Comment: Pragmatism on nicotine could save lives

Encouraging safer alternatives to smoking can help end epidemic

The regulation of tobacco and nicotine products has become less straightforward. Historically, high taxation and restrictions were aimed at achieving total nicotine abstinence. But product innovation now means that there are increasing numbers of products that allow users to satisfy their need for nicotine at a fraction of the risk.

The stakes are extraordinarily high. There are well over a billion smokers globally, spending roughly $700bn a year on the cigarettes that are currently killing over 6m of them annually. This death toll and the associated economic costs are expected to continue to climb long into the future without a fundamental change in current trends in consumption.

From a pragmatic public health perspective, solving the problem should be easy. The deaths are almost entirely due to consumers getting nicotine from the deadly delivery system of inhaling smoke from burning tobacco. Yet nicotine at the dosage levels smokers seek is not particularly harmful on its own.

Great numbers of smokers are already keen to reduce risks, and are ready to try the emerging alternatives such as vaping products, various forms of smokeless tobacco, medicinal nicotine and products that heat, rather than burn, tobacco. But regulation has failed to adapt to these new possibilities. A mix of marketing restrictions, smoking bans, health warnings and tax increases are aimed at stopping people from starting to smoke, getting them to quit and protecting others from second-hand smoke.

Reducing risks by helping smokers switch to less hazardous products has been opposed rather than endorsed, with regulation serving to restrict alternatives to cigarettes. The push to ban potentially less hazardous alternatives to cigarettes, or to put them at a marketplace disadvantage, has largely come from anti-tobacco organisations that fear such products might perpetuate nicotine use and further enrich tobacco companies.

The resulting scenario has thrown up modern-day alliances as odd as the coalition of “bootleggers and Baptists” that propped up the failed anti-alcohol policies of the US in the Prohibition era. For instance, anti-tobacco groups focused on nicotine abstinence co-operated with Altria, which sells over half the cigarettes in the US, to enact stringent controls on less hazardous alternatives to cigarettes by the US Food and Drug Administration.

In this area, the UK has been an outlier. Organisations including the Royal College of Physicians, a professional body, Public Health England, representing the UK government, and Action on Smoking and Health (ASH), an antismoking lobby group, have lined up to promote switching to vapour products, which they acknowledge to be far less hazardous than smoking.

In being open to the benefits rather than just the risks of vaping and other nicotine products, the UK is adhering much more closely to a rational template of health regulation by offering cigarette smokers a viable alternative to total nicotine abstinence. By doing so, it might move more quickly towards ensuring cigarette smoking follows in the path of other unreasonably hazardous activities that now fill history books rather than hospital wards.

David Sweanor is an adjunct professor of law at the University of Ottawa who helped develop tobacco-control laws in Canada and other countries

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