EU membership on health issues. But let’s look beyond the <a href="http://eulawanalysis.blogspot.co.uk/2016/04/the-nhs-ttip-and-eu-referendum.html">discussions of the NHS and TTIP</a> – important as they are. If there is political will to go further in regulating tobacco than EU law requires, our government has the discretion to do so. But EU laws provide a public health baseline, which even the tobacco industry cannot easily undermine.</p><img src="https://counter.theconversation.com/content/58941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara Hervey has received funding from the European Union, the University Association for Contemporary European Studies, the Society of Legal Scholars, the Economic and Social Research Council, Arts & Humanities Research Council, Leverhulme Trust and British Academy. She is a member of the Advisory Board for the grassroots campaigning group Healthier In the EU. The views expressed in this article are not those of the research councils.</span></em></p>Recent cases have upheld the EU’s regulation and the rights of national governments to enforce it.Tamara Hervey, Jean Monnet Professor of European Union Law, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/508712016-02-16T10:49:00Z2016-02-16T10:49:00ZCould FDA e-cigarette regulations help more people quit smoking?<p>E-cigarettes are smoking hot. They are the most <a href="http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html">popular nicotine-delivery products used by kids</a> and the <a href="http://www.cdc.gov/tobacco/basic_information/e-cigarettes/adult-trends/index.htm">majority of adult</a> smokers have tried them. E-cigarettes are a multi-billion dollar industry, with the website Yelp tallying <a href="http://qz.com/608469/what-yelp-data-tells-us-about-vaping/">more than 10,000 vape shops</a> across the country. <a href="http://www.cnbc.com/id/100991511">Wall Street analysts</a> are predicting that revenue from e-cigarettes will surpass traditional cigarettes in a decade.</p>
<p>Given the size of the enterprise, you would think there would be policies and rules in place that would assure e-cigarettes’ safe use and promote them as a tool to quit smoking. After all, the vast majority of long-time adult smokers desperately want to <a href="http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx?g_source=Quitting%2520smoking&g_medium=search&g_campaign=tiles">quit the habit</a>. While vaping is not risk-free, nearly everyone agrees that e-cigarettes are almost certainly better than smoking, if for no other reason than the fact that smoking is <em>so</em> harmful due to the tars and toxins in smoke that are created from burning the tobacco in traditional cigarettes. </p>
<p>Surprisingly, despite the size of the market and the millions of smokers (and some nonsmoking kids and former smokers) who have tried e-cigarettes, there are virtually no federal rules or regulations that govern any aspect of the industry.</p>
<p>That could change soon. Federal officials are expected to come out with a decision any day now that could give the Food and Drug Administration (FDA) authority to develop regulations. But figuring out how to regulate e-cigarettes to maximize their benefits and minimize their risks is harder than it looks.</p>
<h2>What’s at stake for cigarette smokers</h2>
<p>Cigarette smoking is the <a href="http://www.who.int/mediacentre/factsheets/fs339/en/">leading preventable cause of death</a> in the world, killing nearly 500,000 Americans and six million people around the world each year. <a href="http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm">The causes of death and chronic illness</a> include, of course, lung cancer, but also heart disease, diabetes mellitus, colorectal and pancreatic cancer and a range of medical conditions that fall under the umbrella of chronic obstructive pulmonary disease (COPD).</p>
<p>Most adult smokers took their <a href="http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm">first puff</a> of a cigarette as a teenager. And most <a href="http://dx.doi.org/10.1080/14622200412331320743">wish they had never started</a>, and consider it one of the worst decisions they have ever made. </p>
<p><a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5844a2.htm">More than half</a> of middle-age smokers have quit. Quitting can be extraordinarily hard. The average 40-year-old smoker who started in his teens will have made <a href="http://dx.doi.org/10.1111/j.1360-0443.2011.03685.x">more than 20 failed attempts to quit</a>. While there are aids to help people quit smoking, such as Nicotine Replacement Therapy (NRT) and prescription medications Chantix and Zyban, they vary widely in how well they work. There is certainly room for a more effective method. But it’s unclear whether e-cigarettes are the answer.</p>
<p>Some <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961842-5/abstract">research</a> suggests that e-cigarettes are as effective as other smoking cessation approaches. But the research is limited, and the major health and medical organizations currently <a href="http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm198176.htm#learn">do not recommend</a> e-cigarettes for cessation. A noteworthy exception is the United Kingdom, where an e-cigarette became part of the <a href="http://www.dailymail.co.uk/health/article-3348012/First-e-cigarettes-prescribed-NHS-New-Year.html">National Health Service</a> <a href="http://www.nhs.uk/Livewell/smoking/Pages/e-cigarettes.aspx">smoking cessation program</a> in January.</p>
<p>Meanwhile, U.S. smokers are being barraged by mixed messages. Vaping advocates promote e-cigarettes as a potentially life-saving product, but the industry can’t make health claims without going through an FDA review process. (And the FDA doesn’t currently have the authority to conduct such a review.) Right now we are waiting for Office of Management and Budget to approve FDA’s request to extend their current authority to cover e-cigs and other novel products.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rmx7X_uxwDg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">E-cigarettes ads.</span></figcaption>
</figure>
<p>For the first time in generations, there are <a href="http://www.tobaccofreekids.org/tobacco_unfiltered/post/2013_10_02_ecigarettes">glamorous ads on TV</a> for what appears to be smoking (but is actually vaping). One e-cigarette company even ran a “Welcome Back” marketing campaign that appeared designed to entice former smokers to start vaping, a move that could get them readdicted to nicotine and possibly on the road to smoking traditional cigarettes again.</p>
<h2>How are e-cigarettes regulated right now?</h2>
