The future of tobacco – rejecting a prohibitionist anti-smoking movement

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The biggest obstacle in America to the creative destruction of the cigarette is, ironically, the proscriptive culture of mainstream tobacco control whose researchers, activists and regulators are locked in an outdated mindset, fighting anti-smoking battles of last century. Everyone else is ready to move on to a healthier approach to tobacco and nicotine, writes Jacob Grier on Medium.

“Smoking kills. Quit now.” There was no missing the blunt warnings plastered on the cartons of Marlboro cigarettes as the flight attendants half-heartedly paraded the duty-free cart down the aisle of my plane to Switzerland. In case the message wasn’t clear, graphic photographs drove it home: a blackened lung, a close-up of a tracheostomy.

There are still plenty of smokers in the world – about a billion of them, actually – but the glamour of smoking has nearly been extinguished.

Even the big tobacco companies, once utterly shameless in their denials of the dangers of smoking, have given up defending cigarettes on the merits. Philip Morris International, the world’s largest tobacco company and the maker of those Marlboros, now boasts instead of “delivering a smoke-free future” in which the cigarette is eradicated.

Replacing the cigarette

Eradicated, yes. But replaced by something new. I catch a glimpse of that new thing when I land in Geneva. In one of the airport newsstands is a shiny display for IQOS, Philip Morris’s controversial ‘tobacco heating system’. It’s a small electronic device that one could imagine mistaking for some kind of phone accessory. It’s actually designed to deliver inhalable nicotine aerosol from a miniature cigarette.

Unlike the e-cigarettes familiar in the United States, IQOS produces this vapour from actual tobacco. Yet unlike a conventional cigarette, the tobacco used in IQOS never catches fire and never produces smoke. According to Philip Morris, puffing on an IQOS exposes a user to far lower levels of toxic compounds than smoking.

The company has high expectations for this “heat-not-burn” technology, and it’s one reason I’ve come to Europe: to explore potential futures for tobacco.

In the United States, to suggest that tobacco should even have a future is heretical. Our attitudes have been shaped by the millions of deaths caused by cigarettes and by decades of deceit by Big Tobacco.

American public health groups and government agencies take an uncompromising stand against nicotine, seeking to end its use entirely and viewing the fight against smoking as a battle between good and evil. For those who made their careers in the era of all-out war against Big Tobacco, it’s unsettling to think that tobacco may evolve instead of disappear.

Future of tobacco is up for grabs

Perhaps the prospect is not as frightening as it seems. In fact, there’s at least one country where such a future has already arrived, with some of the world’s lowest rates of smoking and smoking-related diseases. That country is Sweden, and tobacco use among Swedes is still robust; they have simply transitioned to a much safer way of consuming it.

Sweden’s unusual story of success points a way toward a more liberal approach to tobacco use, one in which gains in public health are achieved by profit-driven innovation rather than by increasingly coercive prohibitions.

The future of tobacco is very much up for grabs. It’s a struggle over not just what kinds of tobacco and nicotine products people consume, but also who is allowed to produce and sell them.

As the age of the cigarette comes to an end, corporations that spent the previous century merchandising that deadly product are politically and financially well-positioned to seize the market for safer alternatives. Ironically, laws and regulations supported by anti-smoking groups have paved the way toward a future that may once again belong to Big Tobacco.

This is a shortened version of the article The Future of Tobacco, published on the writers' platform Medium. Click here for the original article.

Heat without smoke

The World Health Organization headquarters are located in Geneva. Philip Morris International’s research and development centre is just a short train ride away in Neuchâtel. Yet one gets the impression that employees of the two organisations rarely meet up for happy hour. Official statements from WHO range from sceptical to hostile with regard to heated tobacco, coupled with recommendations for total abstinence.

That puts WHO in conflict with smokers themselves, many of whom like IQOS very much and have found it to be a viable path to quitting cigarettes.

I first encountered the product back in 2016 when an old friend, a lifelong smoker with many previous failed quitting attempts, excitedly showed it to me at a wedding. It was the first product he’d found capable of breaking his habit, and though it wasn’t yet for sale in the United States, he knew people abroad willing to ship him the special tobacco needed to use it. That smuggling enabled him to be one of the first Americans to switch from cigarettes to IQOS, joining the ranks of many smokers in Asia and Europe who’ve done the same.

