Tobacco Reduction: Where Do We Go From Here

November 14, 2014|12:07 p.m.| Scott Briscoe

There is perhaps no U.S. public health victory story as compelling as the decline in tobacco use. Yet, after nearly 50 years of declining use, tobacco remains by far the single largest preventable reason for premature death. There is more work to be done after nearly 50 years of declining use, tobacco remains by far the single largest preventable reason for premature death. There is more work to be done.

In "The Nicotine Fix," an article in The Atlantic this month, researchers Kenneth W. Warner from the University of Michigan and Harold Pollack from the University of Chicago discuss the accomplishments achieved and the work still to be done. Like most things in statistics, the decline in rates of tobacco use is described nicely by a curve. Funny thing about those statistical curves, each new percentage point drop is harder and takes longer to achieve. Warner and Pollack divide those continuing to work on tobacco reduction into three distinct categories: the Traditionalists, the Harm Reductionists, and the Endgamers.

The Traditionalists

Warner and Pollack's subtitle for this group: "If It's Working, Keep Doing It." Quitlines, the "Tips" campaign, punitive taxes, marketing restrictions, mandated warnings, and an ever-shrinking space in which cigarette use is lawful are the tools of this group. It is undeniable that these tools have worked. Warner and Pollack point out the possibility that we're reaching a point where there are diminishing returns for these tactics.

The Harm Reductionists

After a look at the failing history of tobacco harm reduction tactics--namely filters and low tar--the researchers get to the current controversy: e-cigarettes. Warner and Pollack examine these nicotine delivery devices without passing a final positive or negative judgment on them, other than to state an opinion that e-cigarettes and other nicotine delivery being developed are unlikely to have much potential at reducing smoking rates. Interestingly, the researchers note that smokeless tobacco products are generally much less harmful than smoking cigarettes and may be an effective substitute, but they stop short of endorsing the tactic.

The Endgamers

In this camp are the people aiming to drive the curve to zero as quickly as possible, with prohibition being the blunt tool of choice. Of course, outright prohibition of smoking tobacco products in the United States is highly unlikely in any foreseeable timeframe. Warner and Pollack point to other ideas, such as choosing a future date, say 2020, and ban--for life--the sale of cigarettes to anyone born after that date, with those born before the date grandfathered in. Another idea is to regulate the amount of nicotine in cigarettes, gradually reducing it over time to wean smokers off their addiction.

Warner and Pollack propose that for the United States to continue its reduction in cigarette smoking, tactics will need to diversify and embrace a spectrum of approaches that span all three of these categories. Read the article for their specific recommendations--which include everything from not using any additional punitive taxation to regulating e-cigarettes to regulating a chemical alteration of cigarettes to change their taste and make them less palatable. For public health workers on the front lines of trying to reduce tobacco use, it can be useful to think about tactics that cross this spectrum of categories.

Additional resources:

The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General 2014

ASTHO's E-Cigarette site, including an extensive list of resources for states.

ASTHO's Tobacco Use Prevention and Control Position Statement

Comprehensive Tobacco Control: Guide for State and Territorial Health Officials