<p>The federal government has been slow to regulate the fast-evolving e-cigarette industry, but it has been trying. In 2009 the FDA attempted to have e-cigarettes regulated as a drug-device combination, which would require FDA oversight. But the courts didn’t see it that way, and in 2010 ruled that <a href="https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2009cv0771-54">e-cigarettes were tobacco products</a> and had to be regulated as such. When President Obama signed the <a href="https://www.fda.gov/tobacco-products/rules-regulations-and-guidance/family-smoking-prevention-and-tobacco-control-act-overview">Family Smoking Prevention and Tobacco Control Act</a>, it complicated things in that it allowed the FDA to regulate some tobacco products, but it did not explicitly include e-cigarettes (or hookah, cigars and cigarillos and other novel tobacco products). </p>
<p>That meant that for the FDA to regulate e-cigarettes, they had to extend or “deem” their authority to include these novel products. <a href="https://www.federalregister.gov/articles/2014/04/25/2014-09491/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the">FDA indicated their intent to do so</a> in early 2014 and received over 100,000 public comments on their proposed rules, which today are awaiting final action from the Office of Management and Budget.</p>
<p>The net effect is that there are currently no federal rules, and the e-cigarette industry is basically unfettered. The one exception is <a href="http://thehill.com/regulation/healthcare/267424-obama-signs-child-proof-packaging-standards-for-e-cigs">a new law signed by President Obama</a> in January to require childproof caps for the containers of liquid nicotine used in e-cigs. The containers had been blamed for <a href="http://www.prnewswire.com/news-releases/tobacco-free-kids-welcomes-congressional-approval-of-child-nicotine-poisoning-prevention-act-300202642.html">more than 3,700 calls to poison control centers</a> in 2014, with more than half of the cases involving children under 6. </p>
<p>Some state and local jurisdictions have stepped in to <a href="http://www.ncsl.org/research/health/alternative-nicotine-products-e-cigarettes.aspx">pass laws and policies</a> within their authority. For example, most states have passed minimum age of purchase laws, many jurisdictions call for e-cigarettes to follow the same restrictions as tobacco products in terms of where they can be used, and some states are imposing excise taxes on e-cigarettes as well.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107221/original/image-20160104-28980-1phns42.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Should e-cigarettes be treated the same as tobacco products?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-272625431/stock-photo-close-up-of-businessperson-holding-electronic-cigarette-in-hand.html?src=JyIyJVo1W2gSEuV_JRtPdA-1-6">Cigarette and e-cigarette image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Are e-cigarettes tobacco products or not?</h2>
<p>The burning question (pun intended) is whether e-cigarettes should be treated the same as tobacco products (as the courts have ruled and as the e-cig industry fears) or if they should benefit from preferential policies because they are less harmful than traditional cigarettes. </p>
<p>Creating a regulatory framework that varies by the risk of the product makes sense, but is fraught with challenges, mainly because e-cigarettes are relatively new and the science is mixed. Decisions will need to be made about whether e-cigarettes should benefit from differential tax policy, marketing regulations and, perhaps most knotty, where they can be used. Rep. Duncan Hunter, a Republican from California, tried to argue that vaping should be allowed on airplanes, <a href="http://www.cnn.com/2016/02/11/politics/duncan-hunter-vaping-congressman-plane-amendment/">dramatically blowing a cloud</a> of vapor while speaking at a Congressional hearing last week. (He lost that debate.)</p>
<p>Some argue that e-cigarettes should be used to nudge smokers away from traditional cigarettes, and that this could be achieved by having public policies differ based on the harm caused by the product. For example, e-cigarettes and other noncombustible tobacco products could be <a href="http://www.nytimes.com/2015/08/18/opinion/joe-nocera-seeing-good-in-a-tobacco-product.html">taxed at a lower level</a> and be allowed to advertise commensurate with the harm they cause. Advertising for combustible cigarettes would still be severely restricted, but e-cigarettes could be marketed like nicotine replacement therapy.</p>
<p>Some have even made the dubious suggestion that rather than increasing the minimum age of buying <a href="http://tobacco21.org/">tobacco products to 21</a> (as many jurisdictions are doing), having a different minimum age of e-cigarette sales of <a href="http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/should-16-be-age-e-cigarette-purchases">16 years of age</a> so that young people who crave nicotine can start with a less “harmful” product. </p>
<p>We don’t know all the answers, but we do know that smokers urgently need (and want) to quit smoking. The policy challenge for FDA is to have the wisdom to put in place the rules and regulations that will achieve the greatest population health benefit and result in the beginning of the end of smoking as we know it.</p><img src="https://counter.theconversation.com/content/50871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael P. Eriksen receives funding from Pfizer, Inc for tobacco control work in China. He is also the Principal Investigator on the Georgia State University Tobacco Center of Regulatory Science (grant number P50DA036128 from the National Institute on Drug Abuse and FDA Center for Tobacco Products). The content is solely the responsibility of Dr. Eriksen and does not necessarily represent the official views of the NIH or the Food and Drug Administration. </span></em></p>Federal officials could give the FDA authority to develop e-cigarette regulations. But developing regulations that maximize their benefits and minimize their risks is harder than it looks.Michael P. Eriksen, Professor and Dean, School of Public Health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482042015-10-02T17:37:25Z2015-10-02T17:37:25ZPlain cigarette packaging: healthier citizens, sicker state finances?<p>Over the last few years, a new idea for improving public health has been slowly spreading across the world: a ban on selling cigarettes in packages with custom brand designs. Instead of selling branded tobacco, all cigarettes are sold in either plain packages or packages with <a href="http://www.cbsnews.com/pictures/33-new-terrifying-tobacco-warning-labels/">grotesque pictures</a> showing the health consequences of smoking.</p>
<p>The obvious question is: is it effective at reducing smoking rates? The less obvious one: what are the economic consequences of a healthier population? </p>
