APPENDIX 44
Memorandum by the Faculty of Public Health
Medicine (TB 11)
SUMMARY
Smoking is the biggest preventable cause of premature
death in the UK.
The UK population needs to be protected from
the dangerous effects of tobacco smoke.
Despite a large and well-publicised body of
scientific evidence describing the harmful effects of tobacco,
the tobacco industry is still in denial. It continues to obfuscate
the issues and to promote its products without due care or concern
for its customers and those exposed to smoke. In the past the
tobacco industry knowingly marketed tobacco products at the expense
of public health, as it does so today.
Tobacco products should be subject to more rigorous
testing and regulation. It is counter-intuitive that NRT, a pharmaceutical
product with proven benefit, is more strictly regulated than cigarettes,
toxic products containing an additional 400 chemicals; both provide
a means of delivering the addictive drug nicotine.
The current methodology used to assess the tar
and nicotine content of cigarettes is flawed, resulting in misleading
and inaccurate information being given to the consumer.
The promotion of light/low tar cigarettes is
deliberately misleading consumers, which is likely to deter smokers
from quitting and expose the public to greater health risks. Tobacco
companies should be prevented from giving brands a "light"
image, from implying that such cigarettes are safer or less harmful.
THE FACULTY
WOULD SUPPORT
ACTION IN
THE FOLLOWING
AREAS:
The Government should employ new regulatory
powers to ensure that all cigarette packets are labelled with
information that is relevant to the customer.
Current regulation of tobacco additives is wholly
inadequate to protect the consumer. A new regulatory framework
is needed to challenge the use of all additives that may influence
smoking behaviour.
Current regulation of cigarette design is wholly
inadequate to protect the consumer. Consideration should be given
to a new regulatory framework requiring the use of patented designs
that may reduce the harm from cigarettes.
In conclusion, the Faculty of Public Health
Medicine believes that the tobacco industry knowingly misleads
the public; tobacco products should be subject to more rigorous
testing and regulation; and tobacco products should be labelled
with relevant consumer information. This is necessary for the
public to be able to make informed choices to protect their health.
1. INTRODUCTION
The Faculty of Public Health Medicine welcomes
the House of Commons Health Select Committee's enquiry into the
activities of the tobacco industry and is pleased to have the
opportunity to participate in the debate over consumer protection.
Here we provide information on the impact of smoking on the public's
health and the related responsibilities of tobacco companies.
1.1 The Faculty of Public Health Medicine
The Faculty of Public Health Medicine is a professional
organisation giving independent advice on the public's health.
It is a faculty of the three Royal Colleges of Physicians of the
United Kingdom. Our 2,000+ members are public health professionals
of academics in public health medicine.
Public health medicine is the branch of medicine
concerned with improving the health of the population, rather
than treating the diseases of individual patients. Public health
professionals monitor the health status of the community, develop
programmes to reduce risk or screen for early diseases, and help
plan the provision of health care.
1.2 Smoking in the UK
Smoking is the biggest cause of preventable
death and ill-health in the UK. Around 150,000 people die from
tobacco-related diseases each year (1). One in three cancer deaths
and one in five coronary heart deaths are caused by smoking (1).
Tobacco is highly addictive (2). Most smokers report starting
between the ages of 13 and 15 years (3). At that age they believe
they can stop when they want to (4) and do not consider the long-term
effects to be relevant (3). By the time they want to quit they
are addicted (5). There has been no decline in smoking amongst
school children since surveys started in 1982. Indeed smoking
amongst young adults seems to be on the rise (6,7).
Several approaches have had some success in
reducing smoking. Raising prices has been shown to reduce tobacco
consumption (8,9) and governments have influenced prices through
taxation. to Succeed, health education must be supported by other
initiatives. The Faculty believes the Government should take an
active role in protecting consumers from the dangerous effects
of tobacco smoke. We strongly recommend the introduction of more
rigorous testing and regulation to tobacco products as well as
greater regulation of the tobacco industry.
2. SMOKING AND
HEALTH
A link between smoking and lung cancer was first
published in this country as early as the 1950s (10). However,
tobacco companies did not admit to the health risks even though
their own research confirmed the presence of carcinogens in smoke.
The industry responded by creating confusion over the scientific
evidence and attempting to convince the public that new measures
such as putting filters on cigarettes made smoking less harmful
(11).
