106 Tobacco Control 1999;8:106–112
enterprise that, if eYciently executed, would the currently available research evidence and put them on the road to bankruptcy. Phony the disclosures of internal tobacco industry LETTERS TO “No sales to minors” programmes that actu- research from the Minnesota litigation,2 ally serve the industry’s larger marketing clearly establish the pervasiveness of the THE EDITOR plans are one thing. It’s quite another to compensation phenomenon, and cannot jus- expect that Big Tobacco would abandon its tify rejection of the hypothesis that main ingredient for survival. compensation is complete. In his editorial, Douglas considers the Evidence on nicotine compensation comes “control of the product itself” to be the from two main sources: comparison of Letters intended for publication should be a bull’s-eye in targeting the “epidemic of maximum of 500 words, 10 references, and one nicotine intakes among smokers who have table or figure, and should be sent to Simon tobacco-caused illness and death”. The self-selected to smoke brands of diVering Chapman, editor, at the address given on the bull’s-eye should be a denormalised product: nominal yields; and forced-switching studies inside front cover. Those responding to articles or in essence, rendering the palatable unpalat- in which smokers, usually for a brief period, correspondence published in the journal should able. One need not be a vegetarian to avoid are experimentally shifted to lower yielding be received within six weeks of publication. meat that gives oV a bright green glow. brands. These studies have established that Tobacco needs to develop that glow. Given smokers characteristically oversmoke low- Eliminating nicotine in cigarettes the current vigour of the tobacco industry yielding brands and achieve extensive and its global marketing schemes, that’s a compensation for reduced nicotine delivery. EDITOR,—I have read and re-read, with great very tough challenge. Uprooting and denico- The extent of compensation observed varies, interest and enormous puzzlement, the tinising every tobacco plant is an even harder but is usually somewhat less than complete.3 sell. American Medical Association (AMA) But neither of these study designs gives Finally, Douglas argues that the Ford report “Reducing the addictiveness of definitive information. Those who self-select 1 Motor Company couldn’t merely curtail its cigarettes” and the accompanying editorial to lower yielding brands may do so in part 2 marketing eVorts for the defective Pinto, nor by CliVord Douglas, in the Autumn 1998 because their preferred nicotine dose is lower simply raise the price, but rather, the issue of Tobacco Control. and can be satisfied from these brands According to the AMA report, “it is company “had to change the product”. Well and good, but there are no more Pintos on without smoking more intensely; no causal technically feasible to manufacture cigarettes eVect of brand yield in lowering exposure can with low enough nicotine content to fall the roads these days. Consumers moved on to more trustworthy models. It only seems be inferred. With forced-switching studies, below this threshold (of addiction) for most smokers may not achieve full compensation, people.” The AMA and the British Medical ironic that the “safer” Next cigarette would but equally they may find the cigarettes Association (BMA) have developed a suVer the same fate. Next failed to provide unpalatable and the increased intensity of position based on this technical feasibility, the “taste” (that is, nicotine) that smokers puYng required4 unacceptable, so that in the but by what mechanism could nicotine elimi- were seeking, so those consumers also stayed real world they would not elect to smoke nation be enforced worldwide? with, or returned to, more reliable brands. them. It is probably not irrelevant that brands Despite its 139 references, the paper The tobacco-control movement is already with less than 0.5 mg nicotine yield captured appears to avoid discussion of the seen by many as a bunch of nanny-staters and only 3% of the market in the United stages-of-change model. With millions of health Nazis. Technical and political Kingdom in 1994.5 If, through regulation, contemplators and pre-contemplators out imponderables aside, the BMA/AMA smokers had no choice but to switch to there, how would even the most united front proposal could prove a public relations catas- brands whose nicotine delivery was so low of politicians and health authorities achieve trophe. The tobacco industry will soon have that full compensation was impossible, it such a contentious goal? At its core, the us in the bull’s eye, and from a very short BMA/AMA proposal would force unwilling distance. would be necessary to acknowledge that the proposal embodies a degree of coercion and smokers to give up