<h2>Making cigarettes less appealing</h2>
<p>The ban on selling cigarettes in branded packages originated in Australia in 2012. <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/tobacco-kff">Australia’s goal</a> was to reduce smoking rates by making cigarettes less appealing and by making the health warnings more noticeable. </p>
<p>Beyond Australia, <a href="http://www.who.int/fctc/mediacentre/news/2015/ukplainpack/en/">England, Ireland</a> and <a href="http://www.3news.co.nz/world/countries-meet-to-push-plain-cigarette-packs-2015072106#axzz3nNXPXvET">many other</a> countries either have passed or are working on passing legislation to force cigarettes to be sold in plain packages. The laws have received so much attention that even television comics like John Oliver have done shows on the topic.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6UsHHOCH4q8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">John Oliver on plain packaging for cigarettes.</span></figcaption>
</figure>
<p>These laws have met with a variety of public reaction. In France, which is currently considering a plain packaging proposal, the idea is naturally very unpopular with the owners and employees of the roughly 26,000 Tabac shops that have a monopoly on selling cigarettes there. Some of the tobacconists have even taken to <a href="http://www.france24.com/en/20150720-france-tobacconists-protest-against-bill-requiring-plain-packaging-cigarettes">covering speed cameras</a> with plastic bags and dumping <a href="http://www.theguardian.com/world/2015/jul/22/french-tobacconists-dump-four-tonnes-of-carrots-on-street-in-cigarette-protest">tons of carrots</a> in the street in protest.</p>
<p>Public health officials are concerned about smoking because cigarettes kill. The Centers for Disease Control and Contagion estimates that about <a href="http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/">480,000 people</a> die each year in the US from smoking-related illnesses, and, worldwide, “current trends show that tobacco use will cause more than eight million deaths annually by 2030.”</p>
<h2>Does plain packaging help?</h2>
<p>Research into plain cigarette packaging (summarized <a href="http://bmjopen.bmj.com/content/3/7/e003175.short">here</a> and detailed <a href="http://tobaccocontrol.bmj.com/content/17/6/416.long">here</a>) suggests that the removal of branding reduces the desire to smoke. However, the <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2414430">actual impact</a> in Australia is in dispute, partly because <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/tobacco-plain">cigarette taxes were raised</a> around the same time that plain packaging was introduced.</p>
<p>This controversy aside, it remains highly likely that plain packaging does reduce the rate of cigarette smoking. Otherwise, why would the tobacco companies mount such <a href="http://www.smh.com.au/federal-politics/political-news/australia-faces-50m-legal-bill-in-cigarette-plain-packaging-fight-with-philip-morris-20150728-gim4xo.html">expensive legal battles</a> to prevent plain packaging rules from becoming law? </p>
<p>Furthermore, why would they spend so much money on advertising that makes smoking and cigarette packaging so appealing if they really thought packaging design was ineffective? And these companies must be aware of the <a href="http://www.lemonde.fr/idees/article/2015/03/30/oui-le-paquet-de-cigarettes-neutre-est-efficace-contre-la-tabagie_4605657_3232.html">studies</a> involving different population segments in different countries, all of which demonstrate the effects of plain packaging on tobacco consumption. </p>
<p>That said, while we agree that plain packaging laws will improve public health and, most importantly, save lives, we also believe there are economic consequences that merit additional attention before a country passes this legislation.</p>
<h2>Economic costs of fewer smokers</h2>
<p><em>Note: it should be emphasized that the following points in no way argue in favor of smoking (which neither of us do), nor against plain packaging laws (which we both favor). However, they do argue for further economic analysis prior to implementing these laws.</em></p>
<p>First, tobacco taxes provide governments with substantial revenue. The US federal government earns about <a href="http://www.taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=74&Topic2id=80">US$15 billion per year</a> from tobacco taxes, while state and local governments earn almost <a href="http://www.taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=403&Topic2id=80">$18 billion</a> from tobacco taxes annually.</p>
<p>Moreover, the states also receive about <a href="http://www.tobaccofreekids.org/research/factsheets/pdf/0365.pdf">$7 billion</a> annually from a 1998 lawsuit they filed against the major cigarette companies for recovery of their tobacco-related health-care costs. The money from the “Master Settlement Agreement” lawsuit was originally designed to offset Medicaid costs but has actually been used as a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021365/">“cookie jar” by most states</a> to fund all kinds of general programs.</p>
<p>Together this means if everyone in the US were to stop smoking, government health expenditures would fall as the population got healthier, but revenue would also decline by about $40 billion. </p>
<p>Because tobacco-related disease and deaths take time to develop, in the short run governments would see a substantial drop in revenue without a commensurate decrease in health care costs. Such a loss in revenue means that other taxes would have to rise, government spending would have to decrease, or the government would have to borrow more money to balance its budget.</p>
<p>Second, eliminating smoking means people <a href="http://tobaccocontrol.bmj.com/content/early/2015/08/25/tobaccocontrol-2015-052265.short?g=w_tobaccocontrol_ahead_tab">live longer</a>, with the most recent estimates being that the average 40-year-old person in the US would live about three more years. Of course, no one is arguing against living longer! </p>
<p>However, it does mean that both public pensions, like Social Security, and private pensions would require more money to support a larger elderly population. More money would presumably have to be deducted from each paycheck to ensure that pensions would be secure, which means less take-home pay for each worker.</p>
<p>Third, when people get sick and die at a relatively young age, their deaths create jobs and opportunities for career advancement. Research by <a href="http://www.econ.yale.edu/%7Egm76/occjob.pdf">Moscarini and Thomsson</a> into occupational and job mobility found a “decline from the mid-1990s onward, accelerating towards the end of our sample in 2001–2004.” </p>