Witnessing my friend’s success was one reason I accepted an invitation from Philip Morris last summer to visit ‘The Cube’, the company’s R&D headquarters in Switzerland. (I paid all of my own travel expenses for this story.)

The Cube sits alongside Lake Neuchâtel, the blue water reflecting off the glass facade of the modern building built in 2009 at a reported cost of $120 million. Next door is one of Philip Morris’s industrial factories, still churning out combustible cigarettes. The styles of the two buildings are in marked contrast, the new versus the old.

The interior of the Cube is divided into three sections, each named after one of the classical elements: Earth, Water, and Air. (The missing fourth element has no place here. Get it?)

The meeting is intended to highlight PMI’s supposed transformation from the world’s largest producer of cigarettes to a company leading the way toward a non-combustible future. The obstacles are both technological and cultural.

Technological: How do you make a product that’s both safer to use and appealing enough to smokers that they will make the switch? Cultural: How do you establish credibility after decades of proving yourself one of the most dishonest industries in the world?

The IQOS

Inside the conference room, I join another American journalist to inspect an IQOS and a few other smokeless products Philip Morris is developing. The IQOS comes in three components: a hand-held electronic heating element, a charger, and tiny cigarettes called Heatsticks. These are made with a densely packed, specially-treated plug of tobacco that releases nicotine vapour when heated by the device and inhaled by the user. Breaking one open, the tobacco smells light and pleasantly of milk chocolate, aromatically a touch more appealing than the average cigarette, though less complex than a quality cigar.

What it tastes like, however, I couldn’t tell you. An old cigarette marketing slogan had smokers attesting: “I’d walk a mile for a Camel.” I’d traveled 5,000 miles for an IQOS, but I was not allowed to try it. Since neither I nor the other journalist smoke cigarettes, our media contact from the United States, Corey Henry, refused to let us puff on the IQOS.

This was a bit performative, but the message served a purpose. Henry emphasised that this is part of their “good conversion practices”, referring to plans for screening potential buyers at their then-forthcoming first American retail store in Atlanta.

These involve excluding anyone under 21 years of age as well as non-smokers and former smokers, with the aim of avoiding the youth and non-smoker use that has plagued e-cigarette companies like Juul. (Juul is partially owned by Altria, the parent company of Philip Morris USA. Altria and Philip Morris International have operated as separate entities since 2008.)

Though we were not allowed to sample heated tobacco ourselves, we were invited to watch a machine puff on an IQOS and a conventional cigarette side-by-side. The two products were placed inside a plexiglass chamber and attached to air pumps that mimic the way a human smokes.

A technician set it up to ignite the cigarette and heat the IQOS, drawing the air from each through a bright white paper filter. “Here’s the nasty one,” said the tech, holding up the filter exposed to cigarette smoke, now filthy brown with tar. The paper from the IQOS emerged barely changed.

The science basics

The contrast between the filters is a visually striking image, but does it signify anything scientifically? Is the aerosol from an IQOS really that different from the smoke from a cigarette? Answering that is complicated, and much of the presentation by Ignacio Suarez Gonzalez, the company’s regional head of scientific engagement, was devoted to reasons to believe that it is.

Fundamentally, he explained, lower heat leads to lower chemical complexity. A cigarette burns in the range of 600-800° C, releasing or producing hundreds of toxic compounds (“harmful and potentially harmful constituents” in the parlance of tobacco regulatory science).

The tobacco in an IQOS maxes out around 350° C, hot enough to volatilise the nicotine but well below the point of combustion. The result is an aerosol that contains nicotine and mimics some of the sensory experiences of smoking, but with a reduced chemical load.

Reducing exposure; making the switch

Gonzalez is careful to avoid making explicit health claims, but the reductions in exposure can certainly appear impressive. According to PMI research, some harmful constituents are reduced by 95% or more and biomarkers among users who switch from cigarettes to IQOS show encouraging downward trends.

Whether that reduction leads to improved health outcomes, and questions surrounding other components in the aerosol produced by IQOS, remain matters of ongoing debate. The company’s case was, however, compelling enough to persuade the Food and Drug Administration to allow the product for sale in the United States and to advertise that switching cigarettes to IQOS reduces exposure to harmful chemicals.

The other big question is whether smokers will make the switch. IQOS has been legally available in the United States for less than a year and only in selected markets. It has a longer history abroad. PMI reports that the introduction of heated tobacco products in Japan, for example, has accelerated declines of cigarette sales.

