Reduced product toxicity indicates reduced risk

The ISCSH’s first attempt to promote ‘safer smoking’ was to approve new cigarettes with one-quarter of the tobacco replaced with a tobacco substitute. The ISCSH approved modified cellulose cigarettes in their first report issued in 1975.12 33 The products nonetheless failed to attract customers.38 Had these products succeeded, the fate of the ISCSH may have been different. Virginia Berridge notes that the Minister of Health from 1974 to 1976, David Owen, hoped to use the success of tobacco substitutes to regulate tobacco under provisions of the 1968 Medicines Act.13 34 In January 1976, Owen’s MP-ally Robert Kilroy-Silk proposed controlling tobacco products as medicines and upgrading the ISCSH into a regulatory committee.28 The strategy was abandoned following the failure of tobacco substitutes, opposition from fellow MPs and Owen’s reassignment to the Foreign Office.34

The second decade of the ‘product modification programme' centred on lowering tar yields (and presumably toxicity) in cigarettes. This approach assumed that the most toxic materials are in the tobacco tar (which was correct), and that smokers would not ‘oversmoke’ cigarettes with lower tar yields (which was not).38 Smokers’ compensation later revealed that low-tar cigarettes were sometimes even more dangerous than high-tar cigarettes.39 40

Aware of compensation since at least the mid-1970s,41 the industry worried that compensation could ‘undermine consumers’ confidence in the ISCSH’s efforts to reduce tar levels and thereby ‘imperil the achievement of tar reduction objectives in the current Voluntary Agreement’.42 In 1981, the Chairman of the Tobacco Advisory Council (TAC), James Wilson, asked the ISCSH in one of their many private meetings, to ‘reaffirm to (the British government) and (the) TAC their (ie, the ISCSH’s) continuing belief in the principle of tar reduction’.42 Peter Froggatt, then Chairman of the ISCSH, countered that smokers’ compensation might undermine the product modification programme.43 The TAC insisted ‘there is little evidence of full compensation’ and urged the ISCSH not ‘exaggerate directly or indirectly (its) significance’.44

According to internal documents that were not shared with the ISCSH, the industry had significant financial and political dependence on the low-tar programme. In an August 1983 letter to BAT’s board of directors, Lionel Blackman, BAT’s Director of Research and Development for Europe, stated the ‘strong worldwide move towards claiming that people compensate completely and, therefore, that the low tar program is a fraud’ represented ‘the toughest challenge yet to the maintenance of industry credibility’.45 Blackman believed discrediting low tar would lead to dissolution of the ISCSH and far more stringent industry regulation.45 He encouraged accepting reducing tar to 13 mg by 1987 rather than the UK government’s ‘logical alternative’ of tax increases, which would drive away far more consumers.45 It was of ‘over-riding importance’ not to alienate Froggatt and the ISCSH, maintain voluntary agreements and ‘to get Government to acknowledge its support of the low tar concept’.45 Consistent with the TAC’s requests, the ISCSH’s 1983 report stated that there was ‘no clear evidence of marked compensation over long periods’ and while ‘some (compensation) may occur…the lowering of tar and nicotine yields would still result in reduced average intake of these substances’.46

In 1988, consistent with the US Surgeon General’s Report,47 the ISCSH final report stated that reducing tar yields might not render cigarettes ‘safer’.37 The ISCSH nonetheless supported ‘the lower-yield approach as one part of a general strategy aimed at reducing the extent of disease caused by smoking, while at the same time making the public aware of the limitations of that approach’.37

Collaboration with the tobacco industry will not undermine tobacco control efforts

In the late 1970s, the discovery of compensation prompted prominent physicians and grass-root organisations, most notably, Action on Smoking and Health (ASH) to de-emphasise risk reduction (eg, safer smoking) and promote cessation and prevention.15 31 34 Whereas product modification required the industry’s collaboration with government, a focus on prevention and cessation did not need cooperation with tobacco companies. In 1976, the DHSS issued a booklet supporting prevention and cessation, although it also stated controls should only be introduced ‘after consultation with interests likely to be substantially affected'.48 Based on evidence of compensation, the Health Education Council, a government-funded charity, likened safer smoking to ‘jumping from the 36th floor of a building instead of the 39th'.17 ASH simultaneously called for more taxation, media campaigns, advertising bans and ending government partnership with the tobacco industry.15 34 49