<p>If this decreasing trend continues, it suggests the overall US labor market is offering fewer opportunities for advancement. As unfortunate as it sounds, improving public health by eliminating smoking would make it harder for young workers to gain experience and move up in business. In the long term, a healthier population produces a more productive, mobile and flexible workforce, but in the short term eliminating smoking is not beneficial to the labor market.</p>
<h2>Costs and benefits</h2>
<p>In sum, there appear to be clear health benefits when cigarettes are sold in blank or plain packages. At the same time, there are <a href="http://businessmacroeconomics.com/">economic</a> consequences to making that switch. </p>
<p>As already noted, we do not want the reader to finish this article with the belief that we are opposed to plain packaging laws and in favor of smoking. In fact, we both lost a dear friend to lung cancer, and one of us has <a href="http://tobaccocontrol.bmj.com/content/13/4/370.short">published research</a> in “Tobacco Control,” the leading English-language academic anti-smoking journal. </p>
<p>However, in any debate, it is important for everyone to realize that there may be unfortunate drawbacks to even the best of laws, and that these should be accounted for, literally and figuratively, before a country implements blank packaging laws.</p>
<p><em>Andy Koppel, who received a PhD in French Literature from Tufts University, co-authored this article, which was also <a href="https://theconversation.com/limpact-economique-du-paquet-de-cigarettes-neutre-47430">published in French</a>. He was vice president of technical marketing and OEM relations at North Atlantic Publishing Systems and has spent his working life helping to move the printing and publishing industry into the high-tech era. He has no affiliations, investments or connections to any tobacco companies.</em></p><img src="https://counter.theconversation.com/content/48204/count.gif" alt="The Conversation" width="1" height="1" />
France is the latest country to consider a law that would ban branded cigarette packages. How effective are they and what’s the economic cost?Jay L. Zagorsky, Economist and Research Scientist, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/473992015-09-24T09:47:02Z2015-09-24T09:47:02ZVaping as a ‘gateway’ to smoking is still more hype than hazard<p>As e-cigarettes become more popular, there has been a push to understand whether they are a “gateway” to regular, combustible cigarettes.</p>
<p>Two recent <a href="http://jama.jamanetwork.com/article.aspx?articleid=2428954">studies</a> on <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=2436539">e-cigarettes</a> as gateways to smoking in teens and young adults have made <a href="http://www.latimes.com/science/sciencenow/la-sci-sn-e-cigarettes-vape-teens-smoke-tobacco-20150908-story.html">headlines</a>. And opponents of e-cigarettes have <a href="http://www.prnewswire.com/news-releases/jama-study-raises-concerns-youth-e-cigarette-use-could-lead-to-smoking-other-tobacco-products-shows-urgent-need-for-fda-regulation-300130035.html">welcomed</a> any crude signal of gateway effects.</p>
<p>As a <a href="http://dx.doi.org/10.1016/j.drugalcdep.2015.01.001">public</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/8510191">health</a> <a href="http://dx.doi.org/10.1001/jama.1989.03420060114043">professor</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/1273212">with</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/12959791">related</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/12873242">research</a> and interests in tobacco <a href="http://dx.doi.org/10.1016/j.drugpo.2015.02.001">policy</a> as well as in the complex factors that influence use of tobacco/nicotine products, I want to offer some thoughts on this research. Looking for a gateway effect between e-cigarettes and smoking is understandable. But is it the best question to ask about e-cigarette use?</p>
<h2>The studies</h2>
<p>These studies find evidence for a small association (or limited gateway) between e-cigarette use in nonsmokers and a progression to trying cigarettes in a one-year study period.</p>
<p>The <a href="http://dx.doi.org/10.1001/jamapediatrics.2015.1742">more recent</a> of the two studies was published in September 2015 (authored by Primack et al), in JAMA Pediatrics. Researchers followed 694 12-26-year-olds for a year. None had tried cigarette smoking at the study’s start, though 16 had tried e-cigarettes. (Perhaps the worthiest headline would be that only 2% of never-smokers tried e-cigarettes.)</p>
<p>A year later, 10% of the never-triers of e-cigarettes had taken at least one puff on a cigarette. But 38% (six of 16) of e-cigarette triers had taken at least one cigarette puff. This study focused on cigarettes and reports no information on prior hookah, cigar, marijuana, alcohol or smokeless tobacco use. If even two of the 16 were discounted because of prior use of other products, these results would likely be statistically insignificant.</p>
<p>The other <a href="http://dx.doi.org/10.1001/jama.2015.8950">study</a> (authored by Leventhal et al) was published in August 2015 in JAMA. They followed 2,530 14-year-old school students for one year. None were smokers of any combustible tobacco products, including cigars, hookah and cigarettes at the start of the study, but 222 had tried e-cigarettes.</p>
<p>After 12 months, 25% of the e-cigarette triers had smoked at least one puff of a smoked tobacco product, compared to only 9% of the non-e-cigarette triers.</p>
<h2>‘At least one puff’</h2>
<p>Both studies found that young people who tried e-cigarettes were somewhat likelier to try smoked tobacco products, but that doesn’t mean e-cigarettes are a substantial gateway to regular smoking.</p>
<p>Rather than reporting usual measures of current smoking (ie, any cigarettes in the past 30 days) or daily smoking, both studies used “<a href="http://dx.doi.org/0.1001/jamapediatrics.2015.1742">at least one puff</a>” or “just a few puffs” in the past <a href="http://dx.doi.org/10.1001/jama.2015.8950">six months</a> or <a href="http://dx.doi.org/10.1001/jamapediatrics.2015.1742">lifetime</a>.</p>
<p>It is as if an apple researcher thought “taking at least one bite of an apple in the past six months” was an important measure of initiation of apple eating.</p>
<p>But, research shows that a puff on one cigarette is crudely linked with daily <a href="http://dx.doi.org/10.1093/aje/kwp179">smoking</a>. Following teenagers who had not yet puffed on a cigarette, they found that 48% took at least one puff in the 12-month follow-up period. But of those, only 20% became daily smokers.</p>