their satisfying habit. STAN SHATENSTEIN Similarly, tobacco growers and manufactur- compulsory withdrawal. Faced with “unsatis- 5492-B Trans Island, factory” cigarettes, smokers may try to com- ers in more than 100 countries would be pro- Montréal, hibited from marketing almost any currently Québec H3W 3A8, Canada pensate by seeking nicotine from other available cigarette brand. [email protected] sources, such as smuggled cigarettes. The authors discuss the risks of The AMA’s review overlooked the two contraband markets. Until now, such illegal 1 Henningfield JE, Benowitz NL, Slade J, et al for largest, long-duration studies of switching, sales have flourished on price diVerentials, as the Council on Scientific AVairs, American both of which randomised smokers and Medical Association. Reducing the addictive- followed them over a six-month period.67 has been the case here in Canada. If nicotine ness of cigarettes. Tobacco Control 1998;7:281– levels are mandated downwards, but not all 93. These studies found it diYcult to recruit and countries sign on, then foreign tobacco inter- 2 Douglas CE. Taking aim at the bull’s eye: the retain smokers for the study duration, nicotine in tobacco products. Tobacco Control illustrating smokers’ resistance to shifting.8 ests will flood the vacated markets with better 1998;7:215–8. “flavoured” products. Contraband high- One study observed complete nicotine 6 nicotine sales will soar, with tough-to-track compensation and in the other it was close to EDITOR,—If regulators attempt to reduce 7 internet merchants flourishing the most. nicotine in tobacco products, there is a complete. As the authors themselves say, “nicotine- danger that smokers will smoke more The AMA report makes much of a deprived nicotinic receptors can produce intensely to achieve a given nicotine dose short-term study of switching in an in-patient powerful, physiologically based drives to from products with less available nicotine. setting in which little compensation for 9 reinstate smoking.” High-nicotine strains of This phenomenon, known as smoker reduced nicotine was observed. But several tobacco cannot be uninvented. No interna- compensation, is why the International considerations challenge the relevance of this tional convention or protocol can legislate Standards Organisation/Federal Trade Com- finding for the general population of smokers. this unhappy fact out of existence. mission tar and nicotine yield measurements The study lasted three days, and involved The industry and the health community are highly misleading and why so-called low- only 12 smokers, almost all of whom smoked agree that nicotine is the sine qua non of tar cigarettes are far more harmful than their filter brands, who were switched to a smoking. That being the case, either we nominal yields suggest. non-filter Kentucky reference cigarette achieve a virtual prohibition of tobacco prod- We feel that the AMA Council on acknowledged to be unpalatable. They were ucts, thus creating a huge smokers’ revolt, or Scientific AVairs is much too sanguine on the also required to smoke according to an we foist nicotine-reduced cigarettes on an issue of smoker compensation, and that this imposed schedule. unwilling public. Such cigarettes should eVect could undermine the AMA’s suggested There is an overwhelming case for the prove of help to determined quitters, but will programme.1 The authors assert that “even United States Food and Drug Administra- suVer the fate of products like “Next” (the though compensatory oversmoking is a tion’s assertion of regulatory jurisdiction over denicotinised cigarette manufactured by concern, the extent may not prove to be tobacco products, and there are many ways in Philip Morris). Why? Because it will be great, and the accompanying risk of increased which harm could be reduced. But in our impossible to ban either the supply of—or the temporary exposure to tobacco toxins may be view it is not yet possible to justify on health demand for—“richer” alternatives. acceptable if the ultimate benefit will be ces- grounds a programme to remove nicotine The authors of the AMA report see some sation in a few years.” Oversmoking may in from tobacco products. We believe that any hope of solving this problem “by enlisting fact be a serious problem, and it is very risky measures, particularly radical approaches, improved cooperation of manufacturers”. to suggest any policy where health impacts should be rooted in a well-founded Manufacturers will not cooperate in an get worse before they get better. In our view, understanding of smokers’ behaviour. Letters 107