The claim has been corroborated by independent research in academic journals, such as a 2019 analysis in Tobacco Control that found “it is likely that the introduction of IQOS reduced per capita cigarette sales in Japan” and that the introduction of IQOS in specific regions “better predicted the timing of cigarette sales decline” than any national factor.

This is a shortened version of the article The Future of Tobacco, published on the writers' platform Medium. Click here for the original article.

Burden of the past

How that translates into health outcomes will depend on the long-term effects of consuming heated tobacco and whether smokers switch completely or use it as a partial substitute for cigarettes. Sorting out these important questions is complicated by the seemingly unbreachable divide between tobacco companies and mainstream tobacco researchers.

“PMI has the burden of the past to overcome,” says David Sweanor, adjunct professor of law at the University of Ottawa. Sweanor has worked in the field of tobacco control since the 1980s, including serving as counsel to the Non-Smokers’ Rights Association in Canada, advocating for restrictions on public smoking, and advising in litigation against cigarette companies.

Today he advocates for harm reduction, an approach centered on minimising the detrimental health impact of smoking by encouraging smokers to switch to lower-risk alternatives. It’s a divisive idea in tobacco control and it has put him on the outs with many of his peers. “I have colleagues I’ve known for decades who will not talk to me because I support harm reduction,” he says.

When I ask Sweanor about the difficulty of assessing products like IQOS when so much of the research comes from Philip Morris itself, his answer surprises me. “Their science is way better than the science that’s coming from my side,” he says, meaning the side of professional tobacco control.

The field has become polarised over harm reduction, with former allies on issues like smoking bans now bitterly divided over questions about the future of nicotine. “If you look at who’s now running tobacco control, who’s got all the Bloomberg funding, who’s at the Centres for Disease Control, it’s prohibitionists and people who see this in moralistic terms,” he says. That makes it difficult to have pragmatic conversations about whether replacing cigarettes with safer products will save lives.

“A lot of my colleagues aren’t interested in substitution effects,” he says. “You don’t substitute one sin for another sin.” But what if not all sins are equally harmful? People who use tobacco tend to persist in using it, which Sweanor describes as the ‘stickiness’ of the tobacco market. That makes substitution an easier sell than abstinence.

And the benefits of encouraging smokers to switch to safer products are not merely hypothetical. Sweden, the country with the longest history of tobacco harm reduction, has already achieved remarkable results.

How the Swedes stopped smoking

“Shall we fika?” Swedes are famous for their daily pauses to enjoy coffee and pastries with friends and co-workers, and on my first morning in Stockholm they were living up to their reputation. I was here to meet Patrik Hildingsson, vice president of communication and public affairs for Swedish Match, and our topic of conversation was another famously Swedish product: snus, (rhymes with ‘loose’) a kind of oral tobacco that is particularly popular in Sweden.

Unlike American chewing tobacco, snus doesn’t trigger the intense salivation that makes users constantly spit. It’s much more discreet, coming in tiny white packets that get tucked beneath the upper lip.

By any scientific measure, it’s one of the lowest-risk forms of tobacco consumption in the world. Despite this, it’s illegal in the rest of the European Union. Sweden’s entry to the EU in 1995 was contingent on securing special dispensation to ignore the snus ban.

Sweden thus provides something of a natural experiment in tobacco control. While the rest of Europe carried on with typical strategies for battling cigarettes, Sweden allowed smokers access to a much safer alternative.

My meeting with Patrik began on Skansen, an open-air museum dedicated to showcasing various aspects of Swedish culture, from a replica of nineteenth century towns to local fauna like reindeer and wolverines. Among the exhibits is the Snus and Match Museum, which chronicles the country’s unusual history with tobacco.

Sweden’s tobacco story begins much like that of other western nations. In the first act, as in the United States, Swedes adopted oral forms of tobacco. In the second act, like the US and Europe in the 20th century, they switched to smoking industrially-produced cigarettes.

It’s in the third act that things get interesting. While everyone else kept smoking, Swedish men went back to snus.

“Smokers began to take up snus, not because of government messaging or marketing,” says Hildingsson. “It was mouth-to-mouth.” In other words, the widespread transition from cigarettes to snus occurred not as part of a publicly sanctioned health campaign, but from the bottom-up decisions of individual consumers.