Despite decades of further scientific evidence
showing smoking causes many cancers, pulmonary diseases such as
bronchitis, heart attacks, angina, stroke, peripheral vascular
disease, peptic ulcers and other illnesses (12,13), the tobacco
industry still seeks to evade the issue of the deleterious effects
of smoking on health (14).
Sir Patrick Sheehy, former Chief Executive of
British American Tobacco made the following statement:
"I cannot support your contention that we
should give higher priority to projects aimed at developing a
'safe' cigarette (as perceived by those who claim our current
product is 'unsafe'), either by eliminating, or at least reducing
to an acceptable level, all components claimed by our critics
to be carcinogenic...In attempting to develop a 'safe' cigarette
you are, by implication, in danger of being interpreted as accepting
that the current product is 'unsafe' and this is not a position
I think we should take."(15)
The industry's management of controversy has
been most clearly demonstrated in the debate over the effects
of passive smoking. There were numerous reports of the dangers
of environmental tobacco smoke (ETS) in the 1970s and early 1980s
that the tobacco industry tried to play down (16). It has now
come to light that in the late 1980s, Philip Morris funded researchers
in Europe, with the sole aim of countering the negative publicity
surrounding second-hand smoke (17).
Dr Sharon Boyse from British American Tobacco
reported:
"Philip Morris presented to the UK industry
their global strategy on environmental tobacco smoke. In every
major international area they are proposing, in key countries,
to set up a team of scientists organized by one national co-ordinating
scientist and American lawyers (our emphasis) to review scientific
literature or carry out work on ETS to keep the controversy alive."(18)
One example of this type of work is a publication
by a self-styled European Working Group. This group concluded
that passive smoking did not cause cancer (19). None of the "experts"
in this working group had expertise in epidemiology, the main
academic discipline required to evaluate links between exposure
of groups of people to toxic substances and development of disease.
The authors did not publish their review in a peer-reviewed journal,
where the quality of their methods would be scrutinised, but as
a report that is difficult to obtain. One of our members, an epidemiologist
of repute, co-authored a study of the working group's findings.
The epidemiologists published a rigorous rebuttal of the working
group's report, as they found the group's arguments to be seriously
flawed (20).
While increasing scientific evidence confirms
the health risks of passive smoking (21,22,23), the denials from
the tobacco industry continue (24). The Faculty believes that
the evidence for health risks cannot be ignored and supports the
Department of Health's Scientific Committee on Tobacco and Health's
(SCOTH) conclusions that passive smoking is harmful (2).
Conclusion: The Faculty believes that despite
a large and well-publicised body of scientific evidence describing
the harmful effects of tobacco, the tobacco industry is still
in denial. It continues to obfuscate the issues and to promote
its products without due care or concern for its customers and
those exposed to smoke. In the past the tobacco industry knowingly
marketed tobacco products at the expense of public health, as
it does so today.
3. NICOTINE ADDICTION
Some tobacco companies continue to deny that
nicotine is addictive, John Carlisle of the Tobacco Manufacturers
Association (UK):
"The definition of addiction is wide and
varied. People are addicted to the Internet. Others are addicted
to shopping, sex, tea and coffee. The line I would take is that
tobacco isn't addictive but habit forming".(25)
The industry is most likely to adopt this position
since the legal defence of the industry depends heavily on the
argument that smokers can exert "free choice". However,
scientific evidence for the addictive properties of nicotine is
unequivocal; as SCOTH said in 1998:
"Over the past decade there has been increasing
recognition that underlying smoking behaviour and its remarkable
intractability to change, is addiction to nicotine. Nicotine has
been shown to have effects on brain dopamine systems similar to
those of drugs such as heroin and cocaine". (2)
Nicotine is an addictive drug. The tobacco industry
purposefully designs cigarettes to act as a "nicotine delivery
vehicle". For example, in the mid-sixties, Philip Morris
began using ammonia in its cigarette production, which causes
nicotine to be more rapidly absorbed by the smoker (26). Ammonia
technology is now wider used throughout the industry, although
tobacco companies deny manipulating nicotine levels. They know
that cigarettes would not remain viable products without nicotine.
This explains why tobacco companies are anxious to avoid cigarettes
being regulated for their nicotine content.
In this country, the addictive nature of nicotine
is explicitly recognised in the regulation of nicotine replacement
therapy (NRT). As public health professionals responsible for
delivering health improvement programmes that encourage smoking
cessation, Faculty members have already welcomed the introduction
of NRT on prescription and encouraged measures to ensure wider
availability. We can do so with the knowledge that this therapy
has been subject to extensive research to assess its safety and
efficacy. We find it strange that NRT, a pharmaceutical product
with proven benefit, is more strictly regulated than cigarettes
and other tobacco products, with proven toxicity and the unknown
effects of an additional 4,000 chemicals combined.
