Rethinking nicotine: the role of public health law in ending an epidemic.

• Author: Sweanor, David
• Position: 7th National Health Law Conference

CIGARETTE SMOKING IS THE leading cause of preventable death in wealthy countries, and rapidly replicating that status for the rest of the world. The World Health Organization (WHO) predicts that on current trends cigarette smoking will kill a billion people this century. Yet these deaths are almost exclusively caused by the inhalation of smoke rather than from the nicotine these consumers primarily seek. Cigarettes are an incredibly dirty, and particularly addictive, delivery system. It has been known in scientific circles for decades that people smoke for the nicotine but die from the tar, but it is through creative legal measures that we could ultimately prevent the current public health catastrophe.

Consumer acceptable ways to deliver nicotine without the inhalation of the products of combustion already exist, giving robust proof-of-concept for the dramatic role alternative delivery systems could play in fundamentally altering rates of disease and death. Legal measures such as replicating the constitutional challenges that have removed barriers to life saving harm reduction efforts for users of illicit drugs, and well-crafted regulatory reform that seeks the best risk-benefit tradeoff for products designed to make cigarettes obsolete, have enormous potential to rapidly transform the market. As Canada, like other countries, already has to adapt laws due to new nicotine products, the opportunity to target health gains is clear.

Legal reform measures aimed at replacing the current unscientific abstinence-only approach to nicotine with a pragmatic policy aimed at reducing harm would continue a very long line of public health successes on such products as foods, pharmaceuticals, and automobiles, where regulations facilitating risk reduction initiatives have dramatically reduced deaths, injuries, and disease. Intelligent regulatory oversight, including differentiating taxation based on relative risks, could also enable harm reduction initiatives to act synergistically with current policies aimed at preventing smoking onset, encouraging cessation, and protecting third parties from environmental tobacco smoke.

Given the political, social, genetic, and neuroscientific challenges in continuing an abstinence-only approach to nicotine use, legal interventions facilitating harm reduction measures would appear to have the greatest potential for a global breakthrough in reducing cigarette-related mortality and morbidity. Through such legal interventions, Canada could lead the world in tobacco/nicotine policy, much as the country did in past decades on a wide range of other anti-smoking initiatives.

Using legal measures to apply harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century.

LA CONSOMMATION DE CIGARETTES est la principale cause de morts evitables dans les pays riches et le devient rapidement dans le reste du monde. L'Organisation mondiale de la sante (l'OMS) predit que, si la tendance actuelle se poursuit, la consommation de cigarettes tuera un milliard de personnes au cours du siecle actuel. Cependant, ces morts decouleront presque exclusivement de l'inhalation de la fumee plutot que de la nicotine dont les consommateurs recherchent l'effet. Les cigarettes constituent un mode d'administration incroyablement nuisible et particulierement toxicomanogene. II est bien connu des cercles scientifiques, et ce depuis des decennies, que les gens fument pour la nicotine mais meurent a cause du goudron. Ce n'est que par des mesures legislatives creatives que nous pourrions en fin de compte prevenir l'actuelle catastrophe en sante publique.

Il existe deja des manieres acceptables pour les consommateurs d'administrer la nicotine sans inhaler de produits de la combustion. Il s'agit la d'une solide preuve theorique du role remarquable que les modes d'administration de rechange pourraient jouer pour ce qui est de changer le taux de maladie et le taux de mortalite d'une facon fondamentale. Des mesures legales semblables a la reprise des defis constitutionnels qui ont permis d'abolir les obstacles aux efforts de reduction des risques et de sauver la vie des utilisateurs de drogues illegales ainsi qu'une reforme bien pensee de la reglementation en vue d'un compromis entre les risques et les avantages a l'egard des produits visant a remplacer la cigarette disposent d'un enorme potentiel susceptible de transformer rapidement le marche. Etant donne que le Canada, tout comme d'autres pays, doit deja adapter ses lois avec l'avenement de nouveaux produits contenant de la nicotine, il est evident que c'est une occasion de miser sur les gains en matiere de sante.

