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.

 

 

Three Must-Read Articles Supporting Tobacco Harm Reduction

These outstanding recent publications belong in every tobacco harm reduction library. 

1.  Dr. Lynn Kozlowski on e-cigarettes

Kozlowski, dean of the School of Public Health at the University at Buffalo, has published an excellent article in the Huffington Post (here) encouraging smokers to switch to e-cigarettes and encouraging the FDA to use light-touch regulation to keep e-cigs on the market and competitive with deadly cigarettes. 

Kozlowski is a giant in the tobacco research field and a long-time advocate of harm reduction.  He noted in 1984 (abstract here) and 1989 (abstract here) that smokeless tobacco conferred fewer risks to users and therefore might serve as an effective substitute for cigarettes.  He argued in 2003 that there was little evidence that smokeless use was a gateway to smoking, because the majority of users never smoke or smoked cigarettes prior to using smokeless (abstract here), and he has argued persuasively that smokers have a fundamental human right to accurate information about safer forms of tobacco use (abstracts here and here).

2.  Christopher Snowdon on tobacco harm reduction

Snowdon, author of Velvet Glove, Iron Fist: A History of Anti-Smoking (2009, available here), has published a devastating critique of the resistance to tobacco harm reduction in Europe (read it here).  He writes that “The sale of the two least hazardous recreational nicotine products – e-cigarettes and Swedish snus – are banned in many countries despite growing evidence that they can play an important role in reducing the smoking rate…The prohibition of safer tobacco products has led to unnecessary deaths in the European Union and elsewhere.  It is highly likely

that the prohibition and excessive regulation of e-cigarettes will also lead to unnecessary premature deaths.”

Snowdon argues that “The neo-prohibitionist approach is unjustifiable from the perspective of both personal liberty and population health.”  Although he focuses on the European snus ban and the strangulation of e-cigarettes by the EU tobacco directive, Snowden excoriates the FDA for making the designation of smoke-free tobacco products as “reduced risk” dependent on impossible-to-obtain proof that they won’t adversely affect population health.

3.  Thomas Lesnak on the booming cigarette black market

Lesnak, recently retired from the U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), writes in the Daily Caller (here) that the cigarette black market is worth $10 billion.  “That is the widely accepted figure our government estimates is lost each year from tobacco trafficking schemes,” he notes.

I recently described New York City as a “prohibition prison” (here); Lesnak agrees.  He writes, “When politicians say that increasing taxes lowers smoking rates, what they aren’t saying is that higher costs have driven a large percentage of the market – disproportionately youth smokers – to illicit cigarettes.  Millions of New Yorkers now reside within a short walk or a cab-ride from smoke shops that sell 200 cigarettes in plain plastic bags for $10.  Referred to as ‘rollies’ or ‘baggies,’ they feature no health warnings, and produce no tax revenue…Today, it is estimated that 60 percent of the cigarettes sold in New York City are illicit.  Most of these cigarettes are smuggled in from low-tax states like Virginia, North Carolina and Maryland.”

Lesnak correctly diagnoses the problem: “we’re criminalizing tobacco smokers, small and family retailers, and our youth, who are now forced into buying illicit products.  If these sound reminiscent of the failures of Prohibition, it’s because these are the same problems we faced early in the last century as a result of those similarly veined, well-intended policies.  We know exactly how that experiment turned out.  And yet, politicians continue to ignore those lessons.”

Unfortunately, the former federal agent also ignores the lessons of Prohibition and recommends the wrong treatment: “…stiffer penalties, well-funded enforcement, and stronger cooperation among agencies, as well as state and local governments.”  Such measures make the black market more violent and destroy government credibility.  There is little enthusiasm in America for penalizing personal behaviors, especially those that are enjoyed by millions of people.  Instead, politicians should eliminate prohibitive tobacco taxes, legislation and regulation.