Permissive nicotine regulation as a complement to traditional tobacco control
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Abstract Background Cigarette smoking takes a staggering toll on human health and attracts considerable public health attention, yet real solutions seem distant. The 2004 Family Smoking Prevention and Tobacco Control Act (US Senate bill S2461) would have given the US Food and Drug Administration limited authority to regulate cigarettes to "protect the public health." However, such legislation is unlikely to substantially reduce smoking or related deaths. Discussion The past 500 years of tobacco control efforts demonstrate that nicotine prohibition is a practical impossibility for numerous reasons, state revenue being one of the most ominous. The FDA already has regulatory authority over pharmaceutical grade nicotine products, and requires pharmacists to dispense the most addictive of these only with prescriptions. Meanwhile, every corner store can sell far more addictive and dangerous cigarettes to any adult. The FDA could immediately increase competition between cigarettes and clean nicotine products by approving available nicotine products for over-the-counter sales to adults. Similarly permissive regulation of cigarettes and addictive nicotine products will reduce tobacco use and improve smokers' health, but increase nicotine use in the population. Fortunately, restricted youth access and accurate labeling of nicotine's absolute risks will dissuade many non-smokers from experimenting with it, while accurate depiction of its risks relative to cigarette smoking will encourage many smokers to switch. The FDA could take a series of small steps that might ultimately replace a large proportion of cigarette smoking with equally addictive nicotine products, without risking serious public health setbacks. Vaccine, methadone, and injury prevention policies establish relevant public health precedents. Summary Cigarettes, or an equally addictive alternative, will be a permanent and common product in most societies. Regulations restricting only the safest addictive nicotine products are hard to justify. Addictive nicotine compliments other tobacco control strategies. Modern tobacco control policies are applicable to addictive nicotine. Controlled trials and test market studies are urgently needed to evaluate addictive nicotine as an alternative to smoking. Meanwhile, legislators should preserve the Food and Drug Administration's option to permit non-prescription sales of addictive nicotine.Keywords:
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More than 1 billion people smoke worldwide, and 200 million of them are women. The prevalence of tobacco use among women is rising, as is the tobacco-related disease burden. Recently released tobacco industry documents unequivocally establish that the tobacco industry has made a practice of targeting women and girls for decades in an effort to cultivate what it considers an underexploited market. This article discusses the importance of strategies to limit the growth of the tobacco pandemic and describes the World Health Organization's Framework Convention on Tobacco Control, which may have important implications for preventing the further spread of tobacco use among women.
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Tobacco consumption is a major contributor to the burden of chronic noncommunicable disease within the Pacific region. Low and lower-middle income countries are acutely vulnerable to exploitation by the tobacco industry as they often lack the resources and capacity to implement protective tobacco control policies. The Framework Convention on Tobacco Control, which has been signed by 14 Pacific Island Countries and Territories, was introduced in 2004 to guide the priorities for tobacco control policy implementation. Legislation, tobacco industry documents, and peer-reviewed journals were evaluated to assess the current status of tobacco advertising bans of the 8 low and lower-middle income countries within the Pacific region. Results identified that of the 8 Pacific countries reviewed, 3 had comprehensive tobacco advertising bans that prohibit tobacco advertisements in 5 to 7 forms of media, and the remaining 5 countries have weak tobacco advertising bans that provide no protection for youth against tobacco advertising. This research reveals the need for resources to support the introduction of effective policies around tobacco advertising in the low and lower-middle income countries within the Pacific region.
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POLICY POINTS: The tobacco companies prioritized blocking tobacco-control policies in tobacco-growing states and partnered with tobacco farmers to oppose tobacco-control policies. The 1998 Master Settlement Agreement, which settled state litigation against the cigarette companies, the 2004 tobacco-quota buyout, and the companies' increasing use of foreign tobacco led to a rift between the companies and tobacco farmers. In 2003, the first comprehensive smoke-free local law was passed in a major tobacco-growing state, and there has been steady progress in the region since then. Health advocates should educate the public and policymakers on the changing reality in tobacco-growing states, notably the major reduction in the volume of tobacco produced.
