Is it the nicotine or the tobacco?

Recent years have seen a growing recognition that product regulation is critical to dealing effectively with the tobacco epidemic. It is also now widely recognized that, though it is the nicotine that causes dependence, tobacco products (which can be characterized as particularly ‘dirty’ drug delivery devices) are responsible for the vast majority of the damage to health. This duality of a drug and a delivery system has led to different approaches to tobacco product regulation. Some feel that we need to look at removing the nicotine (perhaps very gradually) from tobacco products until they are no longer addictive. Others believe that we should focus on the delivery vehicle and on making alternative — safer — forms of nicotine more readily accessible to consumers. These approaches are, in fact, complementary if we take a pragmatic approach to dealing with the tobacco epidemic. The best form of product regulation would be multifaceted and would reflect the needs of smokers and the other elements of successful tobacco control interventions. The overall goal would be to assist cessation. Tobacco products are consumed for a variety of reasons that combine pleasure, dependence and selfmedication. Discussions of ‘harm reduction’, such as less deadly cigarettes and alternative safer forms of nicotine, are based on concern over the hard core of, usually heavy, smokers who will not quit. Whether this hard core is over 20% or less than 10% of any particular population, the key point is that the people in question cannot simply be left to die prematurely. But distinguishing the hard core from those who are interested in quitting, and capable of it, is critical. A very large proportion of smokers want to quit both smoking and nicotine use. Any comprehensive regulatory regime should do all it can to facilitate this goal. Products and services that have been proved effective in smoking cessation should be widely available and should have marketplace advantages (price, promotion, distribution outlets, package sizes, etc.) compared with tobacco products. If we help those who are alreadymotivated to quit we will have solved a huge part of the tobacco problem, not only through the use of existing products and services, but also through the incentive for better interventions as the market for these goods and services is allowed to grow tomeet consumer demand. For people who cannot or will not be able to exit completely both the tobacco and nicotine markets we should be looking at ways of allowing them to move to alternative forms of nicotine. This could be for a fewmonths or for the rest of their lives depending upon the consumer need, and should be seen as analogous to the treatment of any other chronic, relapsing condition. If a tobacco user can only abstain from smoking through the use of a therapeutic dose of ‘clean’ nicotine, this should be an option. Such products should be made available, and not placed at a marketing disadvantage compared with tobacco products. For those who cannot or will not completely cease using tobacco products, products and services should be available that can help them reduce their tobacco consumption. This can be accomplished through policies that, for instance, allow therapeutic products to be used for smoking reduction and temporary abstinence by smokers not yet ready to quit completely. Such measures offer safer alternatives, allow smokers to gain control over their tobacco use, and reduce the exposure of themselves and others to the toxins in tobacco smoke. With sufficient efforts aimed at providing consumers with viable choices for cessation, treatment and smoking reduction, the tobacco market should be much smaller. But, as it will still exist, less deadly tobacco products should have regulatory advantages over the most deadly products. Tobacco products that do not require combustion (such as the ‘snus’ sold in Sweden) offer clear advantages. So, too, do products that primarily heat rather than burn tobacco. But the marketing of these products should not obscure the greater advantages of ‘cleaner’ delivery systems and of cessation, and the marketing of such products should only be allowed within a strong, resourced and expert regulatory oversight to ensure that such products are truly reducing aggregate harm. Once other choices are available to consumers, existing tobacco products can more effectively be subjected to greater product regulation and marketplace disadvantages. These products could, over time, be de-nicotinized. They could be made less palatable to children, subjected to higher prices, contained to restricted sales outlets or otherwise made less viable. But it is through answering the needs of existing users that these restrictions will become commercially and politically viable. n 1 Legal Counsel, Smoking and Health Action Foundation, Suite 1903, 130 Albert Street, Ottawa, Ontario K1P 5G4, Canada.