Swedish men, in particular, began either quitting smoking by switching to snus or never taking up smoking in the first place, having begun with snus instead.

Meanwhile, in the 1980s and 1990s, Swedish snus producers undertook a scientific review of their production processes with the aim of reducing harmful constituents. This focused on lowering the pH, eliminating microbial activity and phasing out the use of fire-cured tobacco. These changes resulted in greatly reduced exposure to toxicants.

While oral tobacco of any kind is generally lower-risk than cigarettes, contemporary snus is astonishingly so. Its use is not associated with lung or oral cancer, and associations with other diseases that take the lives of smokers tend toward suggestive or non-existent.

When you combine these two trends – product substitution by smokers and safety innovation by a tobacco company – you get the ‘Swedish experience’. It’s a situation in which tobacco use is common and socially acceptable, yet health outcomes are among the world’s best. Within Europe, Swedish men stand out for having both the lowest rate of daily smoking and lowest rate of tobacco-attributed mortality.

The country achieved this without hewing to the abstinence-only approach favoured by public health authorities elsewhere.

No stigma for snus

As a visitor, one of the most striking things about snus in Sweden is the absence of stigma and shame around it, so unlike the way Americans now view cigarettes. Striking up conversations in Stockholm bars, snus consumers told me how much they like it or, in the case of one man who gave it up at his wife’s insistence, how much he misses it every day.

A bartender at an upscale cocktail lounge casually offered me a packet of snus as he removed one for himself, a friendly gesture of hospitality reminiscent of the way an American might have offered a cigarette in decades before smoking bans.

This social acceptability is part of what makes the Swedish experience a contentious topic in public health. By objective measures, Sweden is a public health success. But anti-smoking advocates have spent decades focusing on denormalisation, reframing tobacco use as a disorder rather than a personal choice.

If nicotine is to be used at all, they insist that it be in pharmaceutical products aimed at achieving eventual abstinence, such as nicotine replacement therapies like gums or patches. “If you classify smoking as a disease,” says Hildingsson, “you treat it with medication”. And medication isn’t supposed to be social or pleasurable.

This is a shortened version of the article The Future of Tobacco, published on the writers' platform Medium. Click here for the original article.

Avoiding smoking harms

The alternative to denormalisation and abstinence is a future in which nicotine and tobacco consumption simply evolves to avoid the harms caused by smoking cigarettes. “I think nicotine is here to stay,” says Hildingsson. “Traditional cigarettes are not the future. But nicotine is.”

Sweden is the model of this approach, but there are already glimpses of it bearing fruit in other countries. The share of the Norwegian population using snus surpassed that smoking cigarettes in 2017, with snus usage doubling over the same 10-year period in which smoking rates fell by half.

Iceland has seen a dramatic drop in smoking coinciding with a rise in snus and vaping. Heat-not-burn tobacco is displacing cigarette sales in Asia. And in New Zealand, a combination of higher taxes on cigarettes and increased switching to vaping is resulting in record declines in cigarette sales.

Though you wouldn’t know it from American news coverage, harm reduction is working in the United States, too. Fear-driven reporting about vaping has obscured dramatically good news about smoking. Adult smoking rates continue to fall, the population-level rate of quitting smoking is increasing, and youth cigarette smoking is at the lowest levels ever recorded, all but disappearing among high schoolers.

As in Sweden, much of this progress has come from the bottom-up, driven by small vapour companies and passionate online communities.

This happened in spite of health authorities and mainstream tobacco control.

Media coverage of vaping has tended toward alarmism, and the entire market for e-cigarettes is threatened by federal regulation and prohibitionist lawmakers.

The possibilities for tobacco harm reduction in the United States are deeply imperilled. There’s a very real risk that the United States will end up outlawing the products most capable of competing with cigarettes, entrenching deadly smoking habits, and letting the market for lower-risk alternatives be captured by the world’s largest tobacco companies.

As a writer who has covered tobacco control from the outside for more than a decade, it’s long been obvious that the field is beset by toxic ideological rigidity. That researchers at all levels are finally speaking out about it is overdue.

Yet the problems run deeper than the divide over harm reduction. A more fundamental failure is that many scientists and advocates have simply lost sight of smokers and nicotine users as equal citizens with independent aims and interests.

