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Concluding remarks
  1. jwilkenfield{at}

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    The purpose of this special supplement to Tobacco Control was to explore the state of knowledge about the public health consequences of the population shift to low yield tobacco products during the last half of the 20th century, the lessons that could be learned from that experience, and the policy and health communications recommendations that could be made as a result. The papers in this supplement establish the need for the government and the public health community to take action to correct the public's misperceptions about the supposed benefits of low yield products. Moreover, the various authors appropriately caution the tobacco control community to learn from the low yield travesty in order to prevent a repeat of those mistakes with the introduction of a new generation of so called “less hazardous” products.

    The paper by Thun and Burns (p i4) firmly establishes the failure to find convincing evidence of an important reduction in disease risk for the population of smokers who smoke low yield cigarettes.1Thun and Burns conclude that selected cohort studies in the USA and the UK demonstrate that lung cancer risk continued to increase among smokers from the 1950s to the 1980s despite the widespread adoption of lower yield cigarettes. Moreover, new research shows that prior analysis of earlier data may have produced false positive results because researchers calculated risk on a per cigarette basis but smokers increased the number of cigarettes per day they smoked. They make clear that the discrepancies between the epidemiological studies and observations of population mortality rates over time can be explained by the difference in characteristics of high and low yield cigarette smokers—which include rates of cessation and compensatory changes in number of cigarettes smoked per day. Put simply, they found that there is no public health benefit from low yield products—they are not a safer alternative. As a tobacco control billboard in Arizona declared, “Less tar, same great death rate”.

    Shopland's introduction (p i1) provides the historical basis for the recent state of affairs.2 The finding by Thun and Burns flows naturally from the body of evidence developed during the past decades that smokers who switched from higher tar and nicotine products to lower yield brands smoked more intensely, covered vent holes, smoked more cigarettes, and otherwise altered their smoking behaviour in order to maintain a desired (needed) nicotine level. The finding is confirmed by industry documents which showed that the industry was keenly aware of smokers needs and designed their products with “elastic dosing potential” to enable smokers to compensate and achieve high dosages of tar and nicotine in order to satisfy their addictions.3-6 Finally, the industry's marketing scheme for these products illustrates that the industry used the public's misperceptions about low yield products to create effective and enticing selling messages that promised addicted smokers an alternative to quitting—a safer product. Thus, human biology, manipulated by the business interests of the tobacco industry, combined with a nearly complete absence of accountability by the industry for its overblown claims, produced the current situation.7

    How to rectify the problem

    What can be done to rectify this problem? The question itself has many parts. What should be done about the International Standards Organization/Federal Trade Commission (ISO/FTC) test method that produces the numbers that provide the justification for the low yield designation? What should be done about the low yield designation/descriptors that help perpetuate the deception? And what type of educational messages or public health measures will help convince smokers now that low yield products are a snare and delusion? The remainder of the papers in this issue address the third point. We will only address the first two questions in passing in order to point out the complexity of any solution.

    Much has been written about the fate of the ISO/FTC method, including a National Cancer Institute monograph, which called for major modifications in the system and its reporting.8 This monograph led to a request by the FTC to the Department of Health and Human Services for assistance in determining whether there was any value left to the test methodology and if so what steps should be taken to improve it. At the time of this writing, that report is still forthcoming and the fate of the ISO/FTC machine test in the USA is still an open question. What is clear is that the test is broken and should either be scrapped or radically modified as has been done in Canada, Massachusetts, and Texas. What is also clear is that the design of a new test or new way to measure and regulate cigarettes should rest with an agency, such as the Food and Drug Administration (FDA), with real authority to make the appropriate scientific findings that provide consumers with information relevant to the risk to their health and propose realistic, health based, modifications to the testing of cigarettes.

    The second issue—what should be the fate of low yield descriptors—is also one best left for a full discussion at another time. It deserves a special issue all its own as it is the subject of much policy discussion in the USA, in the European Union, and at the World Health Organization. It is worth describing, however, two current recommendations from stakeholders in the debate. The first is from Philip Morris, the world's largest exporter of cigarettes and the one with a stake in the profits to be made from selling low yield products. The second position is from the proposed text for an international treaty for tobacco control being negotiated under the auspices of the WHO, a stakeholder in the health of the world.

