More research is needed to determine the feasibility of safer nicotine products, such as medicinal nicotine and low hazard smokeless tobacco, replacing smoking tobacco and thereby decreasing the massive burden of ill-health and early deaths caused by smoking, particularly amongst the most disadvantaged in society. These are the conclusions of authors of a Viewpoint published early Online and in an upcoming edition of The Lancet, and are echoed by an accompanying Editorial published in the print issue.
Professor John Britton, Division of Epidemiology and Public Health, University of Nottingham, UK and Dr Richard Edwards, Department of Public Health, University of Otago, Wellington, New Zealand, also concluded that "meeting the challenges of implementing effective tobacco control and nicotine harm reduction policies, both nationally and internationally, needs the creation of dedicated, autonomous, and fully resourced national (and where appropriate international) nicotine and tobacco product regulatory authorities."
The Viewpoint is based on a report to be published on Friday 5 October by the Royal College of Physicians (RCP), and comes during the same week the UK government raised the legal age for buying tobacco from 16 to 18 years.
Smoking killed 100 million people in the 20th century, and is predicted to kill one billion in the 21st century. Most of the 150 million deaths from smoking that are expected over the next 20 years will occur in current smokers who are alive today. Half of all smokers will die prematurely, unless they stop smoking.
The authors do a detailed comparison of smoking with smokeless tobacco, and also safer nicotine substitutes. They explore the paradox that despite being by far the most harmful, cigarettes and other smoked tobacco products are the least regulated; whereas Swedish snus, for example, which has adverse effects up to 90% less than those of smoked tobacco, is banned in many European countries. They say: "Some argue that health professionals should not condone any use of nicotine, and also that encouraging use of alternative nicotine products, particularly smokeless tobacco, would invite abuse of the market by their commercial producers. Others argue that if smokeless tobacco products are an effective and less hazardous substitute for smoking it would be in the public interest to harness that potential benefit, particularly if the Swedish pattern of predominant gateway progression from smoking to smokeless tobacco use could be realised in other countries."
Included in the Viewpoint is a detailed breakdown of proposed initial and continuing functions that a national nicotine regulatory authority could adopt, including taxation, monitoring, packaging, and health information.
The authors say: "We believe that the absence of effective harm reduction options for smokers is perverse, unjust and acts against the rights and best interests of smokers and the public health."
They conclude: "The consequence of failing to intensify tobacco control efforts, and to address the current imbalance in nicotine product regulation, will be the unnecessary perpetuation of current smoking by millions of people, especially in disadvantaged communities, and a continued epidemic of avoidable death and disability. Specifically, cigarettes and other smoked tobacco products will continue to be freely available with few restrictions on their safety or content…most of the millions of smokers alive today will therefore continue to smoke tobacco, and half will die as a result."
The Editorial says: "Britton, Edwards and the other members of the RCP's Tobacco Advisory Group advocate a courageous approach to nicotine addiction. Greater availability of medicinal nicotine, and perhaps even of low-toxicity smokeless products, along with increasing restrictions on smoked tobacco, is likely to reduce tobacco-related mortality and morbidity. Given the known hazards of smoked tobacco, and the numbers of people who smoke, innovative thinking is needed. We support tobacco harm reduction alongside rigorously applied tobacco control policies."
Journal
The Lancet