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The path towards progress in public health has never been a smooth one, especially for efforts to protect the public from dangerous products. Health is deeply political, and one’s life chances, while partly a factor of inherited genetic tendencies, are also substantially shaped by policy decisions made by elected officials and agency personnel at a distant remove from one’s daily life. Those decisions, in turn, are influenced by campaign contributions, personal ideologies and world views, and the political climate of the moment. In some ways, it is amazing that we have made so much progress on tobacco control policy, given the forces arraigned against it.
But it is not only ‘external’ battles that must be fought: within the tobacco control movement, progress has always been accompanied by struggles among those who share the goal of a tobacco-free world, or at the least a world with far less tobacco-caused disease and premature death. Every policy innovation at one time had its doubters, detractors and critics, and some internal battles have been painful to watch.
The current moment is no exception. This special issue focuses on some of the hot topics in tobacco control to highlight new work and new challenges. Among these hot topics: policies related to e-cigarettes, how the public appraises harm and safety, and the possible up and down sides of nicotine reduction or regulation of other ingredients in the product as a tobacco control strategy.
Continuing the heated debates about regulating e-cigarettes and their use, two perspectives are offered on whether e-cigarette use should be permitted in smoke-free public places. Papers led by Chapman1 and Bauld2 illustrate the wide divide that exists among opponents and proponents of such use. The perspectives of smokers and ex-smokers in the UK, to date the most liberal in embracing the potential of e-cigarettes to reduce cigarette smoking, are captured in a paper by Brose et al 3 who find mixed results. Support for use in smoke-free places appeared to be decreasing across two waves of a web-based survey, but there was strong support for equal or higher availability of e-cigarettes compared with conventional cigarettes. Yingst et al 4 studying a mostly US-based online panel of experienced exclusive e-cigarette users, found that most users reported unrestricted use, but that the majority of those who did find their use restricted by public place policies did not find it difficult to refrain from vaping in such places. Shi et al, in a similar study5 found that e-cigarette users reported vaping in places where cigarettes were not allowed, most often in bars and clubs. They conclude that most e-cigarette users do not consider smoke-free laws applicable to e-cigarettes. States and nations are taking widely divergent approaches to this question; no consensus has yet emerged about use in public places. However, in terms of toxicants, Wagener et al 6 suggest that later-generation e-cigarette devices, as compared with cigarettes, deliver less of at least some harmful constituents while matching the nicotine delivery profile of conventional, more harmful combustible cigarettes. This would add to the argument that perhaps these later devices should not be subject to more onerous regulatory approval regimes, while the most deadly combustible products are ‘grandfathered’ under US Food and Drug Administration authority.
In another set of perspectives, Hatsukami7 argues for mandating reductions in nicotine levels of tobacco products, an approach that has been recommended in a World Health Organisation Advisory Note. Is regulating nicotine levels a way to reduce the attractiveness, addictiveness, and appeal of smoking and thereby reduce harm? Or could it create unknown additional harms, especially if undertaken without a comprehensive regulation of all nicotine and tobacco products? Kozlowski8 and Borland9 argue that nicotine reduction could have downsides and should be seen as part of an overall “nicotine maintenance” strategy, not as an end in itself. Donny et al,10 arguing that reduced nicotine cigarettes should be tried in New Zealand, respond to common questions about this approach. However, as Rupprecht et al report,11 weight gain may be a likely consequence of reduced nicotine exposure, similar to that associated with quitting smoking. No government has yet undertaken mandatory nicotine reduction, and the regulatory and enforcement costs associated with such a step will likely limit its chances to high-income countries in the near term. The question is whether this product-intensive effort, which might be countered by the tobacco industry through addition of other ingredients to cigarettes or rebalancing of the chemical stew they constitute, is the most expeditious and acceptable way to reduce tobacco use.
Perceptions about relative safety and how to convey relative harm continue to be sources of contention and policy challenges. In a review paper, Czoli et al 12 report that substantial proportions of respondents in 54 studies reported inaccurate beliefs about the relative harmfulness of smokeless tobacco versus combustible cigarettes. This has important ramifications given the history of ‘no safe tobacco product’ messages that have long been promoted by health authorities, particularly in the USA. A brief report from Wave 1 of the Population Assessment of Tobacco and Health (PATH) study13 finds that users of products marketed with now-banned descriptors (‘light’ and ‘mild’) or currently marketed as ‘additive-free’ or ‘natural’ were more likely to believe that their brands might be ‘less harmful’. A majority of American Spirit smokers reported this belief, despite the brand’s disclaimers. Pearson et al 14 likewise found using PATH data that nearly 64% of American Spirit smokers inaccurately believed that their brand was less harmful than other cigarette brands. But it is not only textual descriptors like ‘natural’ that matter in shaping user perceptions, as Moran et al 15 show in an analysis of American Spirit advertising. Such ads also use other techniques, such as images of plants and nature, to convey ‘natural’ meanings to consumers. Tobacco companies are masterful at reshaping their marketing to continue to convey brand messaging, even when products are banned, as an Industry Watch piece in this issue shows. Brown et al 16 analysed cigarette packs from two Canadian provinces after a menthol cigarette ban had been put into effect. While they found no packs postban that violated the letter of the law by being labelled ‘menthol’, they found that tobacco companies developed new packaging that suggested menthol-like flavouring using colour and new descriptors like ‘smooth’ and ‘green’.
Finally, another set of papers reminds us that policies now taken for granted in some places remain a challenge in others where they have not yet been fully implemented, suggesting there are still conflicts and controversies to be surmounted. Xiao et al 17 used direct observers to assess the effects of Beijing’s Smoking Control Regulation. They found that while smoking was reduced from baseline, substantial smoking still occurred and restaurant staff did not intervene (perhaps to avoid conflict, one surmises). Even in a place like California, however, which passed the first smoke-free workplace law in the USA in 1994, young adults in certain occupations are still exposed to secondhand smoke in service, construction and maintenance, and transportation sector jobs, as Holmes and Ling18 demonstrate from survey data, pointing to the gaps left by exemptions in current law and the new conflicts bound to be produced by trying to end them.
Examining which conflicts and controversies bubble to the top, and where, illumines the enactment of policy discourse, in which everyone can take part. Fights for change are never easy, and it is hard to listen to other points of view when one feels under attack. Civility helps, but doesn’t of itself resolve conflicts. However, after watching the delicate dance of diplomatic language at an earlier World Health Organisation Framework Convention on Tobacco Control Conference of the Parties, I came to see that no progress can be made without it. Let’s hope that in the near future we will have fewer conflicts about tobacco control—because of our hard-won success in achieving an end to this terrible, preventable epidemic.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.