Editorials

Levelling the playing field for regulation of nicotine

Existing laws in Britain offer a promising framework

In a bold new report, the tobacco advisory group of the Royal College of Physicians of London has called for the establishment of a nicotine regulatory authority in the United Kingdom.¹ Regulation of tobacco has not been a conspicuous success at the level of the European Union so far. The reason, as the report from the college points out, is that tobacco legislation at the European Union level has been preoccupied with the operation of a single market rather than with the protection of public health.¹ Rather than wait for the European Union to get its act together, the British government should act now to establish a regulatory framework for tobacco and nicotine.

Of all the possible alternative ways of obtaining nicotine, smoking cigarettes remains by far the most addictive. The reason is that smoking cigarettes maximises the rapidity, frequency, reliability, and ease of attainment of the reward from nicotine.² Nicotine via cigarettes reaches the brain in 10 seconds, which is faster than via intravenous use. Regular smokers of 20 cigarettes per day reinforce their habit with an average of 200 rewards per day. It is much easier and cheaper to purchase a pack of cigarettes (for example, from petrol stations or local supermarkets) than it is to purchase a packet of nicotine gum. Unfortunately, cigarettes are the deadliest form of nicotine delivery available on the market. It is not the nicotine per se but the combustion and release of over 40 carcinogens as well as other toxic chemicals that are responsible for the bulk of premature illnesses and deaths that result when cigarettes are used as intended.

The report is not the first to have noticed the perverse twist on the inverse care law in the regulatory status quo for nicotine products.³ Currently the most toxic form of nicotine delivery is the least regulated, whereas all innovations from pharmaceutical companies (such as nicotine gum and inhalers) are subject to a lengthy and expensive approval process for their marketing, which is overseen by government regulators. The regulatory playing field is tilted distinctly in favour of the cigarette manufacturers. In theory, a cigarette manufacturer who wishes to introduce a perfumed cigarette to mask the smell of tobacco smoke can do so without regulatory obstacles. On the other hand, if a pharmaceutical company wants to add mint flavouring to nicotine gum to make it more palatable, it must endure years of regulatory hurdles.³

It is not a coincidence that cigarettes have so far managed to escape regulation. Soon after taking office, the former United States Surgeon General Everett Koop discovered that tobacco "is considered neither a food nor a drug nor a cosmetic; therefore it is a unique substance, virtually outside regulatory control."⁴ The reason for the cigarette's unique legal status, at least in the United States, is that Congress made sure to insert a clause that specifically excluded tobacco from virtually every major law passed to protect consumers, including the Controlled Substances Act 1970, the Consumer Product Safety Act 1972, and the Toxic Substances Control Act 1976.⁵ This lamentable record culminated in the supreme court ruling two years ago that the Food and Drug Administration lacked the authority to regulate tobacco.

By contrast, the report from the royal college has identified several existing pieces of legislation in the United Kingdom that do not seem to exclude tobacco, including the Consumer Protection Act 1987, the Medicines Act 1968, and the Food Safety Act 1990. These laws offer a promising framework for the regulation of nicotine, including tobacco products.

The urgent need for levelling the playing field in nicotine regulation is underscored by the proliferation of new tobacco products on the market. In the absence of any regulation, cigarette manufacturers have introduced a veritable bazaar of new productsfor example, R J Reynolds's "Eclipse" and Philip Morris's "Accord" (examples of so called smokeless cigarettes), as well as Brown and Williamson's "Advance" and Vector Tobacco's "Omni" (examples of "low carcinogen" cigarettes). New cigarette products are often implicitly marketed to smokers as "safer" alternatives to conventional cigarettes. No Cochrane reviews have yet been conducted to back any claims of "safer" cigarettes. However, history warns us that whenever product modifications are introduced by cigarette manufacturers they are usually nothing more than a marketing exercise designed to deter smokers from quitting.⁶ For example, the seemingly wide range of choice that consumers have in the "low yield" cigarette market is an illusion based on machine yields of nicotine and tar that bear little relation to the actual levels inhaled by smokers.⁷

This is not to deny that genuine reduction of harm might be achievable some day through technological advances. Economic logic means that such technological innovations might be encouraged and sped up by levelling the competitive playing field for products containing nicotine.³ An independent nicotine regulatory authority with jurisdiction over both new tobacco products and other nicotine delivery products would serve the interests of both fair competition and the protection of public health.

Ichiro Kawachi, professor of health and social behaviour. 

Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston MA 02115, USA, (Ichiro.Kawachi{at}channing.harvard.edu)

Footnotes

Competing interests: None declared.