Monday, May 3, 2010

Up in Smoke: How Will Our Tobacco Policies of Today Be Viewed by Future Generations?

In the history of the United States of America there have been more than a few public policies that leave today's generation incredulous.

We look back at the great issues our ancestors faced such as slavery, civil rights, Prohibition, Suffrage, the relocation and assimilation of Native Americans, discrimination, child labor and the wholesale destruction of our natural resources and wonder, "What the heck were they thinking?"

If you looked closely at any situation where a minority group was openly discriminated against and endangered, it usually can be explained with one word - greed. Behind every law or policy, someone stood to gain or lose financially.

Look at today's tobacco policies and cigarette smokers.

Here we have a product that the CDC states "is the single most preventable cause of disease, disability, and death in the United States. Each year, an estimated 443,000 people die prematurely from smoking or exposure to secondhand smoke, and another 8.6 million have a serious illness caused by smoking. Despite these risks, approximately 46 million U.S. adults smoke cigarettes." 1

Yet, rather than remove the deadly product, government officials offered regulation. The tobacco industry was banned from advertising in most media outlets, from sponsoring high-profile sports and ordered to redesign packaging with visible health warnings in an attempt to "protect" consumers. Higher and higher taxes were imposed, with the dual intent of making the price of cigarettes less appealing and to finance the health costs associated with smoking. In spite of this, people not only continued to smoke, new smokers continued to start smoking every day.

Anti-tobacco advocates weren't satisfied with the government's efforts, so they formed health organizations intended to educate smokers and support their efforts to quit. This heightened awareness of the health risks (plus the discovery in the 1950's that smoking was linked to lung cancer) prompted an unprecedented number of smokers to try quitting, but the success rates were less than stellar. This stumped the health groups. People knew that smoking was bad for them, why didn't they just quit?

Researchers finally pinpointed nicotine as being the ingredient in cigarettes that made quitting so difficult. Pharmaceutical companies developed "nicotine replacement therapies" designed to temporarily give smokers the nicotine they craved while they attempted to quit. Smokers had to be convinced that nicotine wasn't the dangerous component of smoking - just the addictive one. A new industry was created around smoking cessation, however, the products only worked for a tiny number of smokers. Over 97% of smokers would either bounce back and forth between smoking and the smoking cessation products or simply give up and go back to smoking. Obviously, helping smokers wasn't working, so maybe guilting or punishing them into quitting would.

Along came reports about "second-hand" and "third-hand" smoke. Based on some questionable research, the health advocates announced that smokers were not just hurting themselves, but also hurting those around them - even from simply touching them after smoking. Suddenly, "anti-tobacco" groups became "anti- smoking" prohibitionists, intent on banning any form of smoking or nicotine use and the attempts to help smokers turned into attempts to de-socialize and de-normalize them. Additional taxes on cigarettes were called "sin tax" and smokers were the sinners.

No serious attempts were made to remove the root cause of all of this trouble - cigarettes. The tobacco companies still made their profits, because smokers still had nothing to help them quit successfully. Sure, more token changes were done to make a good showing to their constituents. They banned flavors that no one really bought anyhow while the most profitable flavor - menthol - remained on the market; cartoon characters and other advertising that supposedly influenced children (even though research showed that stress, peer behavior and smoking family members were the largest influence for new smokers) were censored; smoking in public places was banned and any new recreational products containing nicotine were protested and pulled from the market as a "gateway" to smoking. Nicotine, while shown to be relatively harmless absent the tobacco smoke, was simultaneously vilified in the form of any new "reduced harm" smokeless products while being promoted as an "FDA-approved" pharmaceutical treatment.

That's not to say that the earlier, genuine efforts of the government and health organizations didn't have any impact. In the 1950's, more than half of the population in the U.S. smoked cigarettes. 2 As of 2009, that number had been reduced to approximately 21%, but that was an INCREASE from 19.8% in 2007 and it has remained constant since. The CDC placed the blame on state governments putting little or nothing of their $203.5 billion in tobacco-related revenue towards smoking-cessation programs. One has to wonder where all of that money was going instead.3

Of course, by this time there were many more groups making profits from smokers than just Big Tobacco. Federal and state governments now had billions of dollars coming in from the "sin tax." Big Pharma now had a multi-billion dollar per year smoking cessation industry and was donating huge amounts to the anti-smoking groups, who along with the medical community happily peddled their smoking cessation products. Anti-smoking groups, while mostly not for profit, still employed thousands and paid their leaders and lobbyists handsomely. Suddenly, the livelihood of all of these organizations was inextricably tied to tobacco and to smokers continuing to smoke.

