Tobacco Harm Reduction: Perspectives of the Tobacco Control Community

1
Tobacco Harm Reduction Perspectives of the
TobaccoControl Community

• Kenneth E. Warner, Ph.D.
• Erika G. Martin
• University of Michigan School of Public Health
• Department of Health Management Policy
• Supported by a grant from the Robert Wood Johnson
  Foundation

2
Abstract

• Problem/Objective. Tobacco harm reduction has
  received recent attention due to the tobacco and
  pharmaceutical companies introducing novel
  nicotine-delivery products, as well as the
  failure of traditional prevention/cessation
  programs to assist inveterate smokers. Many of
  these products remain unregulated, especially
  those produced by tobacco companies, and their
  role in reducing tobacco-related health risks
  must be elucidated. Assessing the awareness of
  and opinions on THR among members of the tobacco
  control community is an important first step
  toward this goal.
• Methods. A mixed-mode mail/web survey of
  knowledge, attitudes, and beliefs was sent to
  approximately 2800 attendees of the 2001 National
  Conference on Tobacco or Health. A follow-up
  telephone survey was administered to a random
  sample of non-respondents.
• Results. 70 of respondents indicated
  familiarity with THR. Sentiments toward THR were
  generally negative, and many respondents
  anticipated significant harm from its promotion.
  Responses differed by type of work (scientist
  versus activist), level of education, and primary
  focus (local/state versus national/international).
  The volume of "unsure" responses was not
  trivial, suggesting a need for more information.
• Conclusions. Due to the rapidity with which
  these products are being brought to market, the
  tobacco control community should strive to become
  cognizant of the issues raised by THR. Experience
  with low tar and nicotine cigarettes calls for
  caution in this area however, there is also
  potential for positive public health benefit.
  Active dialogue on these issues should be an
  important component of tobacco control.

3
Problem

• Smoking prevalence in developed countries
  declines slowly and the death toll remains
  frighteningly high.
• The challenges of assisting the inveterate
  smoking population and the appearance of novel
  products on the market purporting to reduce the
  hazards of smoking has led to recent attention to
  tobacco harm reduction among smoking cessation
  leaders.
• It is unclear what grassroots advocates think
  about the topic. Clearly, this group will play a
  large role in determining the future role of harm
  reduction.

4
Survey Definition of Harm Reduction

• Some cigarette smokers are unable or
  unwilling to stop using nicotine. Tobacco harm
  reduction means decreasing total tobacco-related
  death and illness by encouraging these cigarette
  smokers to substitute other potentially less
  hazardous nicotine-yielding products. Examples
  include
• Cigarettes modified to remove one or more toxins.
• Nicotine and non-nicotine pharmaceuticals.
• Cigarette-like devices that heat rather than burn
  tobacco.
• Nicotine lozenges.
• Smokeless tobacco.

5
Methods

• Sample. A convenience sample consisting of the
  2833 U.S.-based registrants for the 2001 National
  Conference. 67.1 adjusted response rate.
• Instrument. Mixed-mode mail/web survey
  administered between Oct. 2 - Nov. 19, 2002.
  Topics included
• Awareness of THR.
• Perception of its present and future importance.
• Support for regulatory policies pertaining to THR
  and conventional products, and assessment of
  whether Congress legislate regulation.
• Perception of which, if any, THR products should
  be recommended by health care practitioners to
  inveterate smokers.

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Methods

• Non-Response Survey. 200 non-respondents were
  randomly selected after the survey closed for a
  brief telephone interview to assess their
  eligibility and familiarity with THR, for use in
  the response rate calculation and response bias
  assessment. The adjusted response rate was
  calculated using the estimated percentage of
  non-respondents ineligible to participate.
• Most questions were constructed as 5-point Likert
  scales. Some categories have been collapsed in
  the data presentation.

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Methods

• Responses for the following groups were compared.
  For each comparison, individuals indicating
  allegiance to both groups were excluded from the
  analysis.
• Scientists versus activists.
• Those focusing on local and/or state concerns and
  individuals with national and/or international
  interests.
• All analyses presented do not include unsure
  and rather not answer responses, except for THR
  familiarity. For this question alone, unsure
  responses were combined with negative responses.
• The significance level was set at plt0.05.