MARTIN J JARVIS stop buying cigarettes, and will live 7 years require supportive education to consumers ICRF Health Behaviour Unit, longer on average. Smoking will cause fewer and health professionals alike, expansion of Department of Epidemiology and Public Health, than 2% of all deaths. treatment options including alternate forms University College London, Smuggling would not be a major problem of nicotine delivery (nicotine replacement 2–16 Torrington Place, in an island state such as New Zealand. Mail medicines), and other supportive measures London, UK; [email protected] order might be permitted in the meantime for preceding and accompanying the phasing out registered nicotine-dependent smokers, but of nicotine from cigarettes. We are CLIVE BATES shops would no longer sell addictive encouraged by the overall experience in Cali- Action on Smoking and Health, cigarettes. The key to success may be fornia and Massachusetts in which there has London, UK pharmaceutical companies developing nico- been remarkably strong support from tine products truly satisfying to those who smokers as well as non-smokers for tobacco 1 Henningfield JE, Benowitz NL, Slade J, et al. for quit smoking but who still want a regular control measures and restrictions on smoking the Council on Scientific AVairs, American nicotine buzz. that a few years ago met with objections. A Medical Association. Reducing the addictive- In New Zealand tobacco control agencies ness of cigarettes. Tobacco Control 1998;7:281– major lesson from these experiences is that 93. will carefully consider this proposal. It is a the viability of a tobacco control measure 2 Hurt R, Robertson C, Prying open the door to potential winner. At the very least, if only one cannot be determined simply by examining the tobacco industry’s secrets about nicotine. group in each country supports it, it will scale the measure in isolation. Rather, the context JAMA 1998;280:1173–81. up the debate several notches, and make it 3 Stephen A, Frost C, Thompson S, et al. in which it is presented—for example, educa- Estimating the extent of compensatory smok- easier for other groups to get support for cur- tional support and increased availability of ing. In: Wald N, Froggatt P, eds. Nicotine, rent policies. alternative products for treatment—is also smoking, and the low tar programme. Oxford: Oxford University Press, 1989:100–15. MURRAY LAUGESEN important. 4 Sutton SR, Feyerabend C, Cole PV, et al. Health New Zealand, A gradual nicotine reduction approach is Adjustment of smokers to dilution of tobacco PO Box 360, Waiheke, also supported by clinical research on smoke by ventilated cigarette holders. Clin Auckland, New Zealand; nicotine withdrawal and treatment, which has Pharmacol Ther 1978;24:395–405. [email protected] 5 Bennett N, Jarvis L, Rowlands O, et al. Living in demonstrated that minimising withdrawal Britain: results from the 1994 General Household symptoms can be achieved by gradual, as Survey. London: HMSO, 1996. 1 Henningfield JE, Benowitz NL, Slade J, et al for opposed to precipitous, nicotine deprivation. 6 Withey CH, Papacosta AO, Swan AV, et al. Res- the Council on Scientific AVairs, American Furthermore, the AMA report recom- piratory eVects of lowering tar and nicotine Medical Association. Reducing the addictive- mended more rapid and extensive surveil- levels of cigarettes smoked by young male ness of cigarettes. Tobacco Control 1998;7:281– middle tar smokers. I. Design of a randomized 93. lance of all forms and patterns of tobacco and controlled trial. J Epidemiol Commun Health 2 National Research Bureau Ltd. Environmental nicotine use to enable rapid detection of 1992;46:274–80. tobacco smoke survey tables. Wellington, New unintended consequences (including strong 7 Frost C, Fullerton FM, Stephen AM, et al. The Zealand: Ministry of Health, 1996. tar reduction study: randomised trial of the 3 Research Solutions Ltd. ASH Fourth form resistance) to guide course corrections. Thus, eVect of cigarette tar yield reduction on smoking survey tables. Auckland: ASH New we support gradual nicotine withdrawal, compensatory smoking. Thorax 1995; Zealand, 1997. accompanied by supportive policies such as :1038–43. 50 4 Stanton WR. DSM-III-R tobacco dependence increases in tobacco taxes, expanded 8 Withey CH, Papacosta AO, Swan AV, et al. Res- and quitting behaviour during late adoles- piratory eVects of lowering tar and nicotine cence. Addict Behav 1995;20:595–603. treatment access, and increased availability of levels of cigarettes smoked by young male 5 Stanton WR, McClelland M, Elwood C, et al. safe forms of nicotine. middle tar smokers. II. Results of a rand- Prevalence, reliability and bias of adolescents’ We share the concerns of Jarvis and Bates, omized controlled trial. J Epidemiol Commun reports of smoking and quitting. Addiction that gradual nicotine reduction could lead to Health 1992;46:281–5. 1996;91:1705–14. 