PRESIDENT’S REPORT

Alternative nicotine delivery systems was the topic of a recent international meeting in Toronto, organized by John Slade and Roberta Ferrence, both SRNT members. The broad question is whether making nicotine more accessible and less hazardous via non-tobacco delivery systems to be used by smokers who cannot quit smoking makes public health sense. Nicotine is currently available in a variety of medication forms and is being test-marketed by R.J. Reynolds as the Eclipse smoking device, an ostensibly less hazardous alternative to cigarette smoking. It seems clear that pure nicotine has substantially less medical toxicity than cigarette smoking, and that smokers are better off using nicotine instead of smoking, even if nicotine use persists indefinitely. The availability of nicotine delivery systems, however, might reduce the likelihood of quitting tobacco use altogether and could result in greater numbers of people who persist in smoking than would occur if smokers were strongly encouraged to quit as the only option.

There is also concern that nicotine delivery systems, particularly those that deliver nicotine to the brain rapidly (similar to cigarette smoking), might reinforce and maintain addiction as do cigarettes. Another concern about rapid nicotine delivery systems is the possibility of attracting nonsmokers to the use of nicotine. A careful study of benefits vs. risks of seeking alternative nicotine delivery systems available will require impact studies by experts in nicotine pharmacology, drug abuse, toxicology, economics, sociology, and public policy. This is clearly an area in which the members of SRNT can contribute greatly.

Another nicotine-related issue discussed at the meeting was regulation of the nicotine content of cigarettes. The pros and cons of policies that would promote the manufacturing and use of cigarettes with reduced nicotine content (presumably less addictive and more likely to promote quitting,) vs. nicotine-enriched cigarettes (which might result in less exposure to other combustion toxins) was debated. The World Health Organization has also been meeting to consider global strategies for cigarette regulation, which is essential, since the cigarette trade is a global issue. The findings of the Toronto conference are being analyzed by a committee that includes a representative from SRNT–Neil Grunberg, Chair of our Scientific Liaison and Public Policy Council. There will ultimately be a written document to which SRNT members will have access.

Tobacco litigation has been prominent in the news. As most of you know, 22 states Attorneys General are suing the tobacco companies for reimbursement of Medicaid health care costs attributable to cigarette smoking. The first of these cases, involving the State of Mississippi, is scheduled to go to trial in June, 1997. Nicotine plays a central role in these lawsuits because nicotine addiction underlies the widespread use of tobacco despite the known health hazards of smoking. Tobacco company documents, such as those described in JAMA last year and in a book recently published by Stan Glantz, show clearly that the tobacco industry has understood the role of nicotine in maintaining tobacco use for many years, while publicly denying that nicotine is addictive.

On March 20, 1997, a settlement between the states and the Liggett Tobacco Company was announced. This settlement included the following five features.

The financial settlement with Liggett is inconsequential because Liggett has not been profitable recently, but acknowledging nicotine addiction and that tobacco causes disease and providing documents related to the industry's knowledge and strategies for dealing with the health hazards of tobacco use should be most helpful in impeaching the other tobacco companies in upcoming trials. As of April 16th, at the time of the writing of this column, there are rumors of a settlement between the state attorneys generals and the tobacco companies. Such a settlement would probably need to be mediated by congress, because it would release the tobacco industry from future liability claims.

Any settlement with the tobacco industry must include strategies to reduce tobacco use. A financial settlement alone will not be very helpful in the promotion of health and would not prevent American children from becoming addicted to nicotine. Recently, David Burns and a number of tobacco and health researchers and policy experts (most are SRNT members) have proposed a series of elements to promote public health that should be part of any settlement. An opinion article describing these elements is currently in press in Tobacco Control. Briefly, these elements are as follows:

SRNT members can help in the effort by lobbying their medical and other health-related organizations, as well as by communicating directly with politicians, with the message that there should be no settlement with the tobacco industry unless these elements to protect the public health are included.

SRNT members will hear much more about alternative nicotine delivery systems and about the state of tobacco litigation at our upcoming annual meeting. You will find the schedule for the meeting on our web page as well as on pages 6-7 of this issue. See you in Nashville in June.