8
Demographics

• Age
• lt30 19.7
• 31-50 55.6
• gt50 24.7
• Female 70.1
• Race/ethnicity
• White, non-Hispanic 80.5
• African-American 9.0
• Asian/Pacific Islander 4.2
• Am. Indian/Alaskan Native 2.7
• Other 1.0
• Education
• ltMasters degree 40.9
• Masters degree 40.5
• Doctoral degree 18.6
• Tobacco control involvement integrally related to
  paid employment 82.1
• Significant tobacco-related volunteer efforts
  71.0

• Principal involvements with tobacco issues
• Advocate/activist 27.9
• Educator 33.7
• Med. professional counseling 6.8
• Program admin./manager 35.3
• Program staff 21.3
• Researcher/scientist 17.8
• Other 12.4
• Demographic focus of tobacco efforts
• Youth/adolescents 73.5
• Elderly 14.0
• Women 36.0
• Minorities 45.4
• General population 67.9
• Geographic focus of tobacco efforts
• Local 66.3
• State 62.0
• National 29.2
• International 7.7

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THR Awareness

• 69.7 were familiar with the term tobacco harm
  reduction prior to receiving the survey.
• Of those familiar with the term,
• 28.5 had first heard the term in the last year.
• 30.7 had first heard the term 1-2 years ago.
• 31.9 had first heard the term 2-5 years ago.
• 8.9 had first heard the term greater than 5
  years ago.

For this question, unsure and no responses
were combined.
10
THR Awareness

• Main sources of information on THR included
  scientific conferences (64.1), professional
  journals (60.7), conversations with non-medical
  colleagues (49.6), media (30.7), tobacco
  industry reports and documents (24.7), and
  conversations with medical professionals or
  colleagues (24.5).
• 42.9 said that THR currently receives a fair
  amount to a great deal of attention in tobacco
  control. 82.7 think that THR will receive a
  fair amount to a great deal of attention in 10
  years.

11
Product Recognition

• Cigarette-like devices.
• Accord 22.4
• Eclipse 52.7
• Favor 5.9
• Premier 30.2
• Cigarettes with reduced carcinogens or low
  tar/nicotine.
• Advance 18.3
• Next 8.8
• Omni 50.1
• Quest 12.6
• Smokeless tobacco products.
• Ariva cigalets 36.0
• Exalt 6.2
• Revel 12.2
• Snus 11.6

• Novel nicotine products.
• Likatine 3.0
• Nicotine water 72.1
• Pharmaceuticals.
• Nicoderm 94.1
• Nicorette 96.4
• Fabricated products (used as controls).
• Cigems 3.8
• Hitex 0.3
• Viva 5.6

Percentages reflect number of respondents
indicating familiarity with each product.
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Future Importance of THR
Comparison of THR and the following methods to
decrease tobacco related health risks, ten years
from now.

• Prevention.
• 12.1 believe THR will have larger role 67.4
  predict it will have a smaller role.
• Cessation.
• 26.0 believe THR will have larger role 38.8
  predict it will have a smaller role.
• Reducing ETS.
• 24.5 believe THR will have larger role 47.5
  predict it will have a smaller role.

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Future Importance of THR
Agreement and disagreement with the following
possible negative effects of tobacco harm
reduction.

• Reduced rate of smoking cessation.
• 49.3 agree 32.1 disagree.
• Children experimenting with nicotine products.
• 48.4 agree 34.4 disagree.
• Unintended negative side effects on health of
  users.
• 63.1 agree 13.0 disagree

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Future Importance of THR

• Eventual impact of THR on the health of the
  American public.
• 26.4 anticipate a net benefit 56.0 foresee
  harm.
• Health risks for individual smokers of smoking
  low tar and nicotine cigarettes versus
  full-strength filtered cigarettes.
• 20.7 perceive an increased risk to individuals
  10.4 think theres a decreased risk.
• Impact on the collective health of Americans if
  low tar and nicotine cigarettes had never been
  marketed.
• 40.4 think U.S. health would have been better
  7.5 predict it would have been worse.

