Sunday, February 03, 2008

Lancet Article on Reducing the Harm of Smoking

The latest issue of The Lancet has an important Viewpoint Commentary on combating the harms of smoking entitled "Tobacco Smoking, Harm Reduction, and Nicotine Product Regulation" by John Britton and Richard Edwards. Here is a sample:

Cigarette smoking is highly addictive, widely prevalent, and very hazardous. Smoking killed 100 million people in the 20th century, and is predicted to kill 1 billion in the 21st century. Worldwide, there are about 1·1 billion smokers, and there are expected to be 1·6 billion by 2025. Half of all smokers will die prematurely, unless they stop smoking.

In the 50 years since the health risks of smoking first became widely recognised, the political and public health responses to smoking at national and international levels have been grossly inadequate. Although the main components of current recommended tobacco control policy have changed little from those first proposed in 1962, they have still not been widely applied and, in any case, achieve a reduction in smoking prevalence of typically about 0·5, and at best 1·0, percentage point per year. Full implementation of these policies might be sufficient to prevent smoking in countries in which the smoking epidemic has yet to take hold, but this is only part of the necessary solution for countries with an established smoking population. In the UK, for example, where 24% of adults still smoke, at a reduction rate of 0·5 percentage point per year it would take more than 20 years to reduce the prevalence of smoking by half. Even then, there will be more than 5 million smokers in the UK alone, predominantly from the most socioeconomically disadvantaged sectors of society, bearing a vast burden of avoidable morbidity and mortality. In fact most of the 150 million deaths from smoking that are expected over the next 20 years will occur in current smokers who are alive today. Since millions of these are unlikely to stop smoking in the near future, we argue, on the basis of a new report from the Royal College of Physicians, that in addition to conventional tobacco control policies, the application of harm reduction principles to nicotine and tobacco use could deliver substantial reductions in the morbidity and mortality currently caused by tobacco consumption. However, achievement of these reductions will require radical structural reform of the way in which nicotine and tobacco products are regulated and used.

....Most people continue to smoke because they are addicted to nicotine. Inhaled tobacco smoke is especially addictive because it delivers high doses of nicotine to the brain very rapidly, and because nicotine confers rewarding properties on other stimuli associated with smoking. Exposure to high nicotine concentrations at an early age might also determine the intensity of addiction through effects on nicotinic receptor numbers in the brain.

....The consequence of failing to intensify tobacco control efforts, and to address the current imbalance in nicotine product regulation, will be the unnecessary perpetuation of current smoking by millions of people, especially in disadvantaged communities, and a continued epidemic of avoidable death and disability. Specifically, cigarettes and other smoked tobacco products will continue to be freely available with few restrictions on their safety or content; the medicinal nicotine market will continue to focus on low-addiction, low-dose, low-effectiveness products while also stifling competition and innovation; and the current irrational regulation of smokeless products will continue. Most of the millions of smokers alive today will therefore continue to smoke tobacco, and half will die as a result.