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Doing the unthinkable (and saving millions of lives)
  1. Richard A Daynard
  1. Dr R A Daynard, Public Health Advocacy Institute, Northeastern University School of Law, 102 The Fenway, Boston, MA 02116, USA; r.daynard{at}neu.edu

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In the 17 years since the journal Tobacco Control began, control of tobacco has made tremendous progress. Smoke-free laws are sweeping the globe. Voters in several US states went to the polls to raise cigarette taxes, funding tobacco control programmes and reducing smoking rates. A 1998 settlement of state lawsuits against the tobacco industry in the United States raised cigarette prices, eliminated most outdoor advertising, funded counter-advertising, greatly reduced youth smoking rates and put millions of documents evidencing industry misbehaviour around the world on the internet. More than 80% of the world’s population now live in countries that have ratified the Framework Convention on Tobacco Control (FCTC), thereby committing themselves to greatly limit cigarette advertising, ban misleading package labelling and require strong package warnings, protect non-smokers, control smuggling and take other steps to discourage smoking. And major foundations have committed over $500 million (£340 million; €390 million) to supporting tobacco control efforts worldwide. Aren’t we in (or at least fast approaching) the best of all possible worlds?

Well, actually, no. There are currently over 40 million cigarette smokers in the US, and around 1.3 billion smokers worldwide. In the US half of all lifetime cigarette smokers will die from cigarette-caused diseases. Each year about 1% of US cigarette smokers die from these diseases; elsewhere, the figure is 0.4%. If nothing were done cigarettes would kill one billion smokers this century; the tobacco control interventions currently on the table would significantly reduce this number but still leave hundreds of millions of premature cigarette-related deaths.

What is to be done? The answer is as simple as it is apparently unacceptable. Cigarettes are the dirty needles of nicotine delivery devices. Addicts who get their nicotine from cigarettes are at least 10 times as likely to die from their nicotine delivery device as those who get it from non-smoked nicotine products. Phase out the cigarettes, while permitting non-smoked nicotine delivery devices to remain on the market, and the great majority of tobacco-caused diseases and deaths will disappear (some, like heart disease and most adverse health effects in non-smokers, almost immediately, while others like cigarette-related cancer will take several decades to disappear completely).

But we all know “you can’t ban cigarettes!” Well, do we?

First, major progress in tobacco control has always required confronting and overcoming conventional wisdom. “There will always be smoking in restaurants and bars”. “Voters will never approve tax increases”. “Lawsuits against tobacco companies are hopeless”. “Any attempt to pass a strong international tobacco control treaty would be killed by tobacco industry opposition”. “Tobacco control isn’t sexy; major funders won’t invest in it”. Indeed, I believed most of these propositions myself, before realising that they don’t have to be true and that actions by tobacco control advocates can contribute to disproving them.

Second, the general public, at least in the US, is well ahead of the tobacco control community on this issue. A 2006 nationally representative poll of US voters found that 45% favoured banning cigarettes while 52% were opposed, despite the complete absence of any public figure advocating such a ban.1 Similarly, annual Massachusetts surveys from 1995 to 2000 showed the proportion of such supporters hovering around 50%.2 Apparently, almost half the public doesn’t understand why a product that kills as many people as cigarettes and has no useful function is still allowed to be sold.

Third, this would not be like the US experiment in prohibiting the sale of alcohol. While Prohibition did reduce alcohol-related injuries and diseases, it proved politically unsustainable. The main motivation for Prohibition was moral health, not public health; when the moral consensus changed, it was repealed. The tobacco control movement’s problem with cigarettes is not “moral”: if cigarettes didn’t sicken and kill so many people, we’d all be doing something else. Furthermore, the desire for the effects of alcohol created a brisk demand for bootlegged products, nurturing organised crime. Nicotine, on the other hand, would continue to be available in a variety of formats, but divorced from the carcinogens, carbon monoxide and irritants that burned tobacco produces.

Fourth, while some tobacco control advocates fear that supporting a cigarette ban would marginalise them in the political process, making it difficult or impossible to effectively promote the measures currently on the table, I believe that is no longer true in the US and possibly other countries. The proposal has been advocated by leading New Zealand health groups without marginalising them. It is certainly true that “You’re really prohibitionists” was at one time a favourite tobacco industry taunt, but most members of Congress and of the public have long since accepted that cigarettes kill both smokers and non-smokers and that serious steps should be taken to deal with the problem. Public health advocacy groups are generally understood to be performing a public service by advocating strong steps to reduce cigarette-caused carnage. While specific members of Congress might or might not agree with the additional proposal of a cigarette phase-out, they would certainly understand the context in which it was being offered.

There are obviously important issues that would have to be considered in a fully specified phase-out proposal. “Roll-your-own” tobacco would probably have to go along with cigarettes, since cigarettes, which do roughly the same damage as commercial cigarettes could easily be made at home. Cigars and pipe tobacco raise closer questions. Smuggling would be a problem as it is with currently illegal drugs, but the problem would probably be manageable: cigarettes are relatively bulky and hence difficult to smuggle in large quantities, and the demand would be reduced by the availability of legal nicotine delivery devices. Finally, the US “War on Drugs” has earned a bad reputation by targeting users for draconian sanctions; the phase-out, by contrast, should be of the commercial sale of cigarettes, and should not punish private possession or consumption.

Phasing out cigarettes will not be easy. But neither were our earlier campaigns. And if this one succeeds, the next generation of public health advocates might actually be able to move on to something else!

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Footnotes

  • Competing interests: Richard Daynard is president of the Public Health Advocacy Institute (formerly, the Tobacco Control Resource Center) and chair of its Tobacco Products Liability Project. He is also professor of law at Northeastern University School of Law. He has been credited with pioneering the strategy of using lawsuits against tobacco companies to achieve tobacco control goals.

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