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Government RegulationConventional Tobacco
Products

• The government should
• regulate marketing techniques. 93.8 agree
  4.3 disagree
• evaluate safety. 94.0 agree 4.1 disagree
• set excise taxes tied to level of risk to user.
  75.2 agree 13.0 disagree
• regulate packaging, including size, design,
  placement of warning. 89.2 agree 5.3 disagree
• gradually phase nicotine content of tobacco
  products down to nonaddicting levels. 29.8
  agree 49.5 disagree

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Government RegulationHarm Reduction Products

• The government should
• set pre-marketing approval of health claims.
  91.3 agree 5.7 disagree
• set product performance standards. 87.2 agree
  7.8 disagree
• mandate pre-marketing approval based on
  significant reduction in health risk. 88.4
  agree 7.9 disagree
• do post-marketing surveillance, banning products
  found to cause unacceptable health risks or
  attract children. 93.2 agree 4.2 disagree
• regulate marketing techniques. 90.4 agree 4.9
  disagree
• set excise taxes tied to level of risk to user.
  65.1 agree 16.7 disagree

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Likelihood of Government Regulation

• Likelihood of Congress authorizing one or more
  methods of regulating conventional tobacco
  products within the next 5 years.
• 29.8 likely 49.5 not likely
• Likelihood of Congress authorizing one or more
  methods of regulating THR products within the
  next 5 years.
• 22.9 likely 54.8 not likely

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Recommendations to Smokers

• Support for medical professionals
  recommending the following products to smokers
  who cannot or will not quit.
• Cigarettes that heat but do not burn tobacco.
  10.0 in favor 77.3 opposed
• Conventional smokeless tobacco products. 6.2 in
  favor 90.2 opposed
• Very low nitrosamine smokeless tobacco products.
  11.0 in favor 81.1 opposed
• Nicotine patches. 75.8 in favor 17.5 opposed
• Tobacco lozenges. 39.3 in favor 48.0 opposed
• Cigarettes with one or more carcinogens removed.
  7.2 in favor 87.2 opposed
• Nicotine gum. 69.9 in favor 21.6 opposed
• Nicotine-free cigarettes. 17.2 in favor 72.4
  opposed
• Low tar/nicotine cigarettes. 6.9 in favor
  89.0 opposed

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Comparison ofActivists and Scientists

• Scientists are more likely to be familiar with
  THR, and to be able to recognize specific
  products.
• Activists have a greater expectation of harm.
  Scientists are more likely to perceive an
  eventual benefit.
• Both groups support the listed regulations of
  both THR and conventional tobacco products.
  Activists are more optimistic regarding the
  likelihood of Congressional law authorizing any
  of the methods of regulation in 5 years.
• Activists are more likely to strongly oppose
  recommending several products for inveterate
  smokers.

20
Comparison of Local and National Level of Focus

• Those with a national/international level of
  focus are more likely to be familiar with THR,
  and to be able to recognize specific products.
• Those with a local/state level of focus have a
  greater expectation of negative unintended
  consequences.
• Both groups support regulation of THR and
  conventional tobacco products. Those with
  local/state interests are more optimistic
  regarding the likelihood of Congressional law
  authorizing any regulation in 5 years.
• Those with a local/state level of focus are more
  likely to strongly oppose recommending several
  products for inveterate smokers.

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Limitations

• Conference registrants may not accurately
  represent the entirety of the tobacco control
  community.
• There may have been a response bias among
  respondents compared to non-respondents. The
  follow-up telephone survey provides evidence that
  those not responding were less likely to be
  familiar with THR.
• There is no registry of the U.S. tobacco
  control community. We believe that the
  conference participants constitute as good a
  representation of this group as is possible.

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Conclusions

• A substantial proportion of the entire grassroots
  tobacco control community is unaware of THR.
• Although respondents do not perceive THR to be an
  important component of tobacco control today,
  they anticipate greater future attention on the
  topic, and many worry about its implications.

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Conclusions

• While strongly supporting governmental regulation
  of both THR and conventional tobacco products,
  respondents do not anticipate Congressional
  legislation mandating such regulation.

24
Conclusions

• The gloomy outlook of the tobacco control
  community towards THR is supported by prior
  experience with low tar/nicotine cigarettes, also
  ostensibly less risky products.
• The debate over THR is almost certain to
  continue, fostered by the continued emergence of
  novel products.

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Conclusions

• Although respondents do not anticipate regulation
  in the near future, the likelihood of such
  control will grow as the tobacco control
  community becomes sensitized to the issues and
  concerned about them enough to lobby hard for
  regulation.