David Sweanor . It's smoking that kills
My fellow anti-smoking advocates have taken their eyes off the ball with their fierce opposition to a new smokeless tobacco product
David Sweanor, Ottawa Citizen Special
Published: Thursday, January 31, 2008
Imperial Tobacco has recently started a test market of a non-combustible tobacco product in Ottawa called "snus." As befits any action by a company responsible for untold thousands of cigarette-caused deaths and a decades-long history of denying science and fighting public health measures, the immediate reaction of some anti-tobacco groups was to attack the initiative. Though that is the expected response, it may not be the wisest one.
There is no doubt that cigarette smoking is an enormous cause of death and disease, responsible as it is for more than 40,000 deaths a year in Canada. Smoking dwarfs the combined death toll from AIDS, illicit drugs, alcohol, homicide and automobile accidents. Yet it is important to recognize that the reason for this tragic toll is not the nicotine that smokers seek but the repeated inhalation of smoke into the lungs in pursuit of it. Smokers smoke for the nicotine, but die from the smoke. Cigarettes can be accurately seen as a "dirty drug delivery system" akin to HIV-infected needles or an alcoholic beverage contaminated with diethylene glycol.
Many of those working to reduce the risks of illicit drugs - as has recently received considerable attention in Ottawa with respect to users of crack cocaine - promote "harm reduction" as one of the key tools to reduce the health toll from drug use. Harm reduction efforts have a long and successful history in many other areas, including highway design, auto safety standards, alcohol regulations, pharmaceutical oversight, food preparation standards and sex education. Pragmatic efforts to improve the health of a population recognize that there are many risky behaviours that will not be eliminated in the foreseeable future. But we can often dramatically reduce the deaths, injuries and diseases caused by such behaviours by finding ways to reduce the associated risks - even as we pursue strategies to completely eliminate the behaviour.
In the case of nicotine self-administration, the continuum of risk is extraordinarily broad. It ranges from the 50-per-cent mortality rate associated with long-term smoking to the massively lower risks from medicinal nicotine products such as Nicorette gum. Indeed, the greatest risk associated with medicinal nicotine products is that smokers will use too little for too short a period of time and thus revert to smoking. While nicotine itself has health risks (and fetal risks are worth noting), at the dosage levels smokers seek these risks are comparable to those associated with caffeine rather than those associated with cigarette smoking.
By way of comparison for tobacco products, the cigarettes Imperial Tobacco sells are at least 10 times, and likely closer to 100 times, more toxic than the non-combustion "snus" product the company is now placing into test markets. Odd, then, that some self-described public health advocates would attack the availability of the less toxic alternative. To follow such a line of reasoning would suggest that we mandate the addition of yet more toxins to cigarettes. After all, if much less toxic products are a bad idea, then much more toxic ones must be a good idea.
here is a more sensible strategy. For smokers who would otherwise not quit and can switch completely to the snus products of Imperial Tobacco, the health gains (including to those sharing air space with the consumer) are significant. Anti-tobacco organizations or tobacco companies that fail to fully inform smokers about such an option are engaged in a fundamental denial of human rights, and the perpetuation of our epidemic of smoking-caused diseases.
In reality, though, most smokers are unlikely be making the switch to Imperial Tobacco's snus, and that is actually where the snus products are likely even more important. Such products are, like the prototype safer car built by Preston Tucker in 1948, an example of "proof of concept." Such a product shows that it is possible to have a far less dangerous product. This should leave us only questions about which alternative products should be offered and how we might best regulate the market to ensure maximum health gains.
Few smokers are currently aware that it is possible to obtain their nicotine at a fraction of the risk they currently face. Were Canadians to become aware of this, there would undoubtedly be demands that tobacco products be regulated in a way that sought maximum reduction in these risks, as there would be for consumer-centric regulation of medicinal nicotine products. If people could meet their long-term needs for nicotine through snus, or through gum, patches, lozenges, inhalers (or who-knows-what new products), why are such options denied to them?
Canada currently is the victim of a "nicotine maintenance monopoly." More than five million of our fellow citizens are only allowed to satisfy their long-term nicotine demand by use of a product that will kill half of them, reduce the quality of life for most of the rest, pollutes the air for all of us and causes users to be unwilling role models for kids.
When dealing with any cause of death, injury or disease, we have four broad areas of intervention: We can try to prevent onset of the behaviour, encourage cessation among those already engaging in it, protect third parties from any associated risks, and reduce the risks for those who will continue the behaviour. This applies whether we are talking about rock climbing, crack smoking, motorcycle riding, drinking to excess, playing goal for house league hockey or ingesting nicotine. The way we use these four broad avenues of intervention will vary, but the goal is always the same: the maximum practical reduction in the risk of harm.
Rather than attacking Imperial Tobacco for introducing a much less toxic alternative to cigarettes maybe we should welcome the opportunity to discuss a rational, health-based regulatory approach for the full range of nicotine delivery products. If in the end there is a better recognition of the limitations of a "just say no" approach to tobacco and nicotine, so much the better.We need to show greater compassion for smokers. We need to offer them far more help to quit and a wider range of less toxic options for those not yet ready, willing and able to quit. We need to provide truthful and non-misleading information about relative risks, and allow consumers to make informed decisions.
Were we to do so, we could have far, far fewer Canadians smoking cigarettes. That would create a public health breakthrough of historic proportions. Such a breakthrough would not stop efforts at reducing overall nicotine use, but, even for those with zero-tolerance for any form of nicotine use, the first step should be to keep the users alive long enough for other interventions to work.
David Sweanor is an adjunct professor of law at the University of Ottawa and special lecturer with the School of Community Health Sciences at the University of Nottingham.