<p>Leventhal et al do acknowledge that future work needs to assess risks of “regular, frequent” smoking. Indeed, until we understand if the observed small gateway is only to experimentation or to frequent, dependent smoking, the more critical question is unanswered. In that only a subset of these observed gateway triers will move on to be regular smokers, it is almost certain that further follow-up of these samples will be unable to demonstrate a major gateway to heavy tobacco use.</p>
<p>Both studies also used a measure of “susceptibility” to smoking that is even more tenuously connected to becoming a future frequent smoker and also can be greatly <a href="http://dx.doi.org/10.1016/j.drugalcdep.2015.01.001">discounted</a> by assessing prior use of other drug products, including smokeless tobacco.</p>
<h2>The gateways that aren’t</h2>
<p>The observed gateway effects in these studies at best indicate some small increased chances of future smoking for the minority of these e-cigarette triers – not large, inexorable movement toward cigarettes for the majority. In fact, drug <a href="http://dx.doi.org/10.1016/j.drugalcdep.2011.12.018">research</a> has generally turned away from the scientific usefulness of causal drug gateway models.</p>
<p>Gateway models began in the 1950s when drug enforcement authorities warned that marijuana use caused deadly heroin <a href="http://dx.doi.org/10.1016/j.socscimed.2014.08.016">use</a>, which <a href="https://www.psychologytoday.com/blog/ending-addiction-good/201408/marijuana-the-gateway-drug-myth">has not been found</a> to be true.</p>
<p>Just as trying beer and liking it (or not) might incline one to try liquor (or not), prior use of one nicotine product can influence use of other nicotine products.</p>
<p>Drug research emphasizes so-called “<a href="http://dx.doi.org/10.1016/j.drugalcdep.2011.12.018">common liability models</a>” in which personal and contextual factors are taken into account as determinants of use or nonuse of products. While “products” themselves can influence the likelihood of using other products, it is important to consider “persons” as a factor determining <a href="https://theconversation.com/so-your-teenager-is-vaping-e-cigarettes-should-you-worry-36398">use</a>. </p>
<p>For example, if religious beliefs contribute to some teenagers not drinking alcohol, not smoking cigarettes, not using e-cigarettes, and at the same time lack of religious beliefs incline other teenagers to do these things, one would see an association between using these various products. Such an association is caused both by factors that influence nonuse of products as well as factors that influence use.</p>
<p>While these studies both attempted to different degrees to control contextual and personal factors that could be linked to smoking, this is easier said than done. The study from Leventhal et al does try to control for the use of alcohol, marijuana and smokeless tobacco (another nicotine product), but uses only one two-level measure of “any use” versus “no use” of all these products. Blunt tools lead to cruder results.</p>
<p>Science aside, gateway rhetoric has long been an important political <a href="http://dx.doi.org/10.1016/j.socscimed.2014.08.016">tool</a>. Fears that e-cigarettes are gateways to smoking are being used to justify policy or <a href="http://www.tobaccofreekids.org/press_releases/post/2015_08_18_JAMA">regulations</a>. Yet, arguments for product regulations can be made forcefully, without needing to wave the gateway flag.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95729/original/image-20150922-25763-a8e0wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many factors can lead to smoking.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-130137086/stock-photo-young-couple-with-cigarettes.html?src=V45APLXScEehjJmqedgY1g-2-55">Couple with cigarettes via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Where should research about e-cigarettes go?</h2>
<p>Let’s flip the question these studies asked. Instead of only asking whether nonsmoking e-cigarettes users move to smoking, why not explore whether higher-risk e-cigarette triers who have also tried smoked products are prevented from becoming established smokers? Such a question surely needs better than the “one puff” measures of product usage and recruitment to smoking.</p>
<p>Leventhal et al found that 75% (the large majority) of baseline e-cigarette users did not smoke at 12-month follow-up, compared to 91% of nonusers of e-cigarettes. But we don’t know how many smokers who tried e-cigarettes in these age groups were still smoking (beyond a puff) in the future. By the limited logic of the current gateway research, patterns of reduced smoking for e-cigarette users compared to smokers could be interpreted as evidence of preventive effects.</p>
<h2>What research should we be doing?</h2>
<p>The tobacco and nicotine products are often already illegal for youth to purchase. But these products are legal for adults. The focus on minor gateway effects for youth should not distract from the need to explore policy and clinical questions about harm and disease <a href="http://dx.doi.org/10.1186/s12954-015-0055-0">risk</a> <a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">from</a> adult use of legal tobacco products.</p>
<p>Cost, convenience, perceived risks (and official messages about risks) as well as personal preferences can influence which among many products are most <a href="http://dx.doi.org/10.1016/j.drugpo.2015.02.001">used</a>.</p>
<p>It is important to understand interrelationships in tobacco/nicotine product use by adolescents and adults, but both the questions and measures need to be broadened. In addition to concerns for lower-risk youth, we need to assess patterns of product use in higher-risk youth who have tried multiple drugs (alcohol, marijuana, cigarettes, cigars, smokeless tobacco and hookahs) and often have <a href="http://dx.doi.org/10.2105/AJPH.2013.301502">mental</a> health issues. We need to understand how best to prevent these youth from becoming regular users as adults of <a href="http://dx.doi.org/10.1056/NEJMsa1211128">deadly</a> smoked products.</p><img src="https://counter.theconversation.com/content/47399/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynn T Kozlowski receives funding from NIH.</span></em></p>Looking for a gateway effect between e-cigarettes and smoking is understandable. But is it the best question to ask about e-cigarette use?Lynn T. Kozlowski, Professor, Department of Community Health and Health Behavior, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/462332015-09-08T10:12:09Z2015-09-08T10:12:09ZHow to dramatically reduce smoking without banning tobacco sales<p>Last November, the Board of Health for Westminster, a town in central Massachusetts, proposed <a href="http://www.nbcnews.com/news/us-news/massachusetts-town-could-be-first-u-s-ban-all-tobacco-n246891">prohibiting all tobacco sales</a> – even e-cigarettes – in the town.</p>