    Philip Morris: We believe that manufacturers should be allowed to continue use of descriptors such as “full flavor”, “light” and “ultra light” to describe brands with differing taste characteristics and reported tar and nicotine yields. However, the limitations of descriptors and the average tar and nicotine measurements to which they relate should also be explained. For that reason, Philip Morris USA supports FDA regulations that would establish a uniform and consistent method for determining and describing specific ranges or reported yield. We also support measures to remind consumers that there is no such thing as a “safe” cigarette, and that a lower reported yield does not mean “safe,” or “safer” than other brands.9

    Contrast that with a provision in the chair's draft text of a Framework Convention on Tobacco Control. In referring to measures that should be taken by parties to the treaty the chair's text states:

    (d) adoption of appropriate measures to ensure that:   (I) the terms “low tar”, “light”, “ultra light”, “mild” or any other similar term that has the aim or the direct or indirect effect of conveying the impression that a particular tobacco product is less harmful than others are not used on any unit packet or package of tobacco products . . .”10

    The stark contrast between these two proposals is based almost entirely upon the focus of the speakers' concerns—industry profits versus the public health. The evidence is too overwhelming that a substantial number of smokers use low yield products because of their mistaken belief that these products are less hazardous.11Perhaps without this crutch they would quit smoking. This is not a chance we should take with public health. The WHO's recommendation is based upon public health concerns and therefore should be accorded the greatest weight. (The FDA rules concerning use of descriptors on food labels provides a useful example of how science based descriptors can be applied.)

    Correcting the misinformation about low yield products

    The last question concerns the types of messages that should be designed and the actions that should be taken by the tobacco control community, public health officials, and other interested parties in order to correct the misinformation that smokers have about low yield products. The remaining papers by Shiffman et al, Kozlowski et al, and Canovaet al address these issues. The Kozlowskiet al paper (p i12) adds to our understanding about the reason that many smokers of Light and Ultra Light products use these products.12 They found, as have many others, that many smokers use lower yield products because of their purported lower tar and nicotine delivery, to reduce the risks of smoking without having to quit, and as a step towards quitting. Kozlowski reports that these smokers have unrealistic expectations regarding the risk reduction that can be achieved by smoking Lights and Ultra Lights. Thus, the study concludes that it is important that smokers be provided with factual information about Lights and Ultra Lights in an effort to promote quitting.12

    The three papers by Shiffman et al explore the type of messages that could effectively counter the misperceptions that consumers have about Light and Ultra Light cigarettes, relying on recent survey and experimental data.13-15 Like Kozlowski, they found that most smokers believe that low yield products are less harsh and deliver less tar and nicotine (p i17).13Further, they found that smokers of all tar levels believe that Lights afford a 25% reduction in risk, and Ultra Lights a 33% reduction in risk. In fact, the beliefs were supportive of one another—that is, smokers of these products believed that the products imparted a substantial health benefit, in part due to their own personal experiences that these cigarettes feel less harsh and in part due to their belief that these products delivered less tar and nicotine. Shiffman et al concluded that beliefs based on these sensory impressions may be psychologically important because they provide a particularly fundamental basis for belief in the health benefits of low yield products.13

    In the second and third Shiffman papers (pp i24 and i33),14 15 the authors explore the effect of two different health messages about low yield products on beliefs and quitting intentions—one message emphasising how the sensory experiences of low yield products can be deceptive (“Feel”), and the other emphasising how cigarette ventilation can undermine nominal reduction in yields (“Vents”). The authors found that the “Feel” message yielded consistently better results in changing both beliefs and quitting intentions. The authors concluded that although the “Vent” message provided information on how the products were designed to “cheat” the smoker from achieving lower smoke yields, it may have been too technical and complex. On the other hand, the success of the “Feel” message was consistent with the research on symptom perception and common sense models of illness, which suggest that people often draw on their bodily experiences to arrive at erroneous conclusions about health threats and appropriate protective behaviour (it feels lighter therefore it must be better for me).

    The implications of this type of research for the public health community were explored in the article by Canova et al (p i43).16 The authors recommend that tobacco control advocates should provide support intellectually and financially for the delivery of strong counter marketing messages debunking the low tar myth. In addition to paying attention to the research and designing messages that address smokers' misperceptions, the authors conclude that the messages should also indicate that there are no standards governing what constitutes a light or reduced risk cigarette and that such cigarettes are not reduced risk. Moreover they note it is important to warn smokers to be leery of the new generation of so-called “reduced risk” products unless and until tobacco manufacturers are fully accountable to the FDA. Just as the tobacco companies 50 year record of claims of “reduced risk” for its low yield products have now been proved to be unfounded, there is no way to assure that this new generation of products will be any better or safer unless the FDA has full and complete authority to regulate tobacco products and the claims made for them.

    This latter message is worth repeating—full and real regulatory authority is needed now (in the USA that would be FDA jurisdiction). It is needed to require tobacco companies to reduce the harm their products cause and it is needed if we are to have a meaningful change in the way tobacco products are marketed.

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