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Clive Bates describes a tobacco industry under competitive pressure from “clean” nicotine used not just therapeutically but recreationally. Depending on how big the recreational nicotine market became, the extent to which tobacco companies moved into the cleaner end of it, and the extent to which demand for traditional tobacco products declined, tobacco companies' customer base and profits might in fact expand significantly under such a scenario.
That the tobacco industry might prosper is neither here nor there. The question we should be concerned about is whether expansion of the nicotine market is the most effective way of reducing the harm currently caused by tobacco.
Should we deregulate nicotine tomorrow?
A recreational nicotine market would be a very large genie to let out of the bottle. It would be global, powerful, and potentially more difficult to regulate than we can currently appreciate.
Imagine a scenario 10 years hence. We have persuaded several governments to remove regulatory barriers for recreational nicotine. As with nicotine replacement therapy today, manufacturers agitate to be allowed to advertise these potentially life saving products. Several million smokers are persuaded to switch to cleaner nicotine. However, several thousand young people who would not have used tobacco become nicotine users; tens of thousands of current smokers who would otherwise have quit altogether instead switch to these products, some exclusively and some in combination with cigarettes; and several thousand ex-smokers are attracted back to nicotine. Does this “collateral damage” matter? Are we still ahead?
Proponents of recreational nicotine concede that nicotine is not risk free. Much more serious, however, it the possibility that people using clean nicotine might be at risk of taking up or returning to smoking at some level.1 After all, no threshold has been established for smoking and the risk of cardiovascular disease. Kawachi and colleagues found that smoking as few as 1–4 cigarettes per day doubles the risk of coronary heart disease.2Duration of smoking is more important than the amount smoked in determining the risk for cancer.3
As with other drugs, it is the totality of the smoking experience—the psychosocial connotations, the ritual of it, the sensuality of the actions—that is reinforcing for tobacco users, not just the delivery of the addictive agent. While it may be technically feasible to manufacture less hazardous nicotine products, it cannot yet be taken for granted that these will be acceptable to consumers still able to buy products that can be smoked. Although they “try try try”, clean nicotine users would just “get no satisfaction”.
Imagine that we have also succeeded in persuading most governments to mandate reductions in carcinogens, and the ratio of nicotine to carcinogens.4 That is, the higher the carcinogen levels, the less nicotine allowed in the cigarette. Several years down the track, however, tobacco companies claim that black market, high strength cigarettes are threatening their viability and the government's tobacco tax revenue. Governments agree to ease the pace on cigarette nicotine reduction, arguing that the widely advertised recreational nicotine products increase the ability of consumers to make informed choices. Unfortunately, however, increasing numbers of nicotine dependent people keep drifting back to cigarettes.
Are we still ahead of where we'd have been if we'd simply mandated hazard reduction in traditional cigarettes? Apart from having created a generation of recreational clean nicotine users, might we also have reduced the numbers of smokers quitting altogether, and only marginally reduced the risk of those who continue to smoke at some level?
What might go wrong?
We should take a little time at this point in the already tragically long history of the tobacco epidemic to think about what might go wrong, and whether the potential benefits outweigh the risks. Clearly and most crucially we need to establish whether smokers are likely to accept ultra-low tar cigarettes that provide vapour but not smoke, and whether consumer appeal might be increased with the right price incentives, packaging, and marketing. Epidemiologists need to advise us about the extent of harm reduction required of reduced smoking and less hazardous cigarettes to offset the risk of fewer people quitting.
Do we have sufficient political skills to persuade governments to implement all and not just some of the pieces of our regulatory package? Are our regulatory skills up to the complexity of the public health challenges that recreational nicotine would create? Are we sure that the availability of recreational nicotine would encourage, not discourage, governments from supporting new more effective tobacco control policies?
Advocates may persuade us that the answers to all these questions are “yes” and that “clean nicotine” isthe best course to pursue. Equally there is an onus on those who do not like the idea to come up with something better . . . for to do as little as we currently do for the world's 1.1 billion smokers is surely not conscionable.