Rethinking Nicotine: The Role of Public Health Law in Ending an Epidemic

Volume 47, No 2
David Sweanor and Adam R. Houston

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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.

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