My fellow anti-smoking advocates have taken their eyes off the ball with their fierce opposition to a new smokeless tobacco product
David Sweanor, Ottawa Citizen Special
Published: Thursday, January 31, 2008
Imperial Tobacco has recently started a test market of a non-combustible tobacco product in Ottawa called "snus." As befits any action by a company responsible for untold thousands of cigarette-caused deaths and a decades-long history of denying science and fighting public health measures, the immediate reaction of some anti-tobacco groups was to attack the initiative. Though that is the expected response, it may not be the wisest one.
There is no doubt that cigarette smoking is an enormous cause of death and disease, responsible as it is for more than 40,000 deaths a year in Canada. Smoking dwarfs the combined death toll from AIDS, illicit drugs, alcohol, homicide and automobile accidents. Yet it is important to recognize that the reason for this tragic toll is not the nicotine that smokers seek but the repeated inhalation of smoke into the lungs in pursuit of it. Smokers smoke for the nicotine, but die from the smoke. Cigarettes can be accurately seen as a "dirty drug delivery system" akin to HIV-infected needles or an alcoholic beverage contaminated with diethylene glycol.
Many of those working to reduce the risks of illicit drugs - as has recently received considerable attention in Ottawa with respect to users of crack cocaine - promote "harm reduction" as one of the key tools to reduce the health toll from drug use. Harm reduction efforts have a long and successful history in many other areas, including highway design, auto safety standards, alcohol regulations, pharmaceutical oversight, food preparation standards and sex education. Pragmatic efforts to improve the health of a population recognize that there are many risky behaviours that will not be eliminated in the foreseeable future. But we can often dramatically reduce the deaths, injuries and diseases caused by such behaviours by finding ways to reduce the associated risks - even as we pursue strategies to completely eliminate the behaviour.
In the case of nicotine self-administration, the continuum of risk is extraordinarily broad. It ranges from the 50-per-cent mortality rate associated with long-term smoking to the massively lower risks from medicinal nicotine products such as Nicorette gum. Indeed, the greatest risk associated with medicinal nicotine products is that smokers will use too little for too short a period of time and thus revert to smoking. While nicotine itself has health risks (and fetal risks are worth noting), at the dosage levels smokers seek these risks are comparable to those associated with caffeine rather than those associated with cigarette smoking.
By way of comparison for tobacco products, the cigarettes Imperial Tobacco sells are at least 10 times, and likely closer to 100 times, more toxic than the non-combustion "snus" product the company is now placing into test markets. Odd, then, that some self-described public health advocates would attack the availability of the less toxic alternative. To follow such a line of reasoning would suggest that we mandate the addition of yet more toxins to cigarettes. After all, if much less toxic products are a bad idea, then much more toxic ones must be a good idea.
here is a more sensible strategy. For smokers who would otherwise not quit and can switch completely to the snus products of Imperial Tobacco, the health gains (including to those sharing air space with the consumer) are significant. Anti-tobacco organizations or tobacco companies that fail to fully inform smokers about such an option are engaged in a fundamental denial of human rights, and the perpetuation of our epidemic of smoking-caused diseases.
In reality, though, most smokers are unlikely be making the switch to Imperial Tobacco's snus, and that is actually where the snus products are likely even more important. Such products are, like the prototype safer car built by Preston Tucker in 1948, an example of "proof of concept." Such a product shows that it is possible to have a far less dangerous product. This should leave us only questions about which alternative products should be offered and how we might best regulate the market to ensure maximum health gains.
Few smokers are currently aware that it is possible to obtain their nicotine at a fraction of the risk they currently face. Were Canadians to become aware of this, there would undoubtedly be demands that tobacco products be regulated in a way that sought maximum reduction in these risks, as there would be for consumer-centric regulation of medicinal nicotine products. If people could meet their long-term needs for nicotine through snus, or through gum, patches, lozenges, inhalers (or who-knows-what new products), why are such options denied to them?
Canada currently is the victim of a "nicotine maintenance monopoly." More than five million of our fellow citizens are only allowed to satisfy their long-term nicotine demand by use of a product that will kill half of them, reduce the quality of life for most of the rest, pollutes the air for all of us and causes users to be unwilling role models for kids.
When dealing with any cause of death, injury or disease, we have four broad areas of intervention: We can try to prevent onset of the behaviour, encourage cessation among those already engaging in it, protect third parties from any associated risks, and reduce the risks for those who will continue the behaviour. This applies whether we are talking about rock climbing, crack smoking, motorcycle riding, drinking to excess, playing goal for house league hockey or ingesting nicotine. The way we use these four broad avenues of intervention will vary, but the goal is always the same: the maximum practical reduction in the risk of harm.
Rather than attacking Imperial Tobacco for introducing a much less toxic alternative to cigarettes maybe we should welcome the opportunity to discuss a rational, health-based regulatory approach for the full range of nicotine delivery products. If in the end there is a better recognition of the limitations of a "just say no" approach to tobacco and nicotine, so much the better.We need to show greater compassion for smokers. We need to offer them far more help to quit and a wider range of less toxic options for those not yet ready, willing and able to quit. We need to provide truthful and non-misleading information about relative risks, and allow consumers to make informed decisions.
Were we to do so, we could have far, far fewer Canadians smoking cigarettes. That would create a public health breakthrough of historic proportions. Such a breakthrough would not stop efforts at reducing overall nicotine use, but, even for those with zero-tolerance for any form of nicotine use, the first step should be to keep the users alive long enough for other interventions to work.
David Sweanor is an adjunct professor of law at the University of Ottawa and special lecturer with the School of Community Health Sciences at the University of Nottingham.
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