End Game Strategies for Tobacco Control

by Anthony Robbins, MD, MPA

Can we really consider "end game strategies" for tobacco?  An Op-Ed in the New York Times makes a strong case for ending tobacco use.  Let me begin with some history.

The World Health Organization's (WHO) Framework Convention on Tobacco Control, adopted in 2003, was developed in response to globalization of the tobacco epidemic.  The Framework's objective is to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke. Unlike previous drug control regulatory strategies, it recognizes the need to address both demand and supply issues.

The Journal of Public Health Policy, where I am co-editor, has been encouraging public health leaders to report on “end game strategies" for tobacco control, especially in the developing world.   In our call for papers we note:

As anti-tobacco groups pressed for the WHO FCTC, they challenged the global tobacco industry’s most deadly strategies for addicting children. Anti-tobacco advocacy was centered in rich or industrial countries and these countries adopted the strongest anti-smoking measures. Can these countries move into a new phase?  ... Today the tobacco industry is spreading its plague to the world’s poorest and most populous countries, employing the same tactics they used in the industrial world before the Framework Convention was in place. As the number of smokers continues to grow, can new efforts and strategies stem this tide?

Researchers from Vietnam, Nigeria, Indonesia (here, here, here) among others have written in JPHP on tobacco control efforts in their nations, and obstacles to them.

Northeastern University law professor Richard Daynard brought the end game challenge home to the U.S.  In the recent New York Times Op-Ed "Two Paths to the Gradual Abolition of Smoking," Daynard spells out just what the Food and Drug Administration can do and what states and localities should do.  He writes the FDA should limit nicotine in cigarettes (and other tobacco products), so that they are no longer addictive. Research shows that when people are smoking very low nicotine cigarettes, further lowering of nicotine content does not lead the smokers to compensate by smoking more cigarettes. States and localities should ban sales of tobacco to anyone born after 2000 (or another chosen starting point).  Thus fewer and fewer people could buy tobacco each year.  This would use the same controls used to restrict alcohol purchases by age.

Daynard writes:

“Some antismoking advocates who support existing approaches (smoking-cessation programs, higher taxes) fear that pushing for an “end game” — a smoking rate below 10 percent — is too ambitious. But then, banning smoking in restaurants, workplaces and bars was once seen as crazy, too. Sometimes, a little crazy goes a long way.”

Anthony Robbins, MD, MPA is co-Editor of the Journal of Public Health Policy.  

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The "End Game" for tobacco is not a public health strategy, but rather a prohibition strategy that, like alcohol and marijuana prohibition, would cause far more problems for society than it resolves.

Mandating nonaddictive nicotine levels in cigarettes would be like restricting the alcohol content of vodka, whiskey, rum, etc. to no more than two percent.

Instead of benefiting public health, mandating very low nicotine levels in cigarettes would cause many/most smokers to compensate (to obtain their desired level of nicotine) by smoking even more cigarettes and by inhaling them deeper and longer, which would further threaten their health and increase secondhand smoke exposure for others.

Another unintended (but obvious) consequence of this back door cigarette prohibition strategy would be a newly created (and eventually violent) black market for untaxed, unregulated and perhaps even lower priced cigarettes (as taxes and MSA payments now account for an average $3.20/pack for legal cigarettes), which could increase cigarette consumption.

Cigarette prohibition also would cause corruption of government officials charged with enforcement, prosecution and adjudication, while depriving the federal and/or state governments of tens of billions of dollars in tax revenue and MSA payments that now fund children’s health insurance and other critically important health programs.

Since its the smoke, not the nicotine, that causes all cigarette diseases and deaths, a far better consumer and public health strategy to significantly reduce cigarette consumption is for the FDA and CDC to begin truthfully informing smokers that all smokefree tobacco/nicotine products (including smokeless tobacco, electronic cigarettes, nicotine gums and lozenges) are 99% less hazardous than cigarettes and pose no risks to nonusers, and to encourage (instead of discourage) cigarette smokers to switch to or substitute smokefree alternatives until they are ready to quit all tobacco/nicotine consumption.

Several million smokers have already quit smoking by switching to moist snuff and electronic cigarettes, and some have quitting smoking by switching to nicotine gums and lozenges.

States should also tax cigarettes at far higher rates than smokefree alternatives since smoking imposes enormous healthcare costs on states, unlike use of the latter products.