Nevertheless, anti-tobacco norms would grow if the laws of the land were enforced. The combination of regular tax or price increases, the prohibition of advertising, and general public discussion of tobacco is showing signs of bearing fruit. There has been, since 1991, a drop of 11% in total tobacco sales, and anti-tobacco activities are proliferating. There are several dark shadows over this sunny picture, however. The overall prevalence of smoking is still around a third of the population, as it has been since at least 1976, when the first surveys began looking at smoking behavior. Within that population, we have fewer men and more women than in the past, but no foreseeable drop in prevalence. We may see prevalence rates rise, for our influence on young people is practically nil compared to the influence of the tobacco promoters and adolescents smoking environment.

Despite a long history of research on the health consequences of smoking generally funded by the formerly government-run tobacco company, SEITA, the main French research bodies have until recently shown little interest or concern about tobacco use research. The national research institutes, INSERM (medical research) and CNRS (scientific and humanities research) have no teams exclusively devoted to tobacco research, while teams do exist for alcohol, AIDS, or illegal drug use. Funding is still available for tobacco-related disease epidemiology; but very little research money is allocated to research on tobacco pharmacology or behavior. In 1995, INSERM included tobacco research among topics in the major research category of consumption behavior, which also includes nutrition, medication, alcohol, and drugs. Nevertheless, it is difficult to find funding for research in tobacco. Most people who could be doing research in either nicotine pharmacology, smoking behavior or tobacco policy evaluation do research in other fields. In terms of public moneys, government agencies provide modest funds to research groups and subsidize anti-tobacco campaigns. There is a strong pervading belief in these organizations, however, that smokers should not be made uncomfortable about their smoking. In addition, smoking is still quite common among researchers. This may explain why some themes are resisted, such as use of fear tactics in health campaigns, measuring how much people actually know and what they believe, and public information campaigns on the ill effects of environmental tobacco smoke. There is a tendency both in government campaigns and those of NGOs to focus on children, in the hope that we can thus pass to a generation of non-smokers, even though there has been no evidence that prevention campaigns are effective in the absence of programs for the entire population. Resources for adults tend to go to specialist cessation clinics. A number of these clinics set up randomized trials of different treatments, usually funded by pharmaceutical companies. Other research is currently being sponsored by the European Union. However, much more could be done, for France is a country with under-utilized potential for both research and social policy concerning tobacco use.

* The Evin Act prohibits all direct or indirect tobacco advertising, sponsorship, or promotion, and establishes clean air standards for enclosed spaces used by the public (e.g., transport, worksites, restaurants, etc.). The law includes provision for evaluation. The price of tobacco has been excluded from the consumer price index, and occasional prices rises occur, either through raised taxes or negotiated retail price rises.

** A small evaluation of the effects of the law showed adherence to the ban on advertising, but only in terms of direct advertising; and only sporadic adherence to the clean air provision of the law: less than 50% adherence on school grounds, 52% adherence in the workplace, less than 30% adherence in restaurants or bars. Clean air standards are being reinforced in public transport. The law allows retransmission of Formula 1 motor-racing (and other motor vehicle sports) from areas where tobacco advertising is allowed.

*** In 1996, the CNCT estimated tobacco company spending on promotions at 1 billion francs (US$2000 million), in the form of cigarette brand name association with other products and promotional give-aways.

**** The rates in 1991 were, for men aged 25-64, 56.8/1000,000, up 17% from 1981, and for women aged 25-64, 6.1/100,000, up 36%. Source: Haut Committee de la Santee Publique, La Santee. Rapport General, La Documentation Francaise, 1994.

Note: A very informative analysis of the differences between France and the United States public policy responses to tobacco can be found in Nathanson, C. Disease prevention as social change: toward a theory of public health. Population and Development Review, 1996; 22: 6609-637.

These decreases in self-reported negative affect occurred without any smoking or other intervention. Thus, we must be cautious in inferring change when experimental designs are flawed. It is clear that the question of whether smokers actually return to pre-quit baseline levels of affect and cognitive performance has not been adequately assessed in the vast majority of studies.