Reducing toxicity exposure for the nicotine‐dependent

The articles by Gilljam & Galanti (2003) and by Fagerström & Schildt (2003) are timely insights into the application of risk reduction principles to tobacco control. Such an approach may be the best basis for finally regulating all tobacco and nicotine products in ways that will ultimately greatly reduce the toll of tobacco-caused mortality and morbidity. To get a handle on the importance of this area of research, it is necessary to revisit the goal of tobacco control efforts and the methods by which this goal can be achieved. As Fagerstrom & Schildt remind us, the objective of our efforts should be to reduce death and disease. In achieving this objective there are many possible interventions, but all are aimed at one of three general outcomes. We can engage in actions that: (1) decrease the onset of tobacco use; (2) increase the cessation of tobacco use; or (3) reduce the risks for those who do not cease using tobacco. Due to the delay between the onset of tobacco use and the onset of the resulting diseases we also know that, for approximately the next 30 years, any reduction in tobacco-related mortality and morbidity can only be accomplished through cessation and toxicity reduction. During this time period we can also forecast that, without major new interventions, smoking will account for roughly 10 000 000 deaths per year, making it the single biggest cause of death worldwide by the year 2030 (World Bank 1999). Despite these clear yet numbing facts, there is far too little being done to develop and implement comprehensive policies to facilitate cessation, and disturbingly little attention to realistic alternatives to the current ‘nicotine maintenance monopoly’ as described by Warner, Slade & Sweanor (1997). Instead, most countries give an irrefutably disreputable cartel control over an incredibly toxic delivery system. This horrendous situation is kept in place in part by a lack of regulation of tobacco products and, in the case of the EU law on snuff—or virtually all countries on medicinal nicotine—by actual regulations that remove competitive threats to the cigarette cartel. All this despite the fact that nicotine is a drug that we know can be of relatively little health consequence when used independent of the toxins produced by its delivery system (Benowitz 1998). Surely the fact that nicotine is the primary reinforcing constituent in tobacco but its delivery through combustion-based cigarettes is the principle cause of the of the death and disease should point us towards regulatory interventions aimed at toxicity reduction. The two papers in this issue of Addiction help us to consider our options for regulatory interventions by looking at the truly fascinating ‘natural uncontrolled experiment’ that has been unfolding in Sweden. The Swedish experience is not necessarily an example to copy, but is surely a gold mine of information that could potentially inform our efforts to develop effective regulatory systems. Gilljam & Galanti find that Swedish male smokers appear to have increased their overall chance of abstinence by 70–80% through use of snus. But they seemingly apologize for the finding by saying that three quarters of quitters reported no use of snus. Thus concluding that snus‘is certainly not a necessary component of smoking cessation at the population level’. But were we to apply the same ‘necessary component’ criteria in evaluating any other tobacco control measure (e.g. tax increases, tobacco advertising bans, nicotine replacement therapy, physician counselling, health warnings, smoke-free policies), we would have to conclude that nothing meets this standard. This, of course, is why we talk about comprehensive action. Similarly, the fact that Australia (or Canada) has smoking rates at a Swedish level without a widely used alternative to cigarettes does not dismiss the importance of understanding the role of snus any more than we should reject Australian experiences simply because Sweden has as low a prevalence of smoking without having done the same things. Important follow-up research, particularly using longitudinal panels of tobacco users, could look at exactly the role snus is playing in relation to cigarette consumption and what lessons it offers for tobacco and nicotine regulatory initiatives to reduce toxicity. The Fagerström & Schildt paper highlights one of the great absurdities of tobacco product regulation. The EU bans snus, which may be the least harmful tobacco product on the planet, while failing to even meaningfully regulate cigarettes, which kill half of long-term users. In addition, the EU leaves untouched other, more toxic, forms of oral tobacco (Bates et al. 2003), and most EU countries place stringent controls on medicinal nicotine products. Under existing EU regulations, as long as a product is not classified as ‘snuff’ it is allowed. This leaves an open-door policy for highly toxic forms of oral tobacco from south Asia and elsewhere. Were someone to simply add a resin to snus that made it chewable the ban would evidently no longer apply—even if the resin was toxic. Clearly, a more health-oriented system of product regulation should be possible. Combined, these articles should help efforts to incorporate toxicity reduction as a key component of tobacco control policies. The fact that many Swedes appear to have used snus to quit smoking, and that this has happened despite strong public health opposition to snus, raises key and interrelated questions of research and regulation. The likelihood of the EU ban on snuff being overturned also underscores the need to look to Sweden for information that could guide evidence-based regulation of all tobacco and nicotine products. Further research needs to effectively mine the Swedish data to look for insights into such issues as the precise relative risks of cigarettes, snus, other forms of non-combustion tobacco and medicinal nicotine. We need to better understand who uses snus and why, and how the market has been, and could be, shaped. We also need to better understand the importance of how information is communicated to consumers. Clearly there are lessons on how even less hazardous products, such as medicinal nicotine products (Kozlowski et al. 2001), can be made more effective as cigarette replacements. As countries around the world move towards the regulation of tobacco products, we need to recall the public health goals of tobacco and we need to better understand how toxicity can be reduced as part of a comprehensive strategy to achieve maximum reductions in death and disease. Better understanding the lessons from Sweden will be a key component of effective regulation. As will a move to evidence-based regulation pragmatically aimed at reducing deaths. I have consulted for manufacturers of pharmaceutical nicotine products and have confidentiality agreements with manufacturers of smoking cessation products that are under development.

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