Wisdom From Smoking Cessation Pioneers

 

A search of the medical literature on the topic “smoking cessation” finds 32,446 published articles, yet, surprisingly, there are no articles linked to this topic until the year 1980, and only 27 articles were published from 1981 to 1990.  Medical researchers primarily focused on smoking cessation in the last three decades -- 1991 to 2000 (4,481 articles), 2001 to 2010 (10,976 articles), and 2011 to the present (16,964 articles).  Despite this impressive volume of research, the U.S. still records 480,000 deaths annually due to smoking.

I was interested to learn more about the 1981-1990 period, as it preceded my entry into the field in 1994 (here, here and here).  I found that several prominent scientists and academicians, who are strong supporters of tobacco harm reduction, populated that period’s author list.  Here they are, followed by PubMed links: John Hughes (here and here), Jed Rose (here), Lynn Kozlowski (here), Ken Warner (here), Jack Henningfield (here), Ray Niaura (here), David Abrams (here) and Saul Shiffman (here).  Three of these articles, and their authors, deserve special mention.

Ken Warner’s 1989 article, “Implications of a Nicotine-Free Society,” clearly shows that this University of Michigan professor has been one of the most forward-thinking leaders in the tobacco research and policy field for many years.  He understood in 1989 that a “nicotine-free society” was not a panacea, and he boldly criticized both sides in the debate: “The tobacco industry implies that the demise of tobacco consumption would wreak havoc with the economy. By contrast, some antitobacco activists suggest that the end of tobacco use would yield a multibillion dollar fiscal dividend. Each argument is fundamentally flawed. The economic impacts of a nicotine-free society would be modest and of far less consequence than the principal implication: a significantly enriched quality and quantity of life.” 

I have some personal insight into Professor Warner’s commitment to tobacco harm reduction.  In 1999, US Tobacco made its first grant to the University of Alabama at Birmingham to support my work.  I contacted numerous well-known tobacco researchers, offering to fund my own travel in order to make presentations on an alternative approach to cessation for inveterate smokers.  The only person to respond was Ken Warner.  He hosted my speech and invited colleagues from across the Michigan medical center.  It was a rigorous event, at which my research and ideas were seriously challenged.  I was, and remain, profoundly grateful to Professor Warner for this amazing opportunity.

Jed Rose at Duke University is another prophet of tobacco harm reduction, and his work long pre-dated and anticipated the recent development of vapor products.  Consider his 1990 article,  “Low-nicotine Regenerated Smoke Aerosol Reduces Desire for Cigarettes.”  His group developed “an aerosol with many of the sensory qualities of cigarette smoke, but with only 3% of the tar and nicotine and none of the carbon monoxide of a typical commercial cigarette… Surprisingly, the smoke aerosol reduced self-reported desire for cigarettes as much as the commercial cigarette. This new method is a promising approach for evaluating the role of sensory cues in smoking, and it may also be useful as a clinical tool for smoking cessation.”          

Finally, there is legendary tobacco researcher Lynn Kozlowski (originally at Penn State, now at the University at Buffalo).  In 1989, he authored “Reduction of tobacco health hazards in continuing users: individual behavioral and public health approaches.”  The article was written for “those smokers who will not stop using tobacco,” for whom “methods are discussed for reducing the risks to health of continued tobacco use… For continuing smokers of cigarettes, fewer cigarettes per day and very-low-tar cigarettes are encouraged, provided filter-vents are not blocked by the smoker. Better yet would be a switch to smoking one or two non-inhaled pipes or cigars each day. Even better would be a switch to use of the minimum acceptable amount of smokeless tobacco or nicotine-containing gum.”  Professor Kozlowski even suggested that “public health measures (e.g., social restrictions, differential taxation, changes in package size) may be the most important means of bringing about less hazardous tobacco use among continuing users.”

In 1994 I started counselling inveterate smokers to switch to smokeless tobacco, and in 2017, my research group recommended “differential taxation” to Kentucky legislators to save smokers’ lives.  I am proud that our proposal was endorsed by Ken Warner and Ray Niaura.

 

 

The Illogic of Condoning Vaping & Condemning Smokeless – Both Are Safer for Smokers

While many American tobacco researchers and policy experts have, of late, moved to endorse reasonable regulation of e-cigarettes and vaping, most persist in condemning smokeless tobacco products, which have been proven to be nearly harmless.  It is irrational to support one and prohibit the other, when both are legitimate harm reduction options for smokers.

