Recent eLetters

The prospect of a tobacco endgame in which death and disease from tobacco would be virtually eliminated is very exciting. We read the May 2013 issue of Tobacco Control on the Tobacco Endgame with great interest. The issue features 20 articles by esteemed co-authors who are known internationally for their work on tobacco control. Each individual article is excellent; however, we were surprised and disappointed that this special issue ignored the very substantial problem of psychiatric comorbidity among smokers. Studies increasingly demonstrate that this group buys and uses more tobacco than any other disparity group (MMWR 2013). They are also very likely to die early from tobacco use, suffer economic burden, and suffer unique consequences such as psychiatric medication complications. The focus of much of the issue is on regulatory approaches or potential changes to tobacco products that may reduce cigarette smoking. While these empirically supported approaches are important, data from New York (http://www.health.ny.gov/prevention/tobacco_control/reports/statshots/volume5) indicates that many important public health policies do not adequately influence smokers with psychiatric comorbidity. A true "end game" strategy must acknowledge the tremendous proportion of smokers with psychiatric comorbidity and offer strategies for addressing this vulnerable population. We agree with Dr Malone when she says that a tobacco endgame "addresses tobacco as a systems issue...{that} reframes strategic debates...{and} advances social justice (Malone 2013, p i42)." Dr. Malone's words validate our concern that psychiatric comorbidity was rarely mentioned in this issue. The word "mental" appears twice (Thomas p56; Chapman p 35) and "comorbid" appears twice (Hatsukami, p 36; Benowitz p 16). A special issue on a tobacco endgame that ignores a group that is hugely overrepresented among current smokers makes it even more likely that this disparate population will continue to be ignored. In past decades the US was successful in driving down smoking rates through public health efforts. Recently these efforts have stalled and we need to consider a new approach. While detailing a comprehensive strategy is beyond the scope of this letter, we are calling for focused efforts, targeting disparate population groups like the poor and the mentally ill. A population approach is reasonable as long as it is also mindful of the "who" that are left smoking. These groups should be given a priority designation for future funding, policy and research efforts because any "endgame" that leaves them behind is no endgame at all.

Conflict of Interest:

None declared

NOT PEER REVIEWED Sincere thanks, Dr. Borland, for your insightful comments recognizing the inherent conflicts between harm elimination and reduction, between policy and profits. As a nicotine cessation educator monitoring the latest wave of irresponsible harm reduction marketing, I have grave concerns that we are only one youth fad away from seeing adolescent nicotine dependency rates skyrocket.

Nicotine addiction is every bit as permanent a disease as alcoholism. It is a wanting disorder in which brain dopamine pathways assign the same use priority to nicotine as they do to eating food. But instead of desiring food 2 to 3 times daily, imagine feeling wanting, urges or craves 15, 20 or even 30 times daily. Imagine that next fix quickly being life's new #1 priority, no longer being able to recall the beauty of going weeks, months and years without once wanting for nicotine.

Marketing suggesting that replenishment anxiety relief is "pleasure" is akin to suggesting that it feels good to stop pounding your fingers with a hammer. We are also seeing laughable harm reduction marketing centered on the concept of "freedom," or that nicotine is as safe as caffeine.

U.S. First Amendment commercial free speech concerns will likely trump marketing control initiatives. In nations where non-profit control is possible, history suggests that keen awareness as to financial conflicts among those permitted to define policy is critical if dependency onset avoidance and effective cessation are goals.

Your government agenda concerns are warranted, Dr. Borland. Nearly four years since passage of the U.S. Family Smoking Prevention and Tobacco Control Act and we have yet to see any meaningful change. Imagine 400,000 annual smoking related deaths and no sense of political urgency.

Imagine knowing that NRT shows efficacy against placebo in studies we know were not blind, while totally ignoring NRT's population level ineffectiveness evidence-base, and the prospect that three decades of feeding replacement nicotine to nicotine addicts may have cost millions their lives.

I am convinced that replacement nicotine has effectively destroyed cessation. Having watched decline in adult smoking grind to near standstill, we now watch as the frustrated harm reductionist throws cessation under the bus.

I live in a nation where this year cold turkey is again expected to generate more successful ex-smokers than all other methods combined. Yet, locating any researcher curious as to the keys to successful abrupt cessation is mission impossible. If neo-nicotine industry influence is allowed to define government's harm reduction agenda expect more of the same.

I submit that advancing delivery technology and declining prices are already heralding the cigarette's demise. As the cigarette industry moves toward enhanced smokeless, NRT and electronic nicotine delivery, the pharmaceutical industry is moving from cessation into maintenance. Market forces are causing it to occur without intervention.

But if heroin were legal would we allow it to be marketed in front of children? An immediate priority should be to compel stores to choose between marketing one of the planet's most captivating chemicals and having adolescents as customers. How hard would it be to pass local laws requiring that "all" nicotine products be sold inside clearly marked nicotine sales locations, where underage youth may not enter? Anyway, well done, Dr. Borland, in encouraging this much needed discussion.

