Smoking cessation: $22 billion market at a crossroads
Public health issues are so complex that they do not lend themselves to simplification. Nonetheless, the stakes are clear: it’s all about saving lives. That is the case in the fight against smoking, which is now at a crossroads.
The only way to understand current policies in the fight against smoking is by analyzing the history of this public health nuisance.
First of all, the initial phase of recognizing that tobacco damages health was long and chaotic. The scientific facts connecting smoking to various cancers were at first denied, then covered up. Next, vast marketing resources were deployed to ensure market growth for a notoriously harmful and dangerous product that continued to attract new users. Lastly, misleading products were devised, including so-called “light” cigarettes that gave the false impression that they would be less carcinogenic.
The other main element of the problem is the focus on nicotine. In the 60s, experts identified nicotine as the addictive ingredient in tobacco. That created the misconception that nicotine was the harmful ingredient in cigarettes. In reality, while nicotine is a chemical composition with downsides in terms of health, it is very benign. In any case, it is not responsible for causing cancers. As Professor Michael Russel wrote in 1976: “People smoke for nicotine, but they die from the tar.”
As the tobacco industry had proven its malice and nicotine had been identified as public enemy number one, the strategy for the fight against smoking seemed clear: preaching total abstinence as the only way to protect one’s health. One major drawback appeared fairly quickly: the task was insurmountable for most smokers…
Enter a new player: the pharmaceutical industry. Identifying a colossal market, and having noted that, rather than being the enemy, nicotine could be an ally, Big Pharma entered the market for alternative nicotine products sold in pharmacies. Patches, lozenges, chewing gum: the idea was to calm your urge with a dose of nicotine while no longer inhaling the smoked fumes that are responsible for cancer. It is a market that some experts estimate will reach 22 billion dollars by 2024, and which launched the idea of “harm reduction”: chewing nicotine gum is certainly not ideal, but still considerably lowers damage, compared to smoking cigarettes.
While it is an effective quitting tool for some, this industry has nonetheless proved itself incapable of offering most users a way out from tobacco, due to complex social and anthropological reasons.
Technological innovation has since offered a new tool, in keeping with the idea of harm reduction. With electronic cigarettes (and now heat-not-burn products), the logic is the same: nicotine is delivered to the former smoker without the smoke and tar connected to burning tobacco in a traditional cigarette. These solutions seem to offer an alternative that works for many smokers who want to quit. The act of bringing the electronic device to the mouth, and the vapor that comes out (reminiscent of smoke) are surely part of the success with former tobacco addicts.
But at the same time, the hand-to-mouth movement and the vapor riles advocates of plain and simple abstinence, who see electronic alternatives as nothing more than a disguised continuation of the cigarette that might even encourage the very young to start. The precedent of the “light” cigarette left its mark. Especially since Big Tobacco is looking to gain a foothold in these new markets, which are expected to offer them and their shareholders a much-needed cash windfall.
That is what some specialists have started calling the “tobacco paradox”: a situation in which one of the answers to tobacco’s public health nuisance is in the hands of those initially responsible for it.
After independent studies by the Food and Drug Administration, Public Health England, the German Federal Institute for Risk Assessment, as well as the British Committee on Toxicology, it is now understood that alternative cigarettes expose the user to about 90% fewer chemical compounds than combustible cigarettes. The scientific debate is therefore behind us. The central battle now is to educate the public, which is made tough amidst a backdrop of deep distrust and caution by public health officials, due to a lack of long-term clinical data.
This is the finding of a recent publication by the National Institute for Health and Care Excellence (NICE), the highest public health authority in Great Britain. For Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, the central issue now is to give good information to those who want to stop smoking. He reminds us that on one hand, the dangers of smoking cigarettes are well known, beyond even a shadow of a doubt. On the other, independent studies show that the harmful components in the vapor produced by e-cigarettes are either absent or present in very reduced quantities. At the same time, the scientific community is still evaluating the more long-term issues of e-cigarettes, which explains why they cannot communicate more definitively on the subject.
However, Gillian Leng concludes, it is disturbing to find that due to these ongoing studies, some smokers refuse to switch to e-cigarettes, and are thus literally encouraged to continue smoking. According to her, the fact that complete clinical studies have not yet been carried out does not negate the scientific community’s conviction that these products are most likely less dangerous than cigarettes, and that smokers should receive information to this effect from health practitioners.
In fact, the results of the annual “State of smoking” study, published by the Foundation for a Smoke-Free World, are disconcerting. They show that most smokers around the world believe that e-cigarettes are more dangerous than cigarettes. For instance, in England, less than 10% of people questioned understand that nicotine is not responsible for cancers. In short, the lack of public knowledge regarding these questions is costing lives, if we are to believe a study published by the renowned Tobacco Control magazine, which says that switching to e-cigarettes could save millions of lives in the United States each year.
This lack of knowledge has its roots in the history of the fight against tobacco, but also in the general public’s weak scientific background. Unfortunately, it is also due to an often ill-informed echo chamber in the general press, which is more interested in catching attention with shocking headlines and giving space to the most alarmist voices than truly explaining a complex subject.