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The publication of a special communication by Ronald Davis in this issue (see page 211) 1 about a report on the effect of tobacco advertising bans (“the Boddewyn report”) that was in fact ghost-written by British American Tobacco caused one of us to experience a memory flashback to the mid-1980s. At that time, MW was working as a research officer in a state health department in Adelaide, South Australia. I (MW) distinctly remember being given the Boddewyn report to provide comment on to my health minister’s office. Even though I was then an inexperienced researcher, I could see that the report was seriously flawed. Because it was apparently the work of such a prestigious-sounding individual and organisation, I became deeply concerned that it could actually influence government policy. I prepared several pages of critique pointing out the problems with the report, added a concise summary, and sent it back up to the minister’s office. I received no further requests about the report, but it was the first time I was shocked by the extent of misinformation from sources allied with the tobacco industry. That situation was one of several that drew me more closely into a career in tobacco …
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The tobacco industry’s aggressive marketing of tobacco products and electronic (e-)cigarettes is well documented. Yet existing restrictions on tobacco and e-cigarette marketing are poorly implemented in most low- and middle-income countries. Ongoing challenges include weak implementation and enforcement of some aspects of the WHO Framework Convention on Tobacco Control and a lack of consensus among health professionals on how to address the tobacco industry’s health claims related to e-cigarettes and other novel tobacco products. We argue that
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Chinese men consume around 40% of the world's cigarettes, causing a substantial and growing burden of tobacco-attributed death and disease. In 2005, the Chinese Government ratified the WHO Framework Convention on Tobacco Control, and tobacco control measures have since increased nationwide. To assess tobacco control progress, obstacles, and opportunities, this Review describes the long-term evolution of cigarette consumption and the associated disease burden in mainland China, and the implementation of five important tobacco control strategies advocated by WHO. These strategies covered tobacco taxation; package warnings; advertising, promotion, and sponsorship bans; public smoking bans; and cessation services. Although only 2% of women in China now smoke, half of all adult men smoke cigarettes. By the 2010s, smoking accounted for about a fifth of all adult male deaths, and this proportion is rising, following a trajectory similar to that seen in the USA 40 years earlier. The self-regulating national tobacco monopoly and its influence on policy, the country's relatively low tobacco tax, and its weak package warnings and enforcement of other tobacco control strategies all highlight challenges in tobacco control. However, these challenges can also provide opportunities to discourage smoking initiation in young women and encourage cessation in men, assisting China's long march towards better health.
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This paper reviews progress in tobacco litigation since Tobacco Control ’s founding 30 years ago, with a focus on cases which are ongoing or recently decided. Litigation in tobacco control falls into several classes: legal challenges brought by the tobacco industry to block implementation of tobacco control measures, public interest litigation brought by civil society to push for higher standards of implementation of tobacco control measures and liability litigation by governments and individuals to hold the tobacco industry accountable for the harm it causes. In each class of cases, there are a number of major case studies which show the importance of international frameworks, including most significantly the WHO Framework Convention on Tobacco Control, to tobacco litigation.
