Institute of Medicine Report: Ending the Tobacco Problem (2)

The main problem with a 400-page report is that few have the time or inclination to read it all. So let me summarize what I thought were some of the interesting points relevant to smoking cessation.

The main section on smoking cessation in chapter 2 provided some interesting facts. Of the 45 million smokers in the US in 2004, 41% (15 million) tried to quit in the previous 12 months. Of smokers trying to quit on their own, between two-thirds and three quarters relapse within 2 weeks. Of all those trying to quit, only around 2% remain quit long term after each quit attempt. One of the studies mentioned in the report asked smokers in four countries if they agreed with the statement, “If you had to do it over again, you would not start smoking”. 90% of smokers agreed, indicating near unanimous regret among smokers for having ever started. Recent data from the United States suggests that teen smokers already regret having started. 61% say they want to quit and 59% made a quit attempt in the past 12 months.

It is this kind of evidence on tobacco addiction, together with the fact that 90% of smokers initiate smoking as children (i.e. before age 18), that helped the Committee on Reducing Tobacco Use conclude that an assertive and perhaps even paternalistic approach to tobacco control is appropriate. One alternative perspective, often proposed by the tobacco industry, is that it’s a legal product and adults have the right to chose whether or not to use it, based on awareness of the risks. The committee took the view that as most smokers became addicted as children, as the risks are so extremely large and as they are frequently not well understood by consumers, it is appropriate to implement a wide range of policies that would lead to a large reduction in tobacco consumption.

One of the more radical strategies discussed in the report was a mandated gradual reduction in the amount of nicotine in and delivered by, all cigarettes. This would require a reduction from around 10-15mg of nicotine IN each cigarette to around 0.5mg IN each cigarette. This roughly corresponds to a reduction from around 1 – 1.5 mg nicotine absorbed per cigarette now, to around 0.05 mg nicotine absorbed per cigarette (i.e. less than a twentieth of the current amount). It was suggested that this may occur over a period of 10-15 years so as to allow smokers the opportunity to get used to the changes. I think it is entirely plausible that cigarettes containing only 0.5mg nicotine and delivering only 0.05mg would no longer be addictive. However, I am concerned that the proponents of this strategy may have underestimated the consumers’ response to these changes.

We would all hope that if this strategy were implemented, smokers would gradually feel they are getting less satisfaction from their cigarettes, and would choose to quit completely. Similarly we would hope that young people who try those minimal nicotine delivery cigarettes would get so little nicotine from them that they would not become addicted. The report acknowledges some of the potential unintended effects but may have missed some. It is widely accepted that during the early part of a nicotine reduction strategy, existing smokers would likely inhale more smoke per cigarette in order to try to get more nicotine. If the nicotine reduction strategy took 15 years, the idea of smokers inhaling MORE smoke throughout that time is a serious problem. There must also be a concern that organized crime would see this as a perfect opportunity to continue to make money by selling off imported (smuggled) high nicotine cigarettes. Then there’s the difficulty of enforcing this type of regulation. How would a policeman, seeing someone smoke a cigarette, determine if it was a new ultra-low nicotine cigarette or an illegally imported normal medium nicotine cigarette? It is also unclear whether this reduced nicotine strategy would apply to tobacco products other than cigarettes, such as cigars, pipe tobacco, roll-your-own loose tobacco, bidis, kreteks or smokeless tobacco? If not, then what’s to stop the nicotine addict from switching from cigarettes to another nicotine delivery product, some of which (all the smoked varieties) would likely be at least as harmful as cigarettes?

So I think the report was correct to suggest that this strategy needs careful consideration, but it could have suggested some other potential strategies (e.g. gradually reducing the toxicity of the smoke delivered by cigarettes, over 10 years, down to the point where cigarettes and other burned forms of tobacco are no longer permissible).

The full report, and various summaries are available online for free at:http://books.nap.edu/catalog.php?record_id=11795

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