Commitment to quit is essential for tobacco harm reduction

Abstract

World No Tobacco Day (WNTD) is marked by the World Health Organization on 31 May each year. In 2021, under the shadow of the most significant viral pandemic in over a century, WHO has chosen ‘Commit to Quit’ as the theme for WNTD and this is important for two key reasons. First and sadly, this pandemic has a long way to run, particularly in resource-constrained countries and a significant proportion of severe coronavirus disease 2019 (COVID-19) illness and mortality is related to the higher risks in current and past smokers. Second, even in a pandemic, continued focus on non-communicable diseases including those tobacco-related is needed. Comparisons are odious but that fact is that, during the course of the COVID-19 pandemic to this point, three times as many people will have died from tobacco-related disease as have died from COVID-19. A focus on commitment to quit is important. The alternate proposition, so-called Tobacco Harm Reduction (THR), the concept that modifications to the nicotine delivery vehicle could render ongoing tobacco use safe or sufficiently less harmful that a smoker might continue its use, has emerged again, phoenix-like, from the ashes of previous failures primarily as a promotional strategy for electronic cigarettes (EC) and heat-not-burn tobacco (HnB) products. For 60 years, under various guises, the tobacco industry and some of its academic acolytes have expounded and amplified the THR concept. It was, and remains, a classic tale of spin over substance and it is a history worth reflecting on. In the early 1950s, with lay and medical articles specifically linking smoking with lung cancer, the tobacco industry was in peril. It had a need for legitimacy, to be seen as having the interest of its consumers at heart and to be included in health and harm discussions even as it denied publicly that smoking caused disease. What emerged was the decadelong ‘Tar Derby’. Filters were added and headline cigarette tar levels greatly reduced. The purported health benefits were widely promoted and careful public messaging created to enhance the image of industry participants. By the time that the US Federal Trade Commission effectively ended the Tar Derby in 1960, millions of smokers who might have committed to quit had instead been falsely reassured. The relative safety inferences were never supported by evidence and later contradicted. Lesson number 1—reliance on intuition in novel situations is fraught with risk. In the 1960s, as evidence of smoking-related harms mounted, the tobacco industry was faced with a stark choice. It could admit publicly that smoking was harmful and commit to creating a proven safer product, the British position, or continue its denial. This discussion, which ran over some years, was best exemplified at the so-called ‘Operation Berkshire’ meeting. Denial won out and would continue but companies individually and secretly experimented on ‘safer cigarettes’ focussing primarily on even lower tar levels. As nicotine was known to be the agent of addiction, cigarettes with high amounts of nicotine relative to tar were a logical first step but were rated by smokers as unpleasant or harsh. The cigarette that emerged at the time featured reduced tar and nicotine in approximately fixed proportion. However, lower nicotine delivery resulted in compensatory oversmoking in the same way as reduction in the number of cigarettes smoked per day does. Neither use of lower tar cigarettes nor a reduction of >50% in cigarettes per day were found to reduce cardiovascular events, repeat hospital admissions for chronic obstructive pulmonary disease (COPD), to have more than a small effect on lung cancer diagnosis and did not reduce overall mortality. Lesson number 2: the relationship between inferred tobacco toxin exposure and harm is not simple or linear. It was apparent from the ‘safer cigarette’ and known to major manufacturers from their research that a de-nicotinized cigarette could be developed but was so unrewarding that smokers would not continue its use. Below a certain level of tar, satisfaction fell away and the compensatory oversmoking was not tolerated. Innovation in the enhancement of nicotine delivery from lower tar cigarettes was required. The Marlboro cigarette emerged; its commercial success primarily attributable to novel product chemistry with manipulation of smoke pH by the addition of ammonium being critical. As revealed in a range of internal documents, this was based on research investment and data generation that probably exceeded in quality that of the ethical pharmaceutical industry at the time. The mild or light cigarette emerged later—a highly marketable cigarette with low or very low tar that remained highly addictive and attractive to current and new smokers (but with no health advantage). Lesson number 3: the greatest expertise in the creation of products that establish and perpetuate nicotine addiction rests within the major tobacco manufacturers. Over the period since 1950, untold millions of lives have been lost because smokers accepted the various THR propositions. The lessons of the past must be learnt. As conceded by its earliest proponents, the argument that complete or partial substitution of EC or HnB products for tobacco smoking will reduce realized harm based primarily on intuition rather than definitive evidence. Are assumptions based on changed chemical exposures to the lung and Received: 2 May 2021 Accepted: 3 May 2021