So, where did that leave the smokers? Well, they were left with half-hearted attempts to help them quit, costly and ineffective "treatments," life as a social outcast and the privilege paying higher and higher prices to expedite an early death.

Then the electronic cigarette arrived.

Developed by a Chinese inventor in 2003 after his father, a heavy smoker, died of cancer (or so the story goes) the electronic cigarette was already a worldwide, multi-million dollar industry by the time the first shipments hit U.S. shores. While the concept was nothing new, the enterprising Chinese were the first to put it all together in a simple yet brilliant device.

Manufacturers put a small amount of medical-grade nicotine into propylene glycol - which was already recognized as safe by the FDA and the EPA - added appealing flavors and then put the solution in to a cartridge. The user attached the cartridge to a small heating element, which was powered by a cigarette-shaped battery, then inhaled the vapor created by the heated nicotine solution. To complete the illusion, the Chinese cleverly added an LED that lights up when the user inhales from the device. They marketed them to committed smokers - those who had no intention of quitting - as a less hazardous alternative to tobacco cigarettes. Smokers got their (relatively safe) nicotine with the sensations of smoking and without the toxic levels of chemicals and carcinogens found in tobacco smoke.

Seems like win-win, right?

Governments should have been happy that smokers would no longer be overwhelming the health care system. Anti-smoking and healthcare groups should have been happy that smokers would no longer inhaling or exposing bystanders to 4,000 chemicals and 50+ human carcinogens. Big Tobacco should have been happy it could now extract the nicotine from their plants, make their own electronic cigarettes and sell consumers a low-risk, recreational product. Big Pharma had the opportunity to make their own electronic cigarettes, develop a step-down plan and sell consumers a highly effective smoking cessation program.

Smokers would have been happy to satisfy their desire to smoke, without the guilt, cost and health hazards associated with tobacco smoking. Smoking, no longer defined only as burning tobacco leaves, would have been able to step out of the penalty box and back into mainstream society; no longer a public health hazard and as socially acceptable as enjoying a glass of wine or a jolt of espresso. Future generations should have been able to look at their history books and see how humanity made one of the most significant advances for public health in decades.

Instead, history may record that greed once again won out over the public's best interest.

Incredibly, the FDA, numerous state governments and a plethora of health and anti-smoking groups came out in full force AGAINST electronic cigarettes. The results of testing by the FDA and several independent labs, which showed that electronic cigarettes "use the same nicotine, with about the same level of trace contaminants as FDA approved NRT products"4 were twisted or completely ignored. Instead the FDA dramatically announced that the devices "contain carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze" and left the public to assume that the levels found were dangerous to humans.5

The FDA used the publicity to justify its declaration that electronic cigarettes were "unapproved drug delivery devices" and would be blocked from the market until they were shown to meet stringent smoking cessation standards. Public health organizations, followed by state legislators (with a sharp prod from the former), used the FDA announcement as a spring board and called for the immediate removal of electronic cigarettes from the market until they received FDA approval.

The former smokers who now used electronic cigarettes and the current smokers who found out about the devices via the FDA press statement weren't buying the spin though. The number of smokers switching to electronic cigarettes and then becoming "e-cig evangelists" to other smokers continued to rise.

When angry and confused consumers called and emailed groups like the American Lung Association, providing positive testimony of their experience with electronic cigarettes and demanding to know why the groups opposed a product that could save so many lives, they were met with canned responses such as: "The FDA hasn't approved them as smoking cessation devices." "We don't know what's in them." "They found antifreeze and carcinogens in them." "Quitting is better."

All of these answers completely ignored the fact that there had been no reports of injury or illness attributed to electronic cigarettes since they were introduced 5 years earlier; several tests (including the FDA test) had shown that the health risks of electronic cigarettes were comparable to FDA-approved smoking cessation products and tens of thousands times less hazardous than tobacco cigarettes; that electronic cigarettes were intended to be a safer smoking replacement for committed smokers and not a treatment for nicotine addiction; and that anecdotal reports from users claimed that the product was a successful replacement for tobacco smoking and improving their health, unlike the FDA-approved smoking cessation products.

One's first instinct is to ask. "What were they thinking??" But if history is any indication, that question has already been answered. One just needs to "follow the money."

So, today we sit at crossroads. History is being made in public health. All we can do now is imagine how future generations will look back upon the players in tobacco policies today. Will they see them as innovative and forward-thinking public health advocates who embraced a life-saving device or will they be revealed as self-serving and corrupt special interest groups - willing to sacrifice the lives of their fellow citizens in order to make a few bucks?Only time will tell.

1. Centers for Disease Control and Prevention,
2. Smoking Statistics,
3. U.S. News and World Report,
4. American Association of Public Health Physicians,
5. U.S. Food and Drug Administration,

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