Just as prohibition of alcohol, marijuana, gambling and sex never achieved their supporter’s idealistic goals while causing many unintended consequences, cigarette prohibition would do the same.

Bill Godshall
Executive Director
Smokefree Pennsylvania
1926 Monongahela Avenue
Pittsburgh, PA 15218

By Bill Godshall (not verified) on 27 Mar 2013 #permalink

Is there an "end game strategy" for TB?

Is there not instead a set of public health strategies that brought TB down from a major public health problem, and have kept it down?

In 1900 TB was killing one out of five Americans. By 1950 a TB death was rare in America.

Today tobacco kills one out of five Americans. And this is hardly improved 50 years after the first Surgeon General's report in 1964. Why is that?

No one who has made a serious study of tobacco is in any way confused on these facts. If you want to go after tobacco disease and death, you have to go after the number one vector for it: the tobacco industry. Nothing proposed here takes that on. It's like going after TB but never mentioning how it spreads, never countering that.

The most effective and cost-effective way of making progress on tobacco is policy change. Smokefree workplaces and public places, a nonsmoking norm, denormalizing the product, tough well-funded counter-advertising that uses the proven effective themes of exposing industry deception and manipulation and the harm of secondhand smoke, uniformly high excise taxes, strong graphic warning labels, bringing the externalities of the product back into the system. These are what the industry fears, and these are what work.

Tinkering with the product has no proven benefit but it seems harmless as long as it doesn't displace what is effective.

Age-based sales restrictions look much like the youth access trap, a failed policy that plays directly into the industry's PR design. So they don't seem harmless.

We don't need to struggle to find what will work. We know what works. We need to do it.

You want an end game? A tobacco death is rare in America. How to get there? We know exactly how to make progress: policy change.

By Jon Krueger (not verified) on 27 Mar 2013 #permalink

I am coninually surprised and alarmed when tobacco control advocates espouse "magic bullets" that will end the tobacco epidemic. Why? Progress in tobacco control thus far has been due to a multi-pronged, comprehensive approach. Secondly, tobacco control experts and governments committed to tobacco control seem to believe that they are able to control both the supply and demand of tobacco as they choose. Most tobacco control initiatives have emphasized demand side approaches and not given enough attention to supply side factors. If factors such as product, price, placement and promotion of tobacco are not strictly controlled, progress is sure to be slow. Unfortunately, the tobacco industry has been able to keep control of all these elements of tobacco supply. Though the end of tobacco/nicotine use is desirable and should be hastened, as long as tobacco industry control of supply continues, the near extinction of tobacco/nicotine use is mostly a far-distant dream, especially in emerting markets like Asia.

By Stephen Hamann (not verified) on 27 Mar 2013 #permalink

The repeal of the Bill of Rights has to start somewhere, so why not on the Ed Page of the Times?

Wait a minute- isn't that the WSJ's job ?

This is how I see it: the most effective way to phase tobacco out will be the same way it was originally phased in - through marketing. Cigarettes were first marketed as trendy and cool. I'm not 100% on the advertising regulations in the US or in other countries, but in Australia and New Zealand, tobacco advertising is completely banned. There are kids growing up here who have never seen an ad for cigarettes. What they do see are graphic violent anti-smoking marketing material created by government departments. Diseased lungs on cigarette packets, brain tumours on TV, amputated limbs in national newspapers.
In of itself, however, that's not enough. Cigarettes are still addictive and at least as far as youth are concerned, they still represent flouting of authority and in some groups, social acceptance.
I believe that in the long term, less and less young people will take up smoking. Youth smoking rates have been declining gradually for decades and are nowhere near what they were in the 1960s and 1970s.
That just leaves the addiction component (and contrary to popular belief, it's not just the nicotine in cigarettes that makes them so addictive: http://genecigs.com.au/why-are-cigarettes-so-addictive/). There will always be people who want to smoke because it gives short-term pleasure. In the long term, however, many of these people will be persuaded through persistent marketing to take up less harmful options. Snus, e-cigarettes, nicotine lozenges, etc etc. Anything that doesn't contain burning tobacco is better than a cigarette.
The problem is that there are mixed marketing messages right now because a lot of the anti-smoking forces think nicotine is as bad as smoke. If they can all agree on a clear, sensible marketing message, it will stand a much better chance of getting through.
My two cents on how the tobacco end game will play out.