In 1977, Robert Hunter, the ISCSH’s first chairman, gave a speech to a joint conference of the British and Scottish Thoracic Societies in which he defended the industry and the ISCSH’s partnership and focus on risk reduction. To Hunter, industry support of tobacco substitutes and low-tar cigarettes was necessary to get consumers to switch.50 By extension, any policy that antagonised the industry or that threatened its profits would foreclose the real possibility of a safer cigarette, which, he argued, the industry alone had the expertise and incentive to produce.50

On several occasions, industry partnership weakened the ISCSH statements on tobacco risks and delayed policy action. For example, in 1978, on seeing a draft of the ISCSH’s second report, HB Grice, then chairman of the TAC, asked that the ‘scientifically inappropriate’ word ‘addictive’ be replaced with the more correct and less emotive ‘dependence inducing’.51 The final draft did not use the word addictive.35 The TAC also asked that the report mention the industry’s ‘impressive progress’ in reducing tar yields up until that point,51 despite concerns expressed in the broader scientific community, several ISCSH members—and, privately, the industry—about whether compensation negated any benefit from tar reduction.38 The Committee obliged.35

In 1981, several studies demonstrated a dose-response relationship between exposure to smoke and the development of lung cancer in non-smokers.52 The TAC claimed the evidence remained equivocal and that the issue was beyond the Committee’s terms of reference.53 Nonetheless, in a draft of its third report, the Committee wrote of pulmonary harms to children exposed to tobacco smoke. The TAC criticised the draft for ‘overlook(ing)…other differences besides exposure to tobacco smoke that may be significance for the observed increase of respiratory illness’ and deemed the papers showing harms of passive smoking to be ‘of poor quality’ which ‘brought science generally into disrepute’.54

In its third report, the ISCSH held its position that second-hand smoke harmed children and adults with respiratory problems, but conceded that ‘many of the reported associations, including that between passive smoking and lung cancer, have not been established unequivocally’.36 Four years later, over TAC objections, the ISCSH stated exposure to second-hand smoke increased by ‘between 10% and 30%’ the development of lung cancer in non-smokers.55

The industry’s influence on British public health extended through the 1990s through the Tobacco Products Research Trust (TPRT): an industry-funded charity established by voluntary agreement in 1982. In the late 1970s, the ISCSH had requested funds from the TAC to commission and monitor the health outcomes of product modification.56 Ultimately, the TAC gave the TPRT £1 million a year for 3 years.34 By 1987, the Trust funded 60% of all research on smoking conducted in Britain, yet conducted no experiments on smoking cessation or prevention.57

In a book summarising the Trust’s work, Peter Froggatt, chairman of the Trust, emphasised the importance of industry involvement, stating that without tobacco industry funds there would have been ‘no research programme and no Trust!’ insisting that the TPRT worked independently at ‘arms-length’ from the industry.57 However, an internal planning document shows that AM Reid—a lawyer for Imperial Tobacco—told ISCSH Chairman Hunter that the TAC was happy to finance TPRT’s research, provided the industry ‘receive(d) proper assurances of support and encouragement from Ministers and officials, and an indication that the results would not be sabotaged by anti-smoking zealots’.58 Bero notes that because of industry involvement, TPRT-funded epidemiological studies (on compensation, nicotine and the adverse effects of tar) lagged far behind internal research the tobacco industry had conducted on low-tar cigarettes.56 Throughout the 1980s, several MPs criticised voluntary agreements as ineffective,59–62 but support from the government continued.63 64

Nicotine addiction is inevitable and so tobacco control solutions must include ongoing nicotine addiction

In each of its four reports, the ISCSH recommended that smokers quit, and that non-smokers not start smoking. Yet, in its 1979 report, the ISCSH wrote that because some people will nonetheless smoke, ‘it is important that such people should be enabled and encouraged to smoke less harmfully’.35 Chairman Hunter made the same argument in his 1977 speech to the British and Scottish Thoracic Societies, ‘the practical way of diminishing the risk is to produce smoking material which is less damaging and perhaps less addictive’.50