<p>Westminster’s three-person Board of Health said that the proposal was meant to protect the next generation from tobacco and nicotine products. The board expressed frustration at its inability to keep up with the seemingly endless barrage of new tobacco products that appealed to minors. Ending all tobacco sales seemed like a clean and quick fix.</p>
<p>But in the face of intense opposition, Westminster’s Board of Health voted to drop the proposal. While banning tobacco sales might have protected children, many felt the proposal infringed on the <a href="https://www.bostonglobe.com/metro/2014/11/12/westminster/S9AyaVOciqpDwMRAuuNpgK/story.html">“rights” and “freedoms” of adults</a>. Some also suggested that people would simply go to other towns to buy tobacco products.</p>
<p>In proposing to ban all tobacco sales at once, Westminster’s Board of Health got ahead of itself. But there are plenty of other strategies that cities and towns can use to effectively reduce tobacco use – especially in young people – that don’t go as far as a total sales ban.</p>
<p>These measures, while aggressive, might help diffuse complaints of “prohibition” and instead keep the focus on dramatically reducing the 480,000 deaths caused each year by tobacco products. And, critically, these policies avoid the pitfalls that doomed the Westminster proposal.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93959/original/image-20150904-14636-12ovaj9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Too young?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-80907247/stock-photo-closeup-portrait-of-smoking-beautiful-young-girl.html?src=UcNNrUhPEgqcElo1ssghoA-1-16">Smoking teen via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>To protect kids, make it harder for them to buy cigarettes</h2>
<p>While tobacco sales to people under 18 are prohibited, <a href="http://www.monitoringthefuture.org/data/13data/13tobtbl2.pdf">most high school students report</a> that they have little difficulty in gaining access to cigarettes. </p>
<p>There are two policy options that would make it a whole lot harder for kids to start smoking, while not preventing adults from buying tobacco products: raise the legal buying age to 21 and restrict cigarette sales to adult-only retailers. </p>
<p>Raising the age to 21 works because high school students get tobacco primarily from friends who can legally purchase tobacco. Ninety percent of those who supply cigarettes to minors are under 21. Raising the <a href="https://theconversation.com/raising-the-minimum-buying-age-for-tobacco-could-mean-fewer-people-start-to-smoke-39036">minimum sales age to 21</a> puts legal purchasers outside the social circle of most high school students. </p>
<p>A <a href="http://tobaccocontrol.bmj.com/content/early/2015/06/12/tobaccocontrol-2014-052207.short">recent study</a> found that raising the tobacco-buying age to 21 in the Boston suburb of Needham led to a nearly 50% decline in youth smoking, a much steeper decline than was seen in surrounding communities. </p>
<p>Already, <a href="http://tobacco21.org/state-by-state/">more than 90 communities around the country</a>, including New York City and the entire state of Hawaii, have <a href="http://iom.nationalacademies.org/Reports/2015/TobaccoMinimumAgeReport.aspx">looked at the evidence</a> and decided to raise their tobacco sales age to 21. </p>
<p>Obviously this helps prevent sales to minors. But raising the tobacco buying age doesn’t shield minors from tobacco advertising. Since other avenues of tobacco advertising (TV, billboards, sports sponsorships) have been sharply limited or prohibited, tobacco companies have focused <a href="http://www.tobaccopolicycenter.org/documents/2015%20Letterhead%20marketing%20fact%20sheet%20v.2.pdf">nearly all of their advertising dollars</a> on retail stores where tobacco is sold. </p>
<p>In effect, the tobacco industry has used marketing contracts with retailers to transform the <a href="http://cphss.wustl.edu/Products/Documents/ASPiRE_2014_ReportToTheNation.pdf">nearly 400,000 retail stores</a> around the country that sell tobacco products into <a href="http://www.tobaccopolicycenter.org/documents/(d)TK_Recruitment.pdf">recruitment centers for new tobacco users</a>. And numerous studies confirm that the more time youth spend in convenience stores (70% visit them at least once a week), <a href="http://www.tobaccopolicycenter.org/documents/%2528c%2529%2520TK_Numbers_final.pdf">the more likely they are to smoke</a>.</p>
<p>Limiting tobacco sales to retail locations that only adults are permitted to enter would remove this barrage of tobacco advertising from the convenience stores where teens spend a significant amount of time. It would also make it easier to prevent minors from purchasing cigarettes. </p>
<p>This is not a radical strategy; it’s similar to how liquor sales are currently regulated in most states. Ideally, limiting cigarette sales to adult-only retail outlets would be done in conjunction with raising the minimum buying age for tobacco from 18 to 21. </p>
<p>These policies wouldn’t prevent adults from purchasing tobacco, but they would help keep youth from taking up smoking (while also making it easier for current smokers to quit). </p>
<h2>Focus on the most dangerous tobacco products</h2>
<p>Westminster’s Board of Health proposal to ban the sale of all tobacco products also included e-cigarettes, which contain nicotine derived from tobacco. This struck many as radical and unwarranted. </p>
<p>The <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1314942">vast majority</a> of all tobacco related deaths result from the use of only one particular product: the cigarette. </p>
<p>People use tobacco products primarily because nicotine is addictive. Nicotine itself is not benign, but on its own it’s much less harmful than the smoke and tar produced by burning tobacco. E-cigarettes and other vaporized nicotine products are almost certainly <a href="http://tobaccocontrol.bmj.com/content/early/2013/03/05/tobaccocontrol-2012-050859.abstract">less toxic and less harmful</a> when used <em>instead of</em> conventional cigarettes.</p>
<p>A bold yet more incremental step would be to allow the sale of potentially less harmful products, like e-cigarettes, while sharply limiting sales of conventional cigarettes and other combusted products. This might take the form of exempting e-cigarettes from the adult-only retailer policies described. Or, potentially, a community might consider prohibiting <em>all</em> cigarette sales, while allowing sales of non-combustible products. </p>
<p>If cigarettes were harder to come by, the “harm reduction” potential of e-cigarettes would be much more likely realized. <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">As summarized by the Surgeon General</a>: </p>