9 Benowitz NL, Kuyt F, Jacob P III. Circadian increased toxin exposure because of compen- blood nicotine concentrations during cigarette ,—We appreciate the interest that our satory increased smoke intake as smokers smoking. Clin Pharmacol Therapeutics 1982; In reply 32:758–64. proposal to gradually remove the nicotine smoked more cigarettes or extracted more from cigarettes has generated as evidenced by toxins per cigarette. This issue was discussed 2 EDITOR,—As proposed by Henningfield et al these three letters and many other communi- on pages 285–286 in the report. There is an for the American Medical Association,1 cations we have received and seen. These let- enormous literature on this topic and we wel- serious nicotine reduction will result in ters give us an opportunity to clarify what come the mini-review provided in the letter increased quitting, and importantly, fewer seem to be the major issues expressed by col- from Jarvis and Bates. Our intent was not to relapses. Smokers will become ex-smokers, as leagues in the scientific and public health imply that compensation would not be a cigarette nicotine content falls gradually community. problem, but rather that, with consideration below the addictive threshold. One of the many debates is whether such a given to research findings (including those Most smokers in New Zealand are periodi- proposal ought to be implemented all at once referred to by Jarvis and Bates), potential cally attempting to quit: 10% said they were with sudden elimination of nicotine from adverse consequences could be minimised. likely to quit within a month; 38% said they cigarettes (for instance, on some future New This conclusion follows from several had quit in the past year for a week or more; Year’s Day) or gradually, as we proposed. The observations. and another 43% quit for a day but less than main argument for the sudden nicotine First, compensation is not an all-or-none a week.2 elimination approach is that it would reduce phenomenon; there are known factors that Though lowering nicotine could make the period during which people seeking to could influence the degree of compensation smoking seem less risky to adolescents, and sustain nicotine intake would inadvertently as well as the consequences of compensation. encourage experimentation, it would help increase exposure to tar and other cigarette Second, prior marketplace experience diVers adolescents to quit sooner. As it is, four out of toxins (the “compensatory smoking” concern from our proposal in that our proposal would five New Zealand smokers at ages 14 and 15 raised by Jarvis and Bates). provide extensive guidance to consumers sayitisdiYcult to quit,3 61% of 18-year-old Shatenstein argues that many smokers are (including meaningful product labelling) to daily smokers say they are addicted,4 and not yet interested in quitting (they are “con- encourage and enable them to minimise 89% of those experimenting at age 15 were templators” or “pre-contemplators” in the compensatory smoking. Third, the degree to still smoking at age 18 years.5 vernacular of the stages-of-change model which compensation occurs and its As with advertising bans, some countries referred to in his letter) and they would consequences can be aVected by the design of will legislate ahead of others. Health agencies strongly resist such an approach. On the con- cigarettes themselves. It appears that most will need to research the policy into a winna- trary, 70–80% of smokers in the United commercially marketed cigarettes have been ble piece of legislation, commit resources for States say they want to quit.1 Even though designed so as to maximise the likelihood of a long fight, build a coalition, feed the media, some may not be “ready” or “prepared” to compensatory smoking by employment of educate the public, and allay smokers’ fears. quit at a given point in time, we believe a physical and chemical engineering tech- Tobacco manufacturers will oppose any ciga- nicotine reduction policy accompanied by niques to ensure delivery of high doses of rette nicotine reduction law with every the other programmatic elements recom- nicotine deep into the lungs.34 Such designs resource at their command. mended in our report2 would motivate many could be prohibited if they undermined the Is this prohibition? No. Smokers will not be or most of them to quit. goals of nicotine reduction and if they fined for possession. Smoking and cigarettes In any event, to address this concern, we contributed to increased occurrence and will remain, and so will nicotine, though suggested phasing nicotine out of cigarettes consequences of compensation. Finally, in mainly in other forms. Cigarette brand names gradually, over up to 10 years from the time parallel to reductions in nicotine, tobacco will survive. The tobacco trade will have 10 the protocol was initiated. As discussed in the manufacturers could be required to provide years to overturn the new law. Smokers will AMA report,2 enabling the process would