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This brief provides an overview of tobacco control legislation, use, and taxation in the country. Costa Rica ratified the WHO Framework Convention on Tobacco Control in 2008. General Law for the Control of Tobacco and its Harmful Effects on Health was adopted in March 2012, and it regulates smoke-free places; tobacco advertising, promotion, and sponsorship, as well as tobacco packaging and labeling in line with FCTC guidelines. This law also sets several norms on tobacco taxation, and it substantially increased the tax burden for cigarettes. In 2012, cigarette prices in Costa Rica increased by 49 percent, and in 2013, the tobacco excise revenue increased by 96 percent. Tobacco taxation and other tobacco control policies in Costa Rica were very successful in terms of public health. The prevalence of smoking both among adults and adolescents declined, and after 2012, the rates of decline increased. In 2015, only 5.8 percent of the adult population smoked daily. In 2018, cigarette production in the country was closed. The tobacco industry claimed that the closure had been caused by increased cigarette smuggling. However, there are no independent estimates of illicit cigarette share on the market, while the tobacco industry used to exaggerate the volumes of smuggled cigarettes. The difference in cigarette prices between Costa Rica and neighboring countries is rather small and is unable to encourage large smuggling. Thus, the observed illicit cigarette sales are likely caused by the factors, which are not related directly to tobacco taxation.
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Tobacco use is the leading preventable cause of death in South Carolina. Smoking-related medical costs amount to $1.1 billion each year, including $393 million for Medicaid. Tobacco growing in South Carolina declined by over 50 percent from 1997 to 2008. Tobacco accounted for less than 10% of the state's cash receipts from all crops in 2007. Despite the low levels of actual tobacco growing and the small role tobacco played in the state's economy in 2008, the cultural construct of being a “tobacco growing state†continued to have a disproportionately large impact on tobacco control policy making. Between 1997 and 2008, the tobacco industry lost its alliances with the Farm Bureau Federation and Commissioners of Agriculture, former staunch industry allies, because of negotiations over the Master Settlement Agreement, the buyout of the Tobacco Price Support system, and increasing purchase of foreign tobacco. Tobacco control Policy Score rankings of 2007/2008 legislators by knowledgeable tobacco control advocates revealed that legislators from the Pee Dee region, historically the stronghold of tobacco agriculture, were similar to the rest of the state's legislators in their attitudes towards tobacco control. Tobacco area legislators were formerly strong allies of the tobacco industry and historically worked with industry lobbyists to ensure defeat or manipulation of tobacco control bills. The 2007/2008 Policy Scores indicated that this was no longer the case. Tobacco control advocates should take advantage of the growing distance between tobacco companies and its former tobacco-growing allies and the decline in the actual importance of tobacco agriculture to challenge the rhetoric and resistance to tobacco control policies in the state. The tobacco industry built significant political influence in South Carolina through lobbyists, alliances with prominent trade associations, campaign contributions and other political expenditures. From 1996 to 2006, tobacco companies, trade associations and producers contributed a total of $680,541 to candidates for state office and to political parties. There is a measurable relationship between tobacco industry contributions and legislative behavior. As rated on a Policy Score scale from 0 to 10, with 10 being extremely receptive to tobacco control and 0 being extremely pro-tobacco industry, for every $1,000 received from the tobacco industry during the 2006 election cycle, a legislator's Policy Score decreased by 1.5 points. Democrats were on average 3.6 points more favorable towards tobacco control than Republicans, after controlling for campaign contributions. South Carolina was selected by the NCI in 1990 to participate in the 17-state ASSIST program. ASSIST funded tobacco control programming within the Department of Health and Environmental Control and established the state's first formal tobacco control coalition, the Alliance for a Smoke-Free South Carolina. The Alliance disbanded in 1997, leaving tobacco control advocacy disorganized and ineffective through 2003. ASSIST ended in 1999 and was replaced by a minimally-funded DHEC Tobacco Division supported primarily by about $1 million annually from the US Centers for Disease Control and Prevention. In 1998, the state signed the Master Settlement Agreement, securing approximately $70 million per year from the major cigarette companies. In 2000, the state securitized its settlement revenue, receiving a lump sum of $900 million up front in lieu of its