Conclusion: The Faculty strongly believes that
tobacco products should be subject to more rigorous testing and
regulation. It is counter-intuitive that NRT, a pharmaceutical
product with proven benefit, is more strictly regulated than cigarettes,
toxic products containing an additional 400 chemicals; both provide
a means of delivering the addictive drug nicotine.
4. LOW TAR
CIGARETTES
4.1 What is low-tar?
Tobacco companies introduced low tar of "light"
brands in response to the well-known health concerns. Although
these products are not marketed with direct claims for health
benefits, the idea that they are "healthier" is implied
by their name and by the reduced tar and nicotine content indicated
on cigarette packs.
The tobacco on low tar cigarettes is in fact
very similar to that of regular cigarettes. The main difference
between the products lies in filter design. The filter of a low
tar cigarette retains some of the tar and nicotine as smoke is
drawn through it, and also has ventilation holes that allow air
to be drawn in (27, 28). This mixing of air is designed to reduce
the tar and nicotine content of the smoke.
Such a reduction is observed when low-tar cigarettes
are tested in a smoking machine and it is these measurements,
using ISO standard procedures and equipment (29), that generate
the figures indicating tar and nicotine content of tobacco products.
However, the figures present a totally inaccurate measure of the
levels of tar and nicotine delivered to smokers' lungs. People
do not smoke in the same way as a machine. Smokers not only alter
their smoking behaviour in response to reduced nicotine levels
(see 4.2) but also tend to place their fingers and lips exactly
where the tobacco industry has positioned the ventilation holes.
A study in the American Journal of Public Health shows that blocking
the holes in this way could increase toxic by-products of smoke
by up to 300 per cent (30). To conclude, there is little relation
between the numbers on a cigarette pack and the real tar and nicotine
exposure of any given smoker with any given cigarette.
Conclusion: The Faculty believes the
current methodology used to assess the tar and nicotine content
of cigarettes is flawed, resulting in misleading and inaccurate
information being given to the consumer.
4.2 Health implications
The policy to test and control cigarettes for
their tar yield was based on the concept that less tar would lead
to less carcinogenic activity (31). However, low tar cigarettes
are not automatically low carcinogen cigarettes. One reason is
that a smoker using a low tar product compensates for the low
nicotine delivery by smoking more and inhaling deeper (32, 33).
Smokers of low tar cigarettes are thus exposed to disproportionately
higher amounts of certain carcinogenic constituents, such as N-nitrosamines,
which may contribute to an increase in a type of cancer that occurs
deep in the lung (34, 35). It is clear that low tar cigarettes,
far from being safer, may actually increase the health risks of
smoking.
In Europe, the success of light cigarettes has
been overwhelming, especially among middle-aged women (36). In
1995, 60 per cent of women cigarette smokers in the EU aged 45
to 64 years old smoked light cigarettes. The prevalence of low
tar cigarette-smoking smokers is lowest in the youngest age groups.
This pattern of consumption, coupled with research for the UK
(37), suggests that people switch to low tar cigarettes as they
progress in their smoking careers and become more concerned about
health. Hence light cigarettes are less important as a factor
in the uptake of smoking, but more important as a substitute for
quitting.
Smokers are deterred from stopping smoking by
the belief that switching to lighter cigarettes is a safe alternative
(36). Recent research findings show that some potential quitters
do operate under this misconception (38). A French follow-up study
of smoking cessation also showed that one out of four French women,
who did not stop smoking during pregnancy, claimed to have switched
to a low tar cigarette brand instead (36).
Warner et al conclude in their study:
"The promotion of light cigarettes has kept
many people smoking who otherwise would have made a concerted
effort to stop. The net effect of the introduction and mass marketing
of these brands, may have been and may continue to be an increased
number of smoking attributable deaths" (39).
In a recent American survey only 10 per cent
of all smokers were aware that light cigarettes could give the
same amount of tar as regular cigarettes (38). The word "light"
is used to describe food products with reduced fat or sugar content
with obvious health benefits. It is therefore unsurprising that
smokers believe light/low tar cigarettes deliver some health protection.
Internal industry documents released through litigation in the
US reveal that for decades the tobacco companies knew that health
conscious smokers could be captured by the marketing of light
brands (40).