The illogic of this dual position is displayed in the work of Dr. Dorothy Hatsukami, a prestigious tobacco researcher, author of 250 published articles (here) and recipient of tens of millions of dollars in NIH funding (available here, including $13 million to study reducing nicotine in cigarettes).  Dr. Hatsukami recently signed a letter to FDA Commissioner Scott Gottlieb (here) and published an article in Tobacco Control (here).

In the letter to the commissioner, Dr. Hatsukami applauded his “openness to the concept of tobacco harm reduction…There is already a considerable body of science and experience suggesting that a harm reduction approach…could yield substantial and highly cost-effective public health benefits…at this time we do not believe that the current regulatory framework for the low-risk nicotine products such as e-cigarettes and smokeless tobacco is appropriate or will deliver the substantial public health benefits we hope and expect FDA’s oversight will bring.”  The letter encouraged the FDA to regulate tobacco products according to risk and to “support informed choice through truthful communication of risk.”

However, in her Tobacco Control commentary, Dr. Hatsukami took a contrary view, fully endorsing the FDA’s proposed standard for NNN, which I have eviscerated here and here.  She wrote, “If [FDA] puts the proposed rule into effect, it would be a significant and important step towards minimising the harms from smokeless tobacco use.”  Surprisingly, she asserted that “the risk for oral cancer is considerably higher for smokeless tobacco users,” and cited a federal study documenting that American men who dip or chew tobacco have no mouth cancer risk (here).

Notably, other signatories to the Gottlieb letter are genuine tobacco harm reduction advocates who have endorsed the substitution of smoke-free tobacco by smokers.  They include Clive Bates of the UK and Canada’s David Sweanor, who filed a comment (here) labeling the NNN rule “reckless and pointless.”  American signatories who are on record about the relative safety of smokeless are Sally Satel (here and here), Kenneth Warner (here and here), David B. Abrams (here) and Raymond S. Niaura (here). 

Base Tobacco Taxes on Tobacco Risks – A Valid Strategy Is Revived

On August 13 the New England Journal of Medicine published a commentary (here) by three prominent tobacco research and policy experts challenging “national, state, and local policymakers” to “expedite the move away from cigarette smoking” by basing tobacco taxes on health risks.  They recommend high taxes on high-risk combustible products, and lower taxes on low-risk smoke-free products like e-cigarettes and smokeless tobacco. 

Economist Frank J. Chaloupka of the University of Illinois Chicago, attorney David Sweanor of the University of Ottawa and economist Kenneth E. Warner of the University of Michigan acknowledge that “the science supporting a difference in risk between combustible and noncombustible tobacco products is well established,” and they conclude that “Sizable public health benefits could derive from current cigarette smokers’ switching to [e-cigarettes] and other noncombustible products.”

I made the same argument in a Tampa Tribune op-ed on August 16.  12 years ago.

In 2003, many states were under pressure to raise tax revenues.  I submitted op-ed columns to newspapers in 16 states, noting: “Excise taxes on tobacco products may be inevitable, but they don’t have to be illogical.  A common sense approach is to tax tobacco products according to risk.  Cigarettes, widely acknowledged as the most dangerous products, are already taxed at high levels by most states, ostensibly to discourage consumption.  But the health impact of smokeless tobacco use is much lower; scientific and medical research has confirmed that smokeless tobacco use carries only about 2% of the risk of smoking.  A rational tobacco tax policy would set taxes on smokeless products at 2% those of cigarettes.” 

The Tampa Tribune published my proposal (click on the image to read it), which included this:

“Taxing tobacco products according to well-established risks will serve the public health goal of reducing the death toll from cigarette smoking.  Economic research shows that a large price differential encourages cigarette smokers to switch to smokeless tobacco.  A growing number of public health experts, including the prestigious Royal College of Physicians in Britain, recognize that smokeless tobacco may be an acceptable substitute for smokers who have been unable or unwilling to quit.  They point to evidence from Sweden where, over the past century, men have smoked less and used more smokeless tobacco than in any other Western country.  The result: Swedish men have the lowest rates of lung cancer -- indeed, of all smoking-related deaths -- in the developed world.

“How have the Swedes achieved this record-setting reduction in smoking?  First, placing tobacco discreetly inside the mouth is far safer than setting it on fire and inhaling the smoke, and the Swedes know it…Second, smokeless tobacco satisfies, because it delivers nicotine almost as efficiently as a cigarette.  Nicotine is addictive, but it causes none of the diseases associated with smoking.  Third, the “spitting image” of smokeless tobacco is history, because modern products, available in Sweden and the US, can be used invisibly and as easily as breath mints.  Finally, in Sweden the price of smokeless tobacco products is less than half that of cigarettes, the difference largely reflecting levels of taxation.”

Twelve years later, it is comforting to see this taxation strategy gaining wider currency.