annual payments through 2019. Refinancing in 2008 moved this date back to 2012. The 2000 General Appropriations bill set up 4 trust funds from the securitized MSA funds, with 73% ($574 million for healthcare), including tobacco control. Only $3.34 million of the MSA revenue was spent on tobacco control between 2000 and 2008. The state allocated an additional $6 million from the General Fund to the DHEC Tobacco Division between 2002 and 2008, with no state funding for the program between 2003 and 2006 and again in 2008. The Tobacco Division developed small-scale but innovative tobacco control programming, particularly community programs to promote policy change and the Rage Against the Haze youth movement. The DHEC leadership did not prioritize tobacco control between 2000 and 2008, although its support increased gradually due to efforts by the Tobacco Division, DHEC regional staff and the voluntary health groups. Funding requests remained at $2 million, significantly below the CDC recommended $62.2 million per year. Limitations by DHEC leadership on the role that DHEC staff play in local community-wide policy change efforts changed in 2007 to allow direct participation, but remained limited in scope. The voluntary health groups failed to prioritize increased funding for the DHEC Tobacco Division relative to their other lobbying focuses and continued in 2008 to act hesitantly in their lobbying of DHEC leadership to support tobacco control funding and policy change. In 2001, tobacco control advocates formed the South Carolina Tobacco Collaborative. It received 83% of its funding from the state health department, limiting its advocacy capacity. Increased funding from voluntary health groups and national partners between 2005 and 2008 allowed the Collaborative and the other prominent tobacco control advocacy groups, the South Carolina African-American Tobacco Control Network and the Smoke-Free Action Network, to increase advocacy between 2005 and 2008. These developments led to notable successes in clean indoor air policies and attempts to increase the state's tobacco tax. The cigarette tax in South Carolina remained the lowest in the nation in 2008, at 7 cents per pack. The last cigarette tax increase was in 1977, with nearly annual attempts to increase the tax defeated by coordinated efforts from the tobacco industry. Tobacco control advocates began to push for a cigarette tax increase in 2000, without success. Between 2006 and 2008, the Collaborative developed a well-funded and well-coordinated public education and lobbying campaign to support a cigarette tax increase. In 2008, the General Assembly passed a 50-cent increase, with $5 million of the annual revenue directed to the DHEC Tobacco Division, over active opposition from the tobacco industry and its allies. Governor Mark Sanford vetoed the bill for its lack of revenue neutrality, and Speaker of the House Bobby Harrell successfully prevented a veto override in the House. The 2006-2008 cigarette tax increase campaign showed that well-funded tobacco control advocacy could be successful over tobacco industry opposition in the legislature. The defeat of the increase bill demonstrated the need for stronger grasstops lobbying and relationship building with legislative leadership. Between 1977 and 1989, local policymakers passed 19 limited clean indoor air ordinances, building momentum for consideration of a state-level clean indoor air bill. In 1990, tobacco control advocates compromised with tobacco industry lobbyists to allow the passage of a weak statewide Clean Indoor Air Act, halting significant progress on clean indoor air through 2005. In 1996, the tobacco industry succeeded in using the Synar Amendment to integrate preemption into a youth access to tobacco amendment. The tobacco industry and tobacco control advocates assumed the provision also preempted local clean indoor air activity. Beginning in 1999, local policymakers in Charleston began to support local clean indoor air ordinance attempts despite assumed preemption. While Charleston did not pass an ordinance until 2006, news coverage of the city's efforts began a wave of consideration of local ordinances, eventually supported by state and local tobacco control advocates and the Municipal Association. Between May 2006 and December 2008, 21 local clean indoor air ordinances passed, 12 of which passed before the state Supreme Court rejected the argument that preemption applied to clean indoor air ordinances. Two localities were sued over their ordinances on preemption grounds, but won both cases in the Supreme Court. During the 2007/2008 legislative session, tobacco control advocates joined together to successfully defeat multiple attempts to institute express preemption through weak clean indoor air legislation supported by the tobacco industry. Given the success of local clean indoor air efforts, the strategy of tobacco control advocates developed during 2008 should be maintained: continue to promote comprehensive local smoke-free ordinances, while avoiding any action on clean indoor air in the General Assembly.
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