reductions in specific toxins—for example, 108 Letters carbon monoxide and tobacco-specific included the kinds of educational and RONALD M DAVIS nitrosamines—for which there is already evi- medical support that our report discussed. Council on Scientific AVairs, dence of significant potential for reduction.5–7 These strategies might have required some American Medical Association, This proposal is like many programmes in supportive research by the company and Chicago, Illinois, USA public health, in which no alternative is approval by regulatory agencies. Lastly, Next THOMAS P HOUSTON devoid of risk, so the course with presumed might have failed because high-nicotine Science and Public Health Advocacy Programs, lesser risk is chosen. An example is yielding cigarettes, backed by aggressive mar- American Medical Association, immunisation—vaccinations are not risk- keting campaigns, were still available as alter- Chicago, Illinois, USA free, but the benefits of immunisation clearly natives to Next; those choices and NEAL L BENOWITZ outweigh the risks. Thus, as we discussed in countervailing influences would not be avail- Division of Clinical Pharmacology and Experimental our proposal, every eVort should be taken able in a nicotine reduction policy imposed Therapeutics, with future cigarettes (whether or not a nico- on a national scale. The only surprise at all University of California, San Francisco, tine reduction strategy is implemented) to concerning Next was that Philip Morris San Francisco, California, USA reduce the occurrence and adverse spent so much money on a cigarette market- JOHN SLADE consequences of compensation—for exam- ing approach that its own history and Department of Environmental and Community ple, by banning hidden ventilation holes and research might have suggested was a doomed Medicine, providing meaningful labelling of the dosing approach. Robert Wood Johnson Medical School, characteristics of cigarettes. The comments by Laugesen oVer the University of Medicine and Dentistry of New Jersey, Shatenstein notes that tobacco manufac- observation with which we concur—that New Brunswick, New Jersey, USA turers would not cooperate in an enterprise nicotine reduction is not the same as cigarette that would threaten their survival. The AMA prohibition. Interestingly, the so-called 1 US Department of Health and Human Serv- report mentioned possible industry coopera- oYcial position of the tobacco industry is ices. The health consequences of smoking: nicotine addiction. A report of the Surgeon General, 1988. tion only in reference to “ways in which con- mixed on this topic. As noted in the letter Rockville, Maryland: Public Health Service, traband could be suppressed by intensifying from Shatenstein, and elsewhere,34 in their Centers for Disease Control, OYce on Smok- anti-smuggling law enforcement activities previously secret documents, tobacco ing and Health, 1988. (DHHS Publication No and by enlisting improved cooperation of (CDC) 88-8406.) industry oYcials did equate cigarettes with 2 Henningfield JE, Benowitz NL, Slade J, et al. for manufacturers.” Manufacturers might be nicotine, calling nicotine the sine qua non of the Council on Scientific AVairs, American forced to cooperate in anti-smuggling eVorts cigarettes. Paradoxically, in the sworn Medical Association. Reducing the addictive- because smuggling is illegal. But even if the ness of cigarettes. Tobacco Control 1998;7:281– testimony of senior tobacco industry oYcials 93. manufacturers don’t cooperate, anti- to the United States Congress in 1994, in 3 Hurt RD, Robertson CR. Prying open the door smuggling activities can proceed quite well recent court cases by experts on behalf of the to the tobacco industry’s secrets about nicotine—the Minnesota trial. 1998; without them, if governments muster the tobacco industry, and in their oYcial JAMA political will and devote the resources neces- 280:1173–81. comments to the United States Food and 4 Slade J, Bero LA, Hanauer P, et al. Nicotine and sary to address the problem. The fact that an Drug Administration (FDA),10 the role of addiction—The Brown and Williamson docu- RJ Reynolds (RJR) marketing partner nicotine has been down-played and framed ments. JAMA 1995;274:225–33. recently pleaded guilty to federal criminal 5 Slade J, Henningfield JE. Tobacco product 8 primarily as a natural cigarette constituent regulation: context and issues. Food and Drug charges of smuggling, and that a former RJR with minor pharmacological and sensory Law Institute Journal 1998;53(suppl):43–74. marketing executive has been charged with eVects. Setting aside, however, any hypocrisy 6 Henningfield JE, Slade J. Tobacco-dependence 9 medications: public health and regulatory aiding tobacco smugglers, provides evidence (and possibly perjury) on the part of the that this is already happening. issues. Food