Time to change attitudes to tobacco: product regulation over five years?

Deaths from tobacco are estimated to rise to 10 million annually by 2030 [1] unless radical change occurs in the prevalence of tobacco use, the nature of tobacco used and the availability of other sources of nicotine. Prevalence reduction works, albeit slowly, and cessation techniques are badly underused. If progress is to be speeded up everything possible has to be done, and this necessarily includes harm reduction as well as acceleration of cessation activities and prevention of initiation. Radical change will not occur unless the public health establishment and governments stop tiptoeing around the tobacco industry and change their attitudes to it. The mistake we make is to treat the tobacco industry as a legitimate commercial enterprise when it is, and should be treated as, a drug manufacturer. Changing this mindset brings into play a large number of possibilities in the way of regulatory control of the product itself, of the emissions when smoked, of the way it is marketed and—most important of all—of the nicotine content and chemistry affecting it. The pharmaceutical industry is regulated in this way and provides many models for the future of tobacco. It should be understood that, once the concept of regulation of the product is accepted, we are on the road towards a policy of harm reduction in terms of reducing the carcinogenicity and toxicity of tobacco, for the simple reason that a regulator would be guilty of negligence if unnecessary levels of toxins and carcinogens (toxicants) were to be permitted. A great deal has been written about product regulation, but it is time to address specifics and look at what could be dealt with in a time-frame of 5 years. • A first, and practical, priority is the setting of upper limits to toxicants in cigarette smoke based on levels already shown to be achievable as demonstrated by survey of the market [2]. Such a step requires review of the present measuring system for cigarette smoke constituents, which is generally regarded as misleading [3]. The Canadian 'intense' system, which abolishes the effect of filter ventilation by taping over the filter, and takes larger (55 ml versus 35 ml) and more frequent (every 30 sec versus 60 sec) puffs than the Federal Trade Commission (FTC) system currently uses, is suitable for comparison between brands and for regulatory purposes. Upper limits for toxicants can be set at levels not much above current market minimum levels [4]. This process has a precedent in the control of automobile exhausts. Filter ventilation can, and should, be forbidden [5]. The outcome should be a less carcinogenic cigarette, although it is less certain (given our present knowledge) that there would be beneficial effects on heart disease or obstructive lung disease. • An ongoing monitoring process would be needed to oversee this. Monitoring not only of cigarette emissions but of usage patterns, quit rates and both public health and industry communication practices. Monitoring needs to be national and, in large populations, regional. If tobacco is to be regulated like a pharmaceutical drug there are existing authorities with experience in many countries. • The second big issue is control of nicotine delivery by the cigarette and consideration of policies which would allow competitive non-tobacco nicotine delivery systems. This means promoting the development and marketing of nicotine replacement therapies delivering a more cigarette-like 'fix' for the user. This idea is controversial, as many are solidly opposed to addictive products being marketed more freely. However, our present position is bizarre—the carcinogenic (tobacco) nicotine delivery system is marketed ubiquitously and freely while nicotine replacement therapy (NRT) is frequently restricted, as well as being heavily regulated to the point of being uncompetitive. One reason pharmaceutical companies have not attempted to provide addictive NRT is fear of regulatory refusal. This is unsurprising, but can be changed by political decision. • The other component of nicotine regulation involves restriction of additives which facilitate nicotine addiction, such as ammonia and sugars [6]. Further, the question of reduction over time in the addictiveness of the cigarette [7] obviously demands consideration but will require a longer time-frame. In essence, the goal here is replacement of tobacco nicotine with clean nicotine as far as the nicotine users will accept. • Packet labelling and design also needs attention. Because FTC measurement of both tar and nicotine is discredited, current measures on the packet need to be replaced. Tar measurement can be dispensed with, as the present qualitative health warnings are adequate. However, the user is entitled to know the dose available from the tobacco delivery device so the cigarette ought to be labelled with the nicotine marked by weight, just as NRT is labelled. No one is yet undertaking this, but discussions between the World Health Organization (WHO) and the International Standards association are beginning. • The marketing issues have been discussed in this journal and elsewhere [8, 9]. In summary, we need to move towards the concept of government-run tobacco-marketing monopolies with power to purchase all the wholesale tobacco products sold and to set the specifications of this, to introduce generic packaging and to abolish advertising. There are partial precedents for this in the control and marketing of pharmaceutical drugs where countries such as the United Kingdom and Australia centralize their purchasing and control of therapeutic drugs. We are currently playing on the tobacco industry's territory of commercial control and marketing. Pharmaceutical style regulation is well established and controlled by competent authorities. Tobacco needs to be brought within their jurisdiction. This is consistent with the WHO Framework Convention [10].

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