Une reforme legale qui viserait a remplacer l'abstinence comme etant la seule methode envers la nicotine, laquelle n'a pas ete prouvee scientifiquement, par une politique pragmatique visant a reduire les risques et les mefaits s'enlignerait sur les tres nombreux succes en matiere de sante publique, sur des produits de consommation comme la nourriture, les produits pharmaceutiques et les automobiles, ou la reglementation facilitant les mesures de reduction des risques ont permis une diminution marquee dans le nombre de deces, de blessures et de maladies. Un regime de surveillance reglementaire intelligent, y compris une taxation differentiee selon le risque, pourrait egalement permettre que des initiatives de reduction des mefaits aient une action synergetique avec les politiques actuelles visant a empecher les jeunes de commencer a fumer, a encourager les fumeurs a arreter et a proteger les tiers de la fumee secondaire.

A la lumiere des defis politiques, sociaux, genetiques et neuroscientifiques que presente une approche a l'utilisation de la nicotine uniquement fondee sur l'abstinence, toute intervention juridique visant a faciliter les mesures de reduction des risques semblerait avoir de meilleures chances d'avoir une percee rapide globale pour ce qui est de reduire les taux de mortalite et de morbidite lies a la cigarette. Grace a de telles interventions, le Canada pourrait etre un chef de file mondial en matiere de politique sur le tabac et la nicotine, tout comme il l'a ete au cours des dernieres decennies pour un large eventail d'autres initiatives antitabac.

Recourir a des mesures legales pour appliquer des principes de reduction des risques aux politiques de sante publique sur le tabac et la nicotine va au-dela d'une politique simplement rationnelle et empreint de compassion. C'est la plus qu'une reponse pragmatique a un marche qui, de toute facon, subit deja d'importants changements. Il est susceptible d'effectuer l'une des plus grandes percees de l'histoire de l'humanite en matiere de sante publique en modifiant de facon marquee les pronostics d'un milliard de deces causes par la cigarette au cours de notre siecle.

CONTENTS I. Nicotine Use: The Problem II. Alternative Nicotine Delivery Method as a "Simple Idea" Solution to Smoking's Health Toll III. Public Health Breakthroughs: A Long History of Long Delays IV. The Problem of an Abstinence Dependence in Nicotine Policy V. The Cultural Barriers to a Health Law Breakthrough VI. The Regulatory Barriers to Achieving a Breakthrough VII. Abstaining from Abstinence Policies VIII. The Role of Enlightened Health Law I. NICOTINE USE: THE PROBLEM

Cigarette smoking is the leading cause of preventable death in Canada. This remains the case despite decades of considerable progress in reducing its prevalence. Health Canada estimates that it causes roughly 40,000 deaths per year, representing 17% of total national deaths. (1) At a global level, it is estimated that cigarette smoking will result in 1 billion deaths this century. (2) By any measure, cigarette smoking remains one of the major public health challenges in Canada, and the world. Critically, this health catastrophe results not from the nicotine that smokers seek, but from the inhalation of smoke in order to obtain it. Replacing combustion-based nicotine delivery has the potential to rapidly resolve the smoking epidemic, just as the provision of clean water deals with cholera epidemics. But such a policy is, ironically, not supported by many of the protagonists in the global effort to reduce smoking. There is a barrier to actually dealing with the delivery system, and overcoming that barrier through a rethinking of overall nicotine policy has huge scope to improve health.

A key component of effective public health policy is the role of law in implementing and protecting health measures, and in balancing issues of individual and collective rights. Determining what makes people sick is a medical-scientific challenge, but solving these issues at a population level once the cause has been identified is typically a social-legal-political endeavour. In the case of smoking and of nicotine, the science on what causes the harm is settled. Health policy measures, including law reform, are critical for applying this knowledge in order to achieve the societal changes necessary to make cigarettes obsolete.

In recent decades, Canada's achievement of a very significant reduction in both cigarette sales and reported prevalence of cigarette smoking has been very closely associated with law reform initiatives. These measures started gaining momentum in the mid-1980s. (3) But the measures that have been used in Canada to date have been limited to dealing with issues about the use of cigarettes, with very little effort directed towards dealing with the product itself (aside from relatively minor issues, such as seeking to ban menthol or reducing the fire risk of discarded cigarettes). Laws have been used to...