Conflict of Interest:

Director of an abrupt nicotine cessation website and author of "Freedom from Nicotine - The Journey Home"

NOT PEER REVIEWED Simon and Melanie,

Thanks for the article. With respect, i'm not convinced by your arguments here however.

Firstly, it is incorrect to broadly assume that millions upon millions of people in the 'real world' quit smoking unassisted. Some of them may have, but most would have been given some kind of assistance, albeit even if very brief. It may be advice from their GP, watched television health marketing messages, received cessation strategy suggestions from friends and relatives, biofeedback on their blood pressure or lung x-ray, advice in a book...and so on. Are you saying that this is not cessation assistance? It's just that it's not the more intense assistance such as NRT that you may be referring to.

Of the millions and millions of those who have quit that you refer to without the more intensive interventions, you do not mention just how many of these are now either a. dead from smoking or b. living a life of misery due to not quitting soon enough. It is a simple but compelling public health argument that we must try to reduce the risk of smoking related disease as best we can, and as soon as we can. This means embracing evidence based interventions such as group behaviour therapy and medications like varenicline. We can not escape the fact that these more intensive approaches increase the odds of quitting (see cochrane reviews)

We will never know just how many people quit 'unassiste'd yet contracted a smoking related disease. Yet they may however have otherwise lived a long and 'relatively' healthy life if only they had professional, intensive support earlier.

Sure, it remains to be seen if devices like the e-cig will enhance cessation, but if it turns out that it actually does, then there is a solid argument to support it's use. If I can increase my odds of quitting now by using say the e-cig, i'd rather at least try that than finally quitting 'unassisted'years down the track only to wind up with lung cancer.

Conflict of Interest:

Consultant conducting smoking cessation interventions and cessation skills training

NOT PEER REVIEWED The authors of "Has the tobacco industry evaded the FDA's ban on 'Light' cigarette descriptors?" examined four distinct indicators to address this research question. They found that: (1) the major cigarette manufacturers removed the terms explicitly stated in the Family Smoking Prevention and Tobacco Control Act of 2010 by switching to colour terms (e.g., Marlboro Gold) to designate sub-brands; (2) the mean percent filter ventilation did not significantly differ between 2009 Light-designated cigarettes and the corresponding post-ban sub-brands; (3) one year after the ban on Light designations, 88%-91% of current smokers reported that it was 'somewhat easy' or 'very easy' to identify their usual brand of cigarettes by the banned descriptor names, Lights, Mediums, or Ultra- lights; and (4) sales of previously-designated Light sub-brands did not significantly change between the first two quarters of 2010 (pre-ban) and the second two quarters (post-ban). Based on these findings the authors concluded that, "Tobacco manufacturers appear to have evaded a critical element of the FSPTCA, the ban on misleading descriptors that convey reduced health risk messages".

This overreaching conclusion is not supported by the evidence reported in the article. Taken in turn: (1) the major tobacco companies demonstrated 100% compliance with the law by eliminating all terms specified in the FSPTCA--the use of colour terms to designate sub-brands is not regulated by the FSPTCA; (2) there is nothing in the FSPTCA that requires, or even suggests, that tobacco companies should modify filter ventilation levels; (3) it is hardly surprising that one year after the ban, almost all then-current smokers could remember the old Full- flavored/Medium/Light/Ultra-light designation of their usual brand of cigarettes--a much more telling test of the effect of these designations on brand preference would have required surveying new initiates to the smoking habit--and in any case, there is little discernable relevance of these data to the question of whether or not the tobacco industry evaded the FDA's ban on Light-type cigarette descriptors; and (4) one would not expect habitual smokers to change brands based on the repackaging mandated by the FSPTCA (provided they could identify the new equivalent), only that recent smoking initiates might display different brand preferences in the first and second two-quarter periods of 2010 due to the switch from Lights -type descriptors to colour-based descriptors, an effect that the published study would have had very limited power to confirm, had the authors looked for it.

Conflict of Interest:

None declared

NOT PEER REVIEWED Prof. Ruth Malone is a real, well known catalyst in controlling use of tobacco worldwide. Now her one very sharp weapon to control tobacco use is to implement a policy in terms of rejecting tobacco industry funded research manuscripts publication. There are currently hundreds of thousands of journals including open access journals and are these journals going to follow the steps of TC policy of TCJ? If the answer to this question is no, the tobacco industry funded research and research articles could be published in journals other than TCJ. Even if the answer to the above question is yes, assuredly not all medical sciences journals will implement this TC ploicy. Therefore there remains a strong possibility that the tobacco industry funded research will continue and their findings, biased or unbiased, will be regularly published in a multitude of journals across the world. The tobacco business, from seedling to production to manufacturing, can not be eradicated completely, but concerned people concerted efforts directed towards controlling this slow fatal addiction should persist and continue in future. Dr. Naseem Akhtar Qureshi MD, PhD Dr. Abdullah M. Al-Bedah MD

Conflict of Interest:

None declared