Friday, June 19, 2015

Next step for tobacco control? Make cigarettes less palatable

TheConversation: Australia has been a world leader in tobacco control. We were the first to introduce plain cigarette packaging in 2012. We were also one of the early jurisdictions to ban “light” or “mild” labelling on packs in 2005 and to remove tar, nicotine and carbon monoxide labelling on packs in 2006. Those steps were taken after it had become clear so-called “low tar” cigarettes were not less harmful. The problem is these tobacco control measures stop outside of the pack, while the cigarettes inside remain essentially the same. A logical next step is to regulate how companies engineer cigarettes to promote their use.

Why regulate cigarettes?

Taking regulation inside the packs to control cigarettes themselves can potentially achieve three broad aims.
The first is to reduce the doses of cancer-causing agents and other toxins received per cigarette. Regulators would first need to identify those harmful substances in tobacco smoke that can be reduced and then mandate reductions to specific harmful substances. If achieved, this would reduce the harms for current smokers, to some degree, especially long-termers who are unlikely to quit.
The second is to reduce their addictiveness, by controlling the doses of nicotine available to smokers. Getting the right dose of nicotine at the right dose rate is what gives smokers that little buzz of enjoyment they seek but it is also precisely what makes smoking addictive. Addictiveness drives long-term smoking so reducing nicotine availability would also mean reducing harm at a population level, as more people successfully quit.
The third – and often overlooked – aim is to reduce the attractiveness or palatability of cigarettes to particular user groups separately from reducing nicotine availability. This means limiting the range of flavour varieties and flavour strengths available, as well as the tobacco industry’s ability to create impressions of reduced harmfulness.
Such restrictions would make it harder for teenagers experimenting with smoking to transition to being regular smokers and make it harder for long-term smokers to avoid thinking about the harmfulness of smoking.

Less harmful? Not quite

In 2006, Australia ended on-pack labelling of tar, nicotine and carbon monoxide yield figures, after having adopted it by voluntary agreement with the tobacco industry in 1981.
Tar, nicotine and carbon monoxide yield figures were a key part of the failed “low tar” harm-reduction system. The cigarettes labelled “light” or “mild” had reassuringly low tar, nicotine and carbon monoxide figures printed on the side of the pack and many smokers believed these cigarettes were less harmful.
Those cigarettes also had sensory characteristics that are appealing to many smokers: less flavour strength, less “impact” or “catch” in the throat, and less lingering irritation on the throat and chest after smoking.
The terms light and mild have been replaced with smooth and fine. me and the sysop/Flickr, CC BY-ND
Getting those figures off packs was an important step, once it became established they told smokers nothing about their actual intakes of harmful smoke constituents. But the “low tar” deception is part of a bigger problem of differences between cigarettes that smokers latch onto as evidence that some of them are less harmful.
After banning the terms “light” or “mild” in 2006, our tobacco industry simply replaced them, using “smooth” and “fine” as the new code words. Each major brand family still has six or seven varieties, ranging from “original”, through “smooth” and “fine”, to “ultimate” – and that’s without counting the menthol varieties.
Smokers still select the taste strength and harshness level that best suits them, then can fine tune further by unconsciously adjusting how they puff.

Regulating filters

It’s time for the government to ban filter ventilation to reduce the palatability of cigarettes. The government should regulate filters, specifying the sizes and designs that are permissible.
Since the 1960s, tobacco companies have used two engineering features to reduce the unpleasant sensations of smoking on the throat. Larger filters and tiny holes in the filter tipping paper called “filter vents” introduce fresh air into each puff and make smoking easier on the throat.
Filter vents. Bill King
But smokers compensate for this. Smokers seek constant nicotine doses of around one milligram per cigarette. They respond to more filtered or more diluted cigarettes by taking bigger puffs and more of them.
There is evidence that increasing filtration efficiency decreases smokers’ exposures to just a few carcinogens (a group called semi-volatiles) but increases their exposures to most of the harmful smoke components in the vapour phase of tobacco smoke. (The vapour phase passes straight through standard cigarette filters.)
There is also evidence that filter ventilation increases smokers’ exposures to a range of carcinogens by encouraging them to take more puffs from each cigarette, which are effectively smaller at the burning end of the cigarette (meaning more products of incomplete combustion).
Filter ventilation is also likely to contribute to smoke particles penetrating deeper into the lungs.
This evidence thoroughly undercuts any “we might make things worse by meddling” justifications for not acting to regulate the engineering of cigarettes.

Regulating additives

The government should also ban the use of all but a very limited number of additives in cigarettes. Sugars, honey, cocoa, liquorice and spices are added to cigarettes to add the right “flavour notes”, cover unpleasant ones and also reduce other unpleasant sensations.
Additives provide the secondary means for the Australian tobacco industry to fine tune the sensory characteristics of cigarettes, making them easier to use and harder to quit.
Canada and Brazil have already taken the lead internationally by banning most additives, although Brazil unfortunately left sugars off the list. Canada exempted menthol cigarettes, but that might change soon, with Manitoba introducing a province-wide ban.
If Australia could set the strongest example so far by comprehensively regulating both of the industry’s tools for optimising the sensory characteristics of cigarettes – filters and additives – the benefits to public health would be substantial and we would once again be at the forefront of tobacco control.