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Editor,—The report of the American Medical Association (AMA), “Reducing the addictiveness of cigarettes”, was written by well respected tobacco experts.1 This time, however, the position taken by the AMA and the British Medical Association (BMA) did not reassure us and the AMA position is even inconsistent with statements of two of the authors made two months earlier. In John Slade’s and Jack Henningfield’s paper presented in Washington, DC on 8–9 April 1998, they said: “Nicotine reduction is an option that should kept be open and carefully explored because of its potential for public health benefit. It is far from being a perfect policy option, however, and . . . there are many other useful things the FDA should do in regulating tobacco products without ever controlling or limiting nicotine itself.” In fact, both authors listed a whole range of concerns that needed to be explored, and concluded that much more research should be conducted before any nicotine reduction strategy is considered for implementation.2 Only two months later, the AMA adopted its resolution to phase out nicotine and provided answers for some of the concerns raised, such as compensatory smoking, smokers assistance, and fear of the black market.
We feel that they were unable to address properly these extremely complex concerns. Nicotine is the driving force behind smoking. A cigarette without nicotine is a different product and nicotine-addicted smokers will still look for their nicotine dose. The AMA authors are aware of this barrier and proposed to increase the range and accessibility of nicotine-delivering medications. This proposal will only partly resolve the problem, as not all smokers want to stop smoking, not all smokers are willing to use non-tobacco nicotine replacement products, and not all smokers who follow a nicotine replacement treatment will eventually stop smoking. Cigarettes without nicotine are a prohibition-type solution that will automatically create an illicit market.
In addition, black market sales were not well addressed in the AMA report. The actual problem of worldwide smuggling cannot be compared with the situation where cigarettes no longer contain nicotine: it would be rather naive to think that “improved cooperation of manufacturers” would ever take place if nicotine were totally banned. Without nicotine there will be no market for cigarettes and without a market there will be no more tobacco industry. Of course the industry will not collaborate: they will continue to organise smuggling from several countries to supply the millions of nicotine-addicted smokers unwilling to accept the prohibition policy of the AMA. According to the authors, “even if there was a contraband market, the size and health impact of that market would be less than the current cigarette market”. Our concern is with the notion that only law enforcement will lead to fewer sales. The downside would be a society where police prosecute smokers of nicotine-containing cigarettes, as were alcohol drinkers in the United States in the 1920s, with all the attendant problems. The AMA resolutions are not a dream to resolve the tobacco problem; they may become a nightmare.
In reply,—The letter by Joossens and Hayes on our proposal to gradually remove the nicotine from cigarettes1-3 raises a misconception about our views that we would like to correct. We believe that requiring the elimination of nicotine enhancers and substantial reductions of nicotine from commercially marketed cigarettes is a strategy that should only be implemented in the context of a range of other essential actions as described in the report. In fact, a major advance of our report, beyond the earlier proposal by Benowitz and Henningfield,1-4 is that a nicotine reduction strategy must be done as part of an overall strategy that considers issues ranging from education, treatment, legislation, and meaningful tobacco product labelling, to the need for supportive research and surveillance to guide the process as well as the importance of alternative products being available. It should be noted that the recommendation referred to by Joossens and Hayes was the fifth of eight and it was stated as follows: “The AMA encourages the FDA [Food and Drug Administration] to assert its authority over the manufacture of tobacco products to reduce their addictive potential at the earliest practical time, with a goal for implementation within five to 10 years.” How long such a process might actually take would depend on many factors as described in the report.
The view that such a nicotine reduction action is conditional on addressing the issues raised in the report is consistent with the earlier conclusions expressed by Slade and Henningfield which similarly argue for a comprehensive approach to reducing the death and disease caused by tobacco1-5 In that sense, the proposal is no more, or less, conditional, than suggestions to reduce the “tar” yield of smoke (which depends in part on prior decisions about how to measure “tar” and what “tar” is) or the dictates of the European Community and World Health Organisation which have successfully reduced the widespread marketing of tobacco product types—for example, Swedish snus or certain American moist snuff preparations—in countries that did not already have them marketed on a widespread scale. Our proposal may be more complex than the aforementioned examples, but the concept is the same, namely to restrict the currently practically unfettered ability of the tobacco industry to develop and market products that maximise addictive effects, regardless of other health consequences. As discussed earlier,1-4 the proposal may seem drastic to some, but the present course of more than 400 000 premature deaths in the United States each year, and rapidly escalating morbidity and mortality globally, is a drastic, unprecedented epidemic that could be checked. Other issues raised by Joossens and Hayes were discussed in the Spring 1999 issue of Tobacco Control.1-6
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