British American Tobacco said in 1971:
"Manufacturers are concentrating on the
low tar and nicotine segment in order to create brands. . . which
aims, in one way or another, to reassure the customer that these
brands are relatively more `healthy' than orthodox blended cigarettes"(36).
It is obviously in the tobacco companies' best
interests to stop their customers from quitting. The light brands,
far from representing a responsible action to protect consumer's
health, actually represent an effective means of boosting the
tobacco market.
Conclusion: The Faculty is deeply concerned
that the promotion of light/low tar cigarettes is deliberately
misleading consumers, which is likely to deter smokers from quitting
and expose the public to greater health risks. Tobacco companies
should be prevented from giving brands a "light" image,
from implying that such cigarettes are safer or less harmful.
4.3 Implications for consumer information
The numbers displayed on tobacco products give
misleading information to the consumer. Regulators in the United
States are now advising smokers not to place any value on tar
or nicotine yields printed on packs. Similar concerns should now
be raised in the EU. The EU Directives that govern the maximum
tar and nicotine yields and the labelling of cigarettes (41) are
both being re-examined by the European Commission. The UK Government
is therefore presented with an opportunity to change the regime
and to provide smokers with more reliable consumer information.
Conclusion: The Faculty believes the Government
should employ new regulatory powers to ensure that all cigarette
packets are labelled with information that is relevant to the
consumer.
5. TOBACCO ADDITIVES
Around 600 additives are used to manufacture
cigarettes in the EU, most of which are food additives. Although
generally screened for their toxicity by ingestion, there has
been no separate testing under conditions of burning and inhalation.
When burnt, these chemicals are likely to break down into different
products that may become toxic or addictive. Tobacco additives
themselves are a major public health issue (42).
The tobacco industry did not start using many
additives before 1970, and there is some concern over the rationale
for their introduction. The sole purpose of some additives appears
to be to increase the addictive "hit" of nicotine, or
enhance the taste of tobacco smoke to make the product more desirable.
If a small amount of a harmless chemical can make cigarettes more
addictive, or make it easier to start or continue smoking, then
the additive may cause great harm by causing additional exposure
to the known carcinogens in cigarette smoke.
Current regulatory frameworks are wholly unsatisfactory.
There are no EU regulations that require tobacco companies to
reduce or control the concentration of specific harmful chemicals
in tobacco smoke, other than the single European Directive governing
the maximum tar yield per cigarette (27, 41). Tobacco companies
are not required to identify chemicals used in their products
nor the purpose of the additives. New regulations are required
to oblige the industry to demonstrate that no additional harm
comes from use of an additive and to make more information available
to a regulator and the consumer. It should become possible to
challenge all tobacco additives that may influence smoking behaviour.
Conclusion: The Faculty believes that current
regulation of tobacco additives is wholly inadequate to protect
the consumer. A new regulatory framework is needed to challenge
the use of all additives that may influence smoking behaviour.
6. CIGARETTE
DESIGN
The tobacco industry has filed numerous patents
that would reduce the levels of some of the known toxic compounds
in cigarette smoke including nitrosamine, benzo(a)pyrene (both
carcinogens) and carbon monoxide (which exacerbates heart disease).
Some of these patents were published over 20 years ago (27), but
none of these innovations have been incorporated into tobacco
products.
Stopping smoking has to be the main aim of public
health measures to reduce the harm from tobacco. However, as nicotine
is a highly addictive chemical, it is likely that many people
will be smokers for the foreseeable future. Regulations that require
that tobacco industry to incorporate modifications such as those
have already been patented, should reduce the harm to both the
active and passive smoker, albeit to a limited extent. As with
low tar there is the risk that some smokers might believe there
is less need to quit smoking because of the safer cigarettes.
It should be made explicit that the switch to a "safer"
cigarette is comparable to "jumping off an eight storey building
instead of a 10 storey building".
Conclusion: The Faculty believes that
current regulation of cigarette design is wholly inadequate to
protect the consumer. Consideration should be given to a new regulatory
framework requiring the use of patented designs that may reduce
the harm from cigarettes.
7. CONCLUSION
The Faculty of Public Health Medicine believes
that the tobacco industry knowingly misleads the public; tobacco
products should be subject to more rigorous testing and regulation;
and tobacco products should be labelled with relevant consumer
information. This is necessary for the public to be able to make
informed choices to protect their health.
October 1999
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