This position was at odds with the British public health community. ISCSH member Dr J Donald Ball also disagreed, submitting a minority report to the ISCSH’s second report in which he disavowed safer smoking.17 Ball argued that the only adequate responses to the epidemic ‘was preventative…requir(ing) measure which stop people smoking or prevent them starting’.65 Robert Hunter later privately apologised to the industry for the minority report ‘not only because of its philosophy but also because it detracted from the main document’.66 TAC Chairman Wilson stated that ‘anything that could be done by the (ISCSH) or the Department of Health to disclaim the minority report would be helpful; (as its) recommendations…would be picked up by anti-smokers and used in an irresponsible and damaging way’.66

The ISCSH’s 1983 Report concluded that low tar, high nicotine cigarettes should be made available to the public, while characterising compensation as a short-term phenomenon less important than lowering tar levels.36 Historian Virginia Berridge argues the growing understanding of nicotine addiction, including the TPRT’s work on nicotine and low tar, ultimately changed the ISCSH’s views on compensation, although a decade after others in British public health.34 Acknowledging compensation, the ISCSH faced a quandary: should the Committee recommend nicotine levels stay the same to prevent compensation but maintain cigarettes’ addictiveness? Or forgo worries of compensation and lower nicotine levels to wean smokers off cigarettes and prevent dependence?67

While the Committee never answered the question, compensation came to inform Froggatt’s private scepticism about the product modification programme. During a 1989 speech to the Royal College of Physicians, Froggatt agreed with critiques that the programme allowed manufacturers to continue to sell ‘zillions of cigarettes’ and conduct ‘consumer acceptability research, which can be commercially very profitable’.68 Froggatt also acknowledged that ‘tinkering with the tar/nicotine ratio’ was ‘hardly morally very edifying and only Jesuitically justifiable’.68 However, this scepticism had minimal impact.

To curtail cigarette use, solutions must be consumer-approved (ie, profitable)

After 1977, the ISCSH was allowed to make recommendations to the TAC,13 and pushed the industry to lower tar yields. However, the TAC argued that tar yields were of a ‘commercial nature’ and beyond the purview of the ISCSH.69 Despite agreeing to tar and nicotine reductions, the industry fought for profitable targets. For example, the Committee met with the TAC to discuss the product modification programme’s shift away from substitutes towards low-tar cigarettes. Here, Chairman Hunter suggested a tar ceiling of 10 mg within the next few years, to which the industry’s response was, according to the anonymous author of the TAC’s meeting notes, ‘extremely uncooperative, if not hostile’.70 The ISCSH’s second report committed to an average tar yield of 15 mg/cigarette within 4 years.

In 1978, the TAC argued that the ISCSH’s recommended tar reductions should depend on consumer demand.51 In June 1979, the TAC then argued, ‘the rate and timing of any (future) reductions’ were ‘primarily political and commercial, and not scientific’ and thus the industry argued the ISCSH was unqualified to make such recommendations.66 The ISCSH was not alone in assuming public health and industry profit must be aligned. In proposing to bring the ISCSH under the Medicines Act, David Kilroy-Silk MP, stated that ‘the industry would be fully involved and consulted at all stages’ of the move.28 In 1980, one Conservative MP voiced support for product modification precisely because it conveniently ‘allow(ed) smokers to have the benefits which they derive from smoking, the Chancellor to have the revenue from the tobacco tax, (and) the tobacco worker[s]…up and down the country to retain their jobs’.71

Tobacco companies successfully delayed the introduction of lower tar products that it thought would be unpopular with consumers, while simultaneously arguing they would improve smokers’ health in a manner ‘consistent both with the need to reduce the harmful effects on health of smoking and with commercial practicalities’.35 The ISCSH continued promoting product modification until the Committee’s end in 1991. To one embittered MP, product modification had ultimately represented an attempt to ‘serve two masters—highlighting the health hazards associated with tobacco while also making use of the revenue it produced’.72 The government terminated the ISCSH in anticipation of 1992 European Community regulations requiring members to establish upper tar levels in cigarettes, rendering the ISCSH redundant.34