early interest focused on pseudo-cigarettes. why? fascination with high-tech products first...

30
Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid- 1980s) Promised large decreases in a major class of toxicants, with a new delivery mechanism

Upload: christiana-horn

Post on 05-Jan-2016

216 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Early interest focused on pseudo-cigarettes. Why?

• Fascination with high-tech products

• First “splash” (Premier, mid-1980s)

• Promised large decreases in a major class of toxicants, with a new delivery mechanism

Page 2: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Interest has switched to other categories of PREPs

Different reasons for different categories

Page 3: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

#1 Modified cigarettes (e.g., Omni and Advance)

• Most likely to appeal to smokers (closest approximation to the “real thing”)

• Least likely to produce great risk reduction for the individual

• Most likely to increase population harm

• Therefore, the greatest source of concern

Page 4: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

#3 Smokeless tobacco products, including modified (e.g., Exalt, Revel)

• Snus history and controversy

• Advertising as “fill in” for times when can’t smoke (e.g., Revel)

• Fear of substitution for NRT products

• Fear of leading to smoking

Page 5: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

#4 Presumed lowest-risk novel products (e.g., Ariva Cigaletts)

• Sheer novelty and our bewilderment about them

• Fear of attraction to children (with risk of subsequent shift to cigarettes)

• “Affront” to the idea of using these products when there are proven pharmaceuticals to substitute for tobacco products

Page 6: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Little interest focused on nicotine pharmaceuticals (category #5)?

• No longer “sexy”• Regulatory approval limited to short-term

use for cessation• Pharmaceutical companies timid about

taking on the tobacco industry• Pharmaceutical companies’ worries about

the public image associated with advocating long-term use.– Sustaining nicotine addiction vs. overcoming it.– Public’s perception of nicotine as a very

dangerous drug.

Page 7: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

What have we learned to this point?

• Experience with earlier generations of “harm-reducing” cigarettes recommends skepticism.

• The risk/use equilibrium addresses the acceptability of the highest- and lowest-risk classes of PREPs, but not those in between.

• The need for formal, government-sanctioned regulation is clear…but its methods are not.

Page 8: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Earlier generations of “harm-reducing” cigarettes

Page 9: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Filter-tipped cigarettes,the response to the lung

cancer scare of the 1950s

Page 10: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a
Page 11: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Filter-tip share of the cigarette market

Year % filters

1950 1

1960 51

(Current 98)

Page 12: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a
Page 13: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

“Low-yield” (low tar and nicotine) cigarettes, the response to the

smoking-and-health scare of the late 1960s, early 1970s

Page 14: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a
Page 15: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Year % low t/n

1967-70 (avg.) 3

1971-74 (avg.) 8

1981 58

Low tar and nicotine share of the cigarette market

Page 16: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

• Even today, 30 years after their introduction, smokers of low tar/nicotine cigarettes believe their risk is well below that of “full-flavor” smokers.

• Yet ample evidence demonstrates that low t/n smokers compensate…

• And the consequence is that low t/n smokers are developing cancers further down in the lung.

Page 17: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Lessons from the risk-use equilibrium

(Kozlowski et al., Tobacco Control, Sept. 2001)

Page 18: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a
Page 19: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Risk/use equilibrium: lessons• Any combusted tobacco product likely constitutes a

very poor prospect for harm reduction. At a population level, it is likely to be harm increasing. Combusted products should not be marketed as harm-reducing.

• Medicinal nicotine likely represents an excellent prospect for harm reduction. It should be encouraged by health professionals today, and (more controversially) marketed by the pharmaceutical industry (with FDA approval secured) – for smokers who cannot or will not quit altogether.

Page 20: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

The great unknown…

Should smokeless tobacco products be promoted as potential harm-reduction products? (Risks being accused of tobacco control heresy…)

Page 21: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Need for regulation

• Establish the toxic exposures associated with new products (old and new exposures; e.g., Eclipse)

• Estimate (guestimate?) the health consequences• Estimate population exposures• Evaluate the implications of risk communication

to health professionals and the public (and define acceptable risk communication)

• Monitor legitimacy of claims• “Level the playing field” between highly regulated

pharmaceuticals and unregulated tobacco products

Page 22: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

What is to be regulated?

• All products?

• All new products?

• All new non-conventional products? (How define “conventional”?)

Page 23: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Methods of regulation

• Approve claims (IOM)

• Adopt performance standards (with or without permitting claims concerning them)

• Pre-marketing approval based on probable degree of decrease in individual risk

• Pre-marketing approval based on probable degree of net benefit or net harm to public

Page 24: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Difficulties in regulating• How establish individual exposure

reduction?• How estimate harm reduction from

individual exposure reduction? (the limits of surveillance)

• How assess population responses to claims and marketing? (again, the limits of surveillance)

• How combine (weak) estimates of individual harm reduction potential with (weak) estimates of population response?

• How address the political barriers to regulation?

Page 25: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

How can we properly educate health professionals and the public about harm reduction? What do we tell them?

Yet another issue

Page 26: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

• Is an era of harm reduction inevitably upon us?

– In today’s (non)regulatory world, yes

• Tobacco industry innovation assures it.

• Will we ever see more explicit and aggressive competition from the pharmaceutical industry?

Concluding thoughts

Page 27: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Concluding thoughts (cont’d.)

• Potential societal benefits of harm reduction are considerable:– Could conceivably lead to more eventual complete

renunciation of nicotine and tobacco – May decrease the toll of tobacco

• Potential risks are substantial too:– Sustain and potentially increase the level of nicotine

dependence in contemporary society (Necessarily bad?)

– Slow progress against the devastating toll of tobacco– Increase nicotine dependence in future generations– Create new health hazards in the process?

Page 28: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a

Concluding thoughts (cont’d.)• Over time, harm reduction may play a large and

increasingly important role within tobacco control.

• For the foreseeable future, its contribution is likely to be small, and possibly negative.– The most consumer-attractive products not likely to

produce net improvement in public health (modified cigarettes)

– Products with the greatest potential for true harm reduction not likely to be popular (medicinal nicotine)

• Harm reduction should never supplant emphasis on prevention and cessation.

Page 29: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a
Page 30: Early interest focused on pseudo-cigarettes. Why? Fascination with high-tech products First “splash” (Premier, mid-1980s) Promised large decreases in a