<blockquote>
<p>The impact of noncombustible [e-cigarettes] on population health is much more likely to be beneficial in an environment where the appeal, accessibility, promotion, and use of cigarettes and other combusted tobacco products are being rapidly reduced, especially among youth and young adults.</p>
</blockquote>
<p>But the evidence to date indicates that e-cigarettes are primarily being used <a href="http://circ.ahajournals.org/content/129/19/1972.full">along with cigarettes</a>, rather than instead of them. In addition, use of e-cigarettes by youth, which is rapidly expanding, puts these youth in danger of “graduating” to cigarette use. </p>
<p>A <a href="http://jama.jamanetwork.com/article.aspx?articleid=2428954">recently published study</a> found that adolescents who had used e-cigarettes were more than twice as likely as their peers to subsequently start smoking. Making it harder for adolescents to obtain cigarettes would help reduce the likelihood that minors using e-cigarettes move on to smoking.</p>
<h2>Get community support before acting</h2>
<p>The most important lesson of Westminster’s experience may be that policymakers cannot get too far ahead of their communities. As public health law scholar Wendy Parmet <a href="http://connecticutlawreview.org/files/2014/11/2.Parmet.pdf">recently wrote</a>:</p>
<blockquote>
<p>Public health laws that are strongly rooted in, and indeed arise from, the public, may face a quite different fate than those that derive from the good intentions of public health policymakers alone.</p>
</blockquote>
<p>Rather than announce a plan to ban the sale of all tobacco products, the Westminster board of health could have instead started a series of community discussions about the problem of tobacco use – and youth tobacco use in particular. </p>
<p>It is likely that such discussions would have quickly produced broad consensus about the need to better protect youth from tobacco, which could have then led to a discussion about potential policy solutions (such as those discussed above).</p>
<p>It is also notable that some of the loudest critics of the proposed Westminster law were proponents (and users of) e-cigarettes, many of whom struggled for years to quit cigarettes. Including this community in early discussions could have led to a shared vision about how to minimize the dangers of e-cigarettes while focusing on the much more significant harms caused by cigarettes.</p>
<p>Making sustainable public health policy requires the slow but important processes of community engagement, education, compromise, and consensus building. With deliberate and incremental steps to reduce the prevalence of tobacco in our communities, we can save countless lives.</p><img src="https://counter.theconversation.com/content/46233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Micah Berman receives funding from the US Food and Drug Administration and the National Institutes of Health. The work discussed in this article were not supported by any funding, and the views expressed are his own.</span></em></p>There are plenty of strategies to reduce tobacco use – especially in young people – that don’t go as far as a total sales ban.Micah Berman, Assistant Professor of Public Health and Law, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/425492015-06-18T20:10:51Z2015-06-18T20:10:51ZNext step for tobacco control? Make cigarettes less palatable<figure><img src="https://images.theconversation.com/files/85518/original/image-20150618-23239-i8uepw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smokers respond to more filtered or more diluted cigarettes by taking bigger puffs and more of them. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-287436329/stock-photo-man-smoking-cigarette.html?src=M2GZNSHi9c62ORDzzBzwVw-1-19">Pe3k/F/Shutterstock</a></span></figcaption></figure><p>Australia has been a world leader in tobacco control. We were the first to introduce <a href="https://www.cancervic.org.au/plainfacts/">plain cigarette packaging</a> in 2012. </p>
<p>We were also one of the early jurisdictions to <a href="https://www.accc.gov.au/media-release/accc-resolves-light-and-mild-cigarette-issue-with-bat-and-philip-morris">ban</a> “light” or “mild” labelling on packs in 2005 and to remove tar, nicotine and carbon monoxide labelling on packs in 2006. Those steps were taken after it had become clear so-called “low tar” cigarettes were not less harmful.</p>
<p>The problem is these tobacco control measures stop outside of the pack, while the cigarettes inside <a href="http://www.tobaccoinaustralia.org.au/downloads/chapters/ch12_tobacco.pdf">remain</a> essentially the same. A logical next step is to regulate how companies engineer cigarettes to promote their use. </p>
<h2>Why regulate cigarettes?</h2>
<p>Taking regulation inside the packs to control cigarettes themselves can potentially achieve three broad aims. </p>
<p>The first is to reduce the <a href="http://tobaccocontrol.bmj.com/content/17/2/132.full.pdf+html">doses</a> of cancer-causing agents and other toxins received per cigarette. Regulators would first need to identify those harmful substances in tobacco smoke that can be reduced and then mandate reductions to specific harmful substances. If achieved, this would reduce the harms for current smokers, to some degree, especially long-termers who are unlikely to quit. </p>
<p>The second is to reduce their addictiveness, by controlling the doses of nicotine available to smokers. Getting the right dose of nicotine at the right dose rate is <a href="http://www.wisebrain.org/media/Papers/NeurobiologyofNicotineAddictionImplicationsfor.pdf">what gives smokers</a> that little buzz of enjoyment they seek but it is also precisely what makes smoking addictive. Addictiveness drives long-term smoking so reducing nicotine availability would also mean reducing harm at a population level, as more people successfully quit.</p>
<p>The third – and often overlooked – aim is to reduce the attractiveness or palatability of cigarettes to particular user groups separately from reducing nicotine availability. This means limiting the range of flavour varieties and flavour strengths available, as well as the tobacco industry’s ability to create impressions of reduced harmfulness. </p>
<p>Such restrictions would make it harder for teenagers experimenting with smoking to transition to being regular smokers and make it harder for long-term smokers to avoid thinking about the harmfulness of smoking. </p>
<h2>Less harmful? Not quite</h2>
<p>In 2006, Australia <a href="http://tobaccocontrol.bmj.com/content/12/suppl_3/iii61.full.pdf">ended</a> on-pack labelling of tar, nicotine and carbon monoxide yield figures, after having adopted it by voluntary agreement with the tobacco industry in 1981. </p>