and Drug Law Institute Journal tobacco industry, there is a diVerence 1998;53(suppl):75–114. We would add two more points about between a proposal to ban the product and 7 Warner KE, Peck CC, Woosley RL, et al. Treat- smuggling. First, it is not plausible that a ment of tobacco-dependence: innovative regu- one that would strip it of a chemical that massive contraband market for commercially latory approaches to reduce death and disease: causes addiction. For those who would seek preface. produced cigarettes could occur without the Food and Drug Law Institute Journal some form of image or status by 1998;53(suppl):1–9. complicity of the cigarette makers or market- consumption of cigarettes, the product could 8 Drew C. RJR subsidiary pleads guilty to ers; this is true whether or not cigarettes use smuggling. New York Times 1998 Dec 23. remain. For those who require nicotine to high-nicotine yielding strains of tobacco. 9 Hwang S. RJR oYcial is arraigned on charges sustain desirable functions, presumably in relating to cigarette-smuggling scheme. Wa l l Therefore, as discussed in the AMA report, most cases as a consequence of their history Street Journal 1999;Mar 1:B7. more eVective monitoring of the transactions 10 US Food and Drug Administration. 21 CFR of chronic nicotine use, other forms of of major tobacco companies would be essen- Part 801, et al. Regulations restricting sale and nicotine delivery would be available which distribution of cigarettes and smokeless to- tial. Second, even if there was a contraband would have been approved by the FDA for bacco products to protect children and market, the size and health impact of that adolescents; final rule. Federal Register 1996; market would be much less than the current safety and eYcacy. This would include exist- 61(Aug 28):44395–618. cigarette market, which is supplied by manu- ing FDA-approved nicotine delivery systems 11 Warner KE, Slade J, Sweanor DT. The emerg- and new forms of “clean” nicotine delivery to ing market for long-term nicotine mainte- facturing operations that produce and ship nance. JAMA 1997;278:1087–92. billions of cigarettes every day in the United either fully or partially replace the nicotine delivered by conventional tobacco products, States alone. The potential for smuggling is 5–7 11 In reply,—While I found the letters from another reason for the recommendation in as has been discussed elsewhere. Shatenstein and Jarvis and Bates to be useful the report to include rigorous surveillance to Therefore, a major goal to improve health contributions to the debate, and generally enable rapid detection of unintended is not to sustain the current system whereby very well informed, several of their points consequences and corrections in course. the most toxic and addictive forms of warrant comment. Shatenstein also mentioned the cigarette nicotine delivery are the most readily Shatenstein argues that the bull’s-eye on marketed by Philip Morris under the brand available, nor a system in which cigarettes the tobacco control target should be “a name “Next”, as an example of a and nicotine are both unavailable. Rather, we denormalised product: in essence, rendering denicotinised cigarette that was widely believe we should be moving toward a day the palatable unpalatable”—in other words, rejected by cigarette smokers. However, the when commercially marketed cigarettes are to make tobacco use so socially unacceptable circumstances surrounding Next were not addictive and no more toxic than that people will stop partaking of it, despite dramatically diVerent from those envisioned necessary; and that conversely, acceptable its addictiveness. After more than a decade as under our proposal. For example, Next ciga- forms of treatment to reduce or eliminate a lawyer-advocate, in which many of my rettes were marketed using terms previously tobacco toxin exposure are more readily eVorts have been devoted to doing this very applied to high-nicotine yielding cigarettes, available. This is not prohibition of a product thing, I cannot agree more that the such as “rich taste”. They were not or elimination of the opportunity to obtain denormalisation of tobacco in the public developed or marketed as a brand that might nicotine; it is the opportunity to make choices mind is a critical feature of any be used as an aid to cessation. Consumers about tobacco and nicotine-product use that comprehensive tobacco control campaign. were not told that switching to these are not compromised by the seductive eVects However, even the most eVective eVorts at cigarettes might lead to nicotine withdrawal of nicotine in cigarettes. denormalisation are destined to take decades symptoms and that they might need to JACK E HENNINGFIELD longer than necessary in the absence of loos- prepare for this, perhaps by gradual Pinney Associates Inc, ening