Blowing Smoke About Tobacco
"Tobacco: deadly in any form or disguise" is the slogan of the World Health Organization's World No Tobacco Day tomorrow. The claim is false: Tobacco is not deadly; the harm is in the smoke. A policy that confuses innocuous tobacco with harmful smoke is responsible for millions of avoidable deaths each year worldwide.
Cigarette smoke is a deadly delivery device for a benign but habit-forming product: nicotine. Nicotine isn't especially dangerous -- about like caffeine. Good policy toward tobacco use would reduce the grave harm of smoking by replacing cigarettes with non-smoked forms of nicotine for the addicts. They might use nicotine safely forever, if harmless delivery systems were widely available.
Instead, nicotine abstinence is the policymakers' only approach to tobacco. Like other abstinence campaigns (alcohol prohibition, sexual abstinence before marriage, just saying "no" to drugs), this one is both moralistic and ineffective.
The human cost of the nicotine-abstinence policy is doleful. More than 430,000 U.S. deaths each year -- one out of every five -- can be attributed to smoking. This is 10 times our death rate from car crashes, 30 times the rate from AIDS -- an unprecedented toll that is a testament to the inadequacy of 40 years of quit-smoking policy.
The surgeon general reported smoking to be a health hazard back in 1964, but the net effect of smoking-cessation messages since then is that between 4 and 5 percent of smokers quit each year. Of the approximately 14 million Americans who try to quit smoking every year, only 2 million succeed. That failure leaves 45 million to 60 million American smokers, more than one-fifth of American adults. Most of them smoke regularly. Another million or so start smoking each year. In fact, of all the Americans alive today who ever smoked regularly, half are smoking now.
Obviously, nicotine use is a popular and tenacious habit. Equally obviously, tobacco policy is a failure. Surveys show that a majority of current smokers would like good alternatives to smoking as ways of getting nicotine. But we will not tell nicotine users that there are safe ways to continue to use the legal drug they crave. Apparently, our policymakers would rather see those people get sick and die.
Alternative nicotine delivery could be easy. Nicotine replacement therapy could work long-term. Gum and the patch are already available, but not to everyone. Also, they are still approved only for short-term use and can deliver only small doses -- inadequate for heavy users.
Smokeless tobacco would work. It comes in several forms. One is chewing tobacco, made famous by cowboys and ballplayers. But other forms are handier, less messy and far less dangerous than smoking. Yet health officials label smokeless tobacco as "not a safe alternative to smoking," despite much evidence that it is quite safe. Indeed, current policy is so wedded to nicotine abstinence that officials will lie to discourage widespread use of smokeless tobacco as a way of delivering the drug.
As Carl V. Phillips, an epidemiologist at the University of Alberta, has shown, evidence points to a low risk of health hazards stemming from smokeless-tobacco use. That includes virtually no evidence of risk of oral cancer. Phillips's calculations show that total mortality from "smokeless" is about a hundreth of that from smoking.
And then there's what many smokers nowadays really do: Mix periods of abstinence (encouraged by smoke-free workplaces and restaurants) with periods of light smoking. Mixing light or occasional smoking with other nicotine-delivery products might be even safer -- but it can't be studied as a possible alternative because current funding goes only to research on how to quit smoking, not on finding a safe level of smoking.
How shameful that the United States is willing to allow almost a half-million Americans to die each year, and that the World Health Organization is prepared to allow up to 5 million annual deaths worldwide -- all because of a delivery device -- cigarette smoke -- whose hazards are well known and largely avoidable.
Where's the usually progressive public-health establishment on this? We are generally not given to telling people, "Stop doing what you are doing." We prefer health promotion in the form of seat belts, motorcycle helmets, condoms, syringe exchange, ingredient labels, and warning labels, rather than forcing people to quit their habits. But with tobacco we have jettisoned our tolerance and thrown all our support to nicotine abstinence.
We cannot ignore tobacco in its one deadly "disguise": cigarette smoke. Neither should we ignore a deadly nicotine-abstinence crusade disguised as tobacco control.
The writer, an epidemiologist, is on the faculty of the School of Health Sciences of Hunter College at the City University of New York.