Thoughts on the nicotine revolution
By David Sweanor
Imagine a time and place where the leading cause of cancer death was consumer consumption patterns, and where innovative technology was developed that allowed these consumers to change their behaviors to something greatly less hazardous. This new technology actually gave them something they preferred and that even cost them less than sticking with the old, deadly alternative. Imagine that businesses were allowed to promote and sell the new technology and competition and sensible regulation led to ever-better, more reliable and safer versions of this new technology. Well, stop imagining, because it has already happened, and we are using it every day.
It was refrigeration. As recently as the 1940s, stomach cancer was our largest cause of cancer deaths. But it was already declining steeply, it continued to fall rapidly, and it’s now thankfully rare. With the advent of refrigeration, diets changed. Out went the highly salted, pickled, smoked and easily contaminated foods, and in came more fresh fruits and vegetables. This huge public health breakthrough was led by entrepreneurs and consumers, and it was self-financing. So if you want to celebrate the ability of innovative technology to largely eliminate the leading cause of cancer death, send a fan letter to General Electric and go hug your refrigerator.
But refrigerators aren’t an anomaly in being an entrepreneurial intervention that saved lives. We can think of the Lambeth Waterworks Company, which opted to source water for its customers in London from upstream in the Thames when the competition was sourcing it downstream from the city’s sewer outlets and causing cholera epidemics. Or those who saw a competitive advantage in sanitary food manufacturing, or in science-based pharmaceuticals in place of snake oil, or in installing safety features in their cars. We live in a world made massively less hazardous through the work of visionaries and the workings of markets.
Many business and public health breakthroughs look obvious, even inevitable, in retrospect. People deride the Royal Navy for taking decades to act on information showing citrus prevented scurvy, and decry the nearly 200 years from the time mankind knew how to prevent smallpox until the time we eliminated that horrible disease. So, how will history judge what we are doing about cigarette smoking?
Likely not favorably. We have known for decades that people smoke for the nicotine, but what kills them at such a horrendous rate is the inhalation of the smoke. Getting nicotine without the smoke, as we have seen with Swedish snus and medicinal nicotine, can eliminate the vast majority of all the harms. We also know that consumers are spending roughly $800 billion a year buying cigarettes, and being stuck with that product not through choice but because others have chosen to limit their access to viable alternatives. Given the ability, markets could meet consumer demand in a way that facilitates a breakthrough that could leave hundreds of millions of people with hugely improved health and numerous entrepreneurs having done well by doing good. With policies that actually facilitate market transformation rather than hindering it, the move away from lethal cigarettes could rival the pace of change in other areas of technology. We could make smoking history, and innovation could also facilitate those who are wishing to cease using nicotine altogether.
GETTING TO SENSIBLE
To get to such a breakthrough will require some deeper thinking about how best to deal with nicotine, and an abandonment of measures that treat nicotine use as if it were an immoral act rather than an issue of public health and consumer rights. Abstinence-focused campaigns based on imposing an absolutist morality on others intensify the evils they hope to destroy, as the historian Richard Hofstadter pointed out about alcohol prohibition. It has happened with Prohibition, the war on drugs, abstinence-only messages on sexual activity, blame-the-driver approaches to auto safety, and it’s happening now with the war on nicotine. When the stakes are high—and they are exceedingly so, with roughly 1.5 billion people getting their nicotine through inhalation of the products of combustion—pragmatism must win out over dogmatism.
“Getting to sensible” is often a serious public policy challenge, and it’s certainly a difficult task when there are vigorous efforts to create a moral panic about alternatives to cigarettes. Consumers have traditionally lost out in the battles over nicotine because others were able to impose choices on them. Products like medicinal nicotine were so heavily regulated as to not be viable alternatives to cigarettes. Many countries actually banned noncombustible alternatives like snus and moist snuff, thus protecting the much more deadly cigarette business. For decades, consumers desperately looking for safer alternatives were not just denied accurate information on and access to truly less hazardous products; they were also misled into believing that “light” cigarettes were safer.
But innovative technology has a way of disrupting markets, and the rapid transformation of electronics, combined with the role of the Internet for getting information and social media for sharing it, means that vapor products have acted much like Uber. Instead of seeking permission to exist, they simply showed up in the market, and when challenged under what were seen as outdated laws, the entrepreneurs fought back. The end result is that the technology became very widely used before those opposing its existence could stop it. Those who have a vested interest in the status quo must fight not only the innovators but a very broad swath of consumers who prefer the new product. It is hard to ban a product used by millions, just as it is hard to stop a civil rights march if enough people are marching.
The opposition to alternative nicotine products will not die easily. Among other things, major U.S. funding bodies adopted a moral-absolutist goal of a “tobacco-free America” rather than a pragmatic public health one of reducing the burden of disease. Then, in some truly twisted logic, they decided that tobacco-free vapor technology constituted a tobacco product. So we see a near-endless parade of funded studies aimed at furthering a moral panic, reminiscent of what was seen in the war on alcohol and the war on drugs. Studies that often betray rather than honor the goals of science. Studies that will often point to a “potential problem” without either specifying whether there is any actual risk to vapers or comparing any identified risk to that of continued smoking. Studies, in short, that deceive rather than inform.
BETTING ON INNOVATION
So, who is going to win this war on nicotine? Will an abstinence-only approach actually end up protecting the cigarette cartel? Or will a growing band of pragmatic revolutionaries fundamentally change the market and achieve not only a marketplace transformation but a public health breakthrough of historic proportions?
Were one to place a bet, go with the innovators. Matching their creativity, work ethic, personal drive, commitment and consumer support to that of the bureaucrats, moralists and cigarette companies wishing to preserve the status quo is (fortunately) a very uneven fight. We will soon see the market deliver a range of alternative products, some without vapor, some aimed at specific niches of the current cigarette market, some aimed at easing people off nicotine altogether. Many will be hugely better than anything seen to date. Innovation and competition does that. There are millions of lives to be saved and billions of dollars to be made replacing lethal cigarettes. There are simply too many bright people with too great an interest in a better future to believe that innovators will stop innovating and smokers will be denied access to and accurate information about alternatives. Sensible regulators, knowing they can’t defeat innovative technology, will opt to work with it to facilitate the rapid end of the cigarette epidemic.
Lung cancer is now our leading cause of cancer deaths. It dwarfs other types of cancer. Just 80 years ago, before cigarette smoking became the primary vehicle for obtaining nicotine, lung cancer was as rare as stomach cancer is now. Of course, smoking causes a broad array of other cancers and numerous other diseases. It is truly a totally unnecessary modern-day catastrophe, and on many levels—health, economics and consumer rights among them. But modern markets can change quickly, entrepreneurs can see opportunity when it occurs, and consumers with information and options for using it can change the course of history. So go show your refrigerator you are prescient. Tell it that it is about to have company in the annals of historic public health breakthroughs.
David Sweanor is an adjunct professor with the Faculty of Law at the University of Ottawa. He is also with the Centre for Health Law, Policy & Ethics at the University of Ottawa.