the vice grip of the product itself on the reduction of smoking from their regular ciga- 4800 Montgomery Lane, Suite 1000, brains and central nervous systems of rettes. They were not marketed as part of a Bethesda, Maryland 20814–3433, USA; hundreds of millions of users. Millions more national programme that would have [email protected] will become addicted as adolescents and die Letters 109 painfully and prematurely as adults, a direct would still be readily available to them in prevention-related activities, a yearly compe- and certain consequence of leaving control of other forms. tition will be carried out, in which pupils cre- the product in the hands of the cigarette Finally, Shatenstein asserts that proposing ate their own web pages. These pages will be makers. the gradual reduction of nicotine in tobacco rated by a jury of experts. The best page will In my editorial,1 I observed that the Ford products will spawn accusations of nannyism be awarded a prize. Motor Company had to change its defective and the hurling of the “health Nazi” insult, The schools participating in the competi- Pinto car when it was found to be killing and that this will place us, not tobacco prod- tion would at first create their own “smoking people in low-speed crashes, an analogy I ucts, in the bull’s-eye. On the contrary, while prevention page” showing preventive activi- used to help explain why cigarette the tobacco industry and its sympathisers will ties that they carry out in school. companies should likewise be forced to always reserve their choicest epithets for their Furthermore, the schoolchildren could change their products. Shatenstein responds adversaries, the proposal to phase out present their attitudes toward smoking and by noting that “there are no more Pintos on nicotine should help to shift the focus of pub- smoking prevention, their individual work the roads these days” and that “[c]onsumers lic anger squarely toward the tobacco (such as paintings, songs, and writings) and moved on to more trustworthy models”. He industry. The AMA report should be used as their personal achievements (for example, notes in the same paragraph that American a platform for focusing on the industry’s mal- percentage of pupils who quit smoking). consumers chose not to switch to the Next feasance, not on the assertive good intentions A competition between schools via the (denicotinised) cigarettes when they were of the public health and medical internet appears to combine the following marketed briefly in the early 1990s. First, communities. The tobacco companies’ diVerent goals in an ideal way. Shatenstein overlooks the fact that the Pinto misconduct caused the nicotine-fuelled + The development of individual web pages is merely one example of a much larger phe- calamity from which we now seek to extricate is in itself a fascinating activity for school- society, and they must be challenged as to nomenon, in which government safety children, thereby providing attractive and their “right” to continue to make and sell reinforcing behavioural alternatives. authorities around the world have required products that they deliberately render addic- The positive experiences gained during improvements in the design and manufac- + tive at the same time that they fail to render the project become associated with the ture of all motor vehicles. In the United them less hazardous. subject of smoking prevention. States, every mass-marketed automobile has The letters assailing the AMA report + The publishing of own smoking preven- long been required to meet strict safety essentially wave the white flag of surrender, tion activities on the internet—which is standards, which have been progressively ceding to the tobacco industry the extraordi- accessible worldwide—provides powerful strengthened over time. Thus, once the nary discretion to use, manipulate, and freely ways of public commitment for schoolchil- Pinto was deemed hazardous, it could no adulterate their products to exploit the effects dren as well as teachers. This kind of pres- longer be sold without first being fixed. of a highly addictive drug on a planet of entation of results and achievements will As for the example of Next cigarettes, he human guinea pigs. This position inevitably create pride in the pupils. fails to recognise that consumers failed to buy brings to mind an observation I once heard the denicotinised product in part because its made by my friend Garfield Mahood. In his The competition is open to schools in Ger- manufacturer, Philip Morris, deliberately inimitable style, the Canadian tobacco- many and the United Kingdom. Further neglected to inform the public that the prod- control leader intoned to an audience of information about the project can be found at uct was not only non-addicting, but was also, health advocates, “Those who say it cannot