<p>Tar, nicotine and carbon monoxide yield figures were a key part of the failed “low tar” harm-reduction system. The cigarettes labelled “light” or “mild” had reassuringly low tar, nicotine and carbon monoxide figures printed on the side of the pack and many smokers believed these cigarettes were less harmful. </p>
<p>Those cigarettes also had sensory <a href="http://cdrwww.who.int/fctc/guidelines/ArtElevenKozlowskiFive.pdf">characteristics</a> that are appealing to many smokers: less flavour strength, less “impact” or “catch” in the throat, and less lingering irritation on the throat and chest after smoking.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/85520/original/image-20150618-23223-een8oa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The terms light and mild have been replaced with smooth and fine.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/pyxopotamus/3565505580/in/photolist-6r59A9-r2BA4F-6qZXmP-6qZY9i-q5MjbX-6r5akJ-CJ1T3-6TdKFU-edfMM-d8aEj-e3nAp2-9Afpv-9AiV1-7ve4se-9AiUZ-6Kyhku-aiVm1g-q5yGFy-29zNZ-4fGnid-4JkCry-9kimqC-qWjjFQ-6r2SdV-6S1DDQ-6r5a7f-4WsVp2-bU9Pj4-b2Q3qe-Bsyws-6r5awC-8XEAjv-4QXydP-jCApZ-8v8nn8-cMot7-6UGbM1-84UUgx-mhhEjc-mhirmz-fteXc8-GzFUT-7PWVzm-5azjs9-6hDjoZ-3akKT7-3akKYs-efz9F-qfgU1S-a8mwyi">me and the sysop/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Getting those figures off packs was an important step, once it became established they told smokers nothing about their actual intakes of harmful smoke constituents. But the “low tar” deception is part of a bigger problem of differences between cigarettes that smokers latch onto as evidence that some of them are less harmful. </p>
<p>After banning the <a href="https://www.accc.gov.au/media-release/accc-resolves-light-and-mild-cigarette-issue-with-bat-and-philip-morris">terms</a> “light” or “mild” in 2006, our tobacco industry simply replaced them, using “smooth” and “fine” as the new <a href="http://tobaccocontrol.bmj.com/content/14/3/214.extract">code words</a>. Each major brand family still has six or seven varieties, ranging from “original”, through “smooth” and “fine”, to “ultimate” – and that’s without counting the menthol varieties. </p>
<p>Smokers still select the taste strength and harshness level that best suits them, then can fine tune further by unconsciously <a href="http://cdrwww.who.int/fctc/guidelines/ArtElevenKozlowskiFive.pdf">adjusting</a> how they puff. </p>
<h2>Regulating filters</h2>
<p>It’s time for the government to ban filter ventilation to reduce the palatability of cigarettes. The government should regulate filters, specifying the sizes and designs that are permissible.</p>
<p>Since the 1960s, tobacco companies have used two engineering features to reduce the unpleasant sensations of smoking on the throat. Larger filters and tiny holes in the filter tipping paper called “filter vents” introduce fresh air into each puff and make smoking easier on the throat. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84046/original/image-20150605-14125-12612jn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Filter vents.</span>
<span class="attribution"><span class="source">Bill King</span></span>
</figcaption>
</figure>
<p>But smokers compensate for this. Smokers seek constant nicotine doses of around one milligram per cigarette. They respond to more filtered or more diluted cigarettes by taking bigger puffs and more of them. </p>
<p>There is <a href="http://chinancd.cn/contents/pdf/incomplete%20compensation%20does%20not%20imply%20reduced%20harm.pdf">evidence</a> that increasing filtration efficiency decreases smokers’ exposures to just a few carcinogens (a group called semi-volatiles) but increases their exposures to most of the <a href="http://www.ncbi.nlm.nih.gov/pubmed/17654296">harmful smoke components</a> in the vapour phase of tobacco smoke. (The vapour phase passes straight through standard cigarette filters.)</p>
<p>There is also <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">evidence</a> that filter ventilation increases smokers’ exposures to a range of carcinogens by encouraging them to take more puffs from each cigarette, which are effectively smaller at the burning end of the cigarette (meaning more products of incomplete combustion). </p>
<p>Filter ventilation is also likely to contribute to smoke particles penetrating deeper into the lungs.</p>
<p>This evidence thoroughly undercuts any “we might make things worse by meddling” justifications for not acting to regulate the engineering of cigarettes. </p>
<h2>Regulating additives</h2>
<p>The government should also ban the use of all but a very limited number of <a href="http://www.who.int/tobacco/industry/product_regulation/factsheetingredients/en/">additives</a> in cigarettes. Sugars, honey, cocoa, liquorice and spices are <a href="http://www.tobaccoinaustralia.org.au/downloads/chapters/ch12_tobacco.pdf">added to cigarettes</a> to add the right “flavour notes”, cover unpleasant ones and also reduce other unpleasant sensations. </p>
<p>Additives provide the secondary means for the Australian tobacco industry to fine tune the sensory characteristics of cigarettes, making them easier to use and harder to quit. </p>
<p>Canada and Brazil have <a href="http://www.who.int/tobacco/industry/product_regulation/factsheetingredients/en/">already taken the lead</a> internationally by banning most additives, although Brazil unfortunately left sugars off the list. Canada exempted menthol cigarettes, but that might change soon, with Manitoba introducing a province-wide ban. </p>
<p>If Australia could set the strongest example so far by comprehensively regulating both of the industry’s tools for optimising the sensory characteristics of cigarettes – filters and additives – the benefits to public health would be substantial and we would once again be at the forefront of tobacco control.</p><img src="https://counter.theconversation.com/content/42549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill King is currently funded by a tobacco harm reduction research grant from the Victorian Health Promotion Foundation. His salary has previously been supported by grants and consultancies to research teams at the Cancer Council from the Australian National Health and Medical Research Council (NHMRC), US National Institutes of Health (NIH), Australian Competition and Consumer Commission and Australian Department of Health and Ageing. Bill King conducted research for the ACCC investigation into lights and milds. Their report to the ACCC is confidential.</span></em></p>Past tobacco control measures have changed the pack, while the cigarettes inside remain the same. A logical next step is to regulate how companies engineer cigarettes to promote their use.Bill King, Senior research officer, Cancer Council VictoriaLicensed as Creative Commons – attribution, no derivatives.