A place for pleasure

An insightful external critique comes from anthropologist Kirsten Bell, who has argued compellingly that both mainstream and heterodox tobacco researchers tend to hold a dismissively reductive view of smokers’ motivations.

To the prohibitionist wing, smokers are mere slaves to the tobacco industry who have been manipulated by marketing and addiction. To some supporters of harm reduction, they are nicotine-seeking automatons whose need for a chemical fix can be channelled toward safer delivery sources. Neither approach treats smokers as fully human, as people with complex desires that include the pursuit of pleasure.

“Alongside the discourses of harm and addiction that dominate both tobacco control and tobacco harm reduction, there must also be a place for pleasure,” Bell concludes in a paper on the topic. “What, if we were to take pleasure seriously, might tobacco control and tobacco harm reduction actually look like?”

Bell posed the question seven years ago, and tobacco control’s ongoing failure to answer it explains many of the problems presently arising. New prohibitions are now routinely put into place without a moment’s concern for the autonomy of consumers, who tend to have lower incomes and less education than the anti-smoking advocates lobbying for laws restricting their behaviour.

Last week, California banned flavoured tobacco and e-cigarettes a single dissenting vote. Last year in Michigan, an emergency order threatened jail terms of up to six months for selling flavoured e-cigarettes, with restrictions enforced by armed police going store-to-store. And small businesses catering to vapers nationwide are in an ongoing fight for survival.

A bizarro world

This is the future of tobacco on the current track: a bizarro world where some of the safest nicotine sources are banned while conventional cigarettes remain available in every convenience store, with much of the public misinformed about where the real danger lies.

The regulatory process will grind on while state and local governments impose increasingly onerous restrictions on vaping. Products with immense promise to help Americans quit smoking will be forbidden while conventional cigarettes, heated tobacco and tobacco company-backed mass market e-cigarettes remain permitted by the FDA.

In this future, the mainstream tobacco control movement that has long sought to eradicate smoking and defeat the tobacco industry will accomplish neither. Cigarette smoking will be prolonged by the demonisation of vaping, while companies like Philip Morris reap the rewards of a protected market for cigarette alternatives in which only they and a few other large corporations have the financial resources to secure government approval.

This future is neither smart nor humane.

A better future?

What would a better future look like? One can imagine making marginal improvements through smarter technocracy or more rational regulation, but the broken culture of tobacco control needs a more fundamental fix. That begins with embracing the old-fashioned liberal idea that adults must be free to make their own decisions.

That doesn’t mean giving up on fighting smoking. Health authorities can still persuade potential smokers with accurate information and nudge them with higher taxes and regulations on the most dangerous products.

We know from Sweden and elsewhere that this is effective; offer smokers a source of nicotine that’s cheaper than a cigarette, similarly enjoyable, and far less likely to kill them, and many of them will take it up. The proposition is so simple that it doesn’t even need to be planned to be successful.

This liberal future would entail accepting potentially ongoing use of nicotine, and not just in therapeutic or pharmaceutical senses. People have sought the drug for centuries because they find it useful, meaningful or pleasurable. There would undoubtedly be some who still smoke, either because they’re addicted or because they simply enjoy it.

Current trends suggest, however, that the cigarette would at last suffer creative destruction, becoming a niche product replaced by better, lower-risk alternatives. And those alternatives would compete on a fair playing field, one in which the power of the state would not be enlisted to shut down small vapour shops to clear the market for supposedly reformed tobacco companies.

Unfortunately, the biggest obstacle to this future is the illiberal culture of mainstream tobacco control. As the very name of the field suggests, ‘control’ is what these researchers, activists and regulators demand. They remain locked in the outdated mindset of the last war, still fighting the Manichean anti-smoking battles of the previous century.

Everyone else – smokers, snus users, vapers, even tobacco companies – is ready to move on to a freer, healthier approach to tobacco and nicotine. We can achieve a safer, smarter future, but only if we stop ceding the moral high ground to prohibitionists stuck firmly in the past.

Jacob Grier writes about tobacco, public policy and other vices. His articles have appeared at Slate, Reason, The Atlantic, The Washington Post, The Los Angeles Times, The Daily Beast, Eater, Imbibe and many other publications. His books include The Rediscovery of Tobacco: Smoking, vaping, and the creative destruction of the cigarette. Website: www.jacobgrier.com

 

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