UICC Tobacco Control Fact Sheet 8

Policies to Prohibit New Methods of Nicotine Delivery.
Countering Future Tobacco Marketing Strategies

Introduction

Tobacco induced disease is a major international public health challenge. The product which causes most health damage is the cigarette, which dominates all of the markets of the world. It is not surprising that governments, health workers and tobacco control advocates tend to ignore the actual and potential health damage caused by other forms of tobacco use. 

Recently however a new threat to health in many countries has been identified from other tobacco and nicotine delivery products aggressively marketed by the transnational tobacco companies.

Historically, tobacco has been used in many different ways. Oral use of smokeless tobacco is one of the commonest traditional uses. Approximately 100 million people in India and Pakistan use smokeless tobacco, mainly as a constituent of traditional chewing mixtures, although even in these countries, smokeless tobacco use is declining among younger age groups. Smokeless tobacco use was also common in the USA and Europe until, around the beginning of the 20th century, cheap mass-produced cigarettes became widely available. Smokeless tobacco consumption declined steadily thereafter, becoming confined to parts of Scandinavia and the USA, and largely restricted to older people. The transnational tobacco companies came to dominate the international tobacco market with marketing and distribution techniques which have made manufactured cigarettes available and desirable in every corner of the globe. Oral and other traditional tobacco products came to be produced mainly as a cottage industry for local use, or by smaller companies manufacturing products for a traditional and declining market.

Health Effects

The health implications of smokeless tobacco use and of the use of new nicotine delivery systems are serious enough to warrant action by public health authorities.

1. Smokeless Tobacco-There is conclusive scientific evidence that the use of smokeless tobacco causes cancer in humans. The evidence is strongest for cancers of the oral cavity, but use of oral tobacco has also been shown to increase the risk of cancers of the pharynx, larynx, oesophagus, pancreas and urinary tract. Smokeless tobacco use also increases the incidence of periodontal disease and causes oral leukoplakia, which in some cases may become malignant. Oral tobacco use can lead to nicotine dependence and addiction, and may contribute to cardiovascular disease, peptic ulcer, and fetal toxicity.
2. Nicotine-Nicotine, an alkaloid, is an extremely powerful drug. The US Surgeon General has affirmed that the way in which nicotine causes addiction is similar to drugs such as heroin and cocaine. Nicotine is absorbed by the body very quickly, reaching the brain within about seven seconds. It stimulates the central nervous system, increasing the heart beat rate and blood pressure, leading to the heart needing more oxygen.

New Forms of Oral Tobacco

Within the past 25 years the decline in oral tobacco use in some developed countries, notably Sweden and the USA, has been reversed. As cigarette smoking prevalence declined in some industrialized countries, tobacco companies began to look for other products which might appeal to new markets.

Smokeless tobacco, in the form of moist snuff for oral use, was the first of these products. Two major manufacturers in the USA and Sweden began aggressive marketing campaigns in the 1970s. Traditional products were repackaged and presented as a new and modern form of tobacco use. The main target market was teenage boys but the new products were also marketed as socially acceptable and less hazardous alternatives to cigarettes. The strategy was so successful that while in 1970 fewer that 1% of teenage boys and young adults in the USA reported using smokeless tobacco, by 1985 25% of white males aged 18-24 used snuff or chewing tobacco. In Sweden a similar trend has been observed. The success of these products testifies to the effect which promotion of tobacco products can have on young people, and demonstrates the cynicism of the manufacturers who claim that tobacco promotion is only aimed at brand share, and not at recruiting new users.

New Nicotine Delivery Products

Tobacco manufacturers have also started to develop products which deliver nicotine to users, and which may or may not contain tobacco. These have included a chewing gum containing about 20% tobacco and l mg of nicotine per piece, and a smokeless "cigarette", which consisted of a plastic tube which delivered an aerosol of nicotine to the mouth. In India a toothpaste containing tobacco has been developed. These products are intended to appeal to markets where cigarette smoking is declining, or where a manufactured product may compete with traditional products.

Nicotine Replacement

Nicotine products developed for therapeutic use in smoking cessation, such as chewing gum and nicotine patches, are different in character from the products developed by tobacco manufacturers for commercial reasons. They are tested for effectiveness and safety and are subject to appropriate controls. However, the current interest in nicotine replacement therapy is undoubtedly seen as an opportunity by tobacco manufacturers, some of whose products are promoted as aids to cessation.

International Developments

Having captured a new market in the USA and Sweden, the tobacco manufacturers initiated programmes for international expansion. This strategy was blocked, however, by determined action by medical and dental professionals, tobacco control experts, and governments. In 1985, a US company opened a factory in Scotland to supply oral tobacco products to Europe and other markets where oral tobacco use was unknown. A regional office was opened in Hong Kong, and joint ventures were planned with a Swedish company to market oral tobacco products in other areas, including Canada and Latin America.

The UK initiative provoked outrage among health professionals and led to an unprecedented public campaign to persuade the government to ban the product. The company attempted to transfer its successful marketing strategy to the UK. However complaints from the public forced the withdrawal of television advertising, advertising near schools, promotions based on free or money-off offers, free samples, campaigns to recruit students, etc. Protests included a demonstration by doctors, dentists and members of Parliament, petitions and demonstrations, letters to ministers and to the press, etc. Many retailers refused to stock the product in the face of community disapproval. The product never became widely available. Legislation making it illegal to sell smokeless tobacco products to children was passed. The government's medical advisers stressed the health issues involved, and ministers received an unprecedented level of representations from the public. After a campaign sustained for over two years, the UK government announced its intention in 1988 to ban the product.

The tobacco company challenged the UK government's decision in the courts, and the US government brought diplomatic pressure to bear on its behalf, but the ban came into effect in 1990. The European Commission introduced a Community-wide ban which came into effect in 1992.

Other countries, including Hong Kong, Ireland, Israel, Japan, Saudi Arabia, Taiwan, Singapore and Australia have banned oral smokeless tobacco products. In the USA health authorities became aware of the issue too late to prevent the habit from taking hold, but promotion is now controlled, education programmes have been introduced, and new products are included in tobacco control programmes. US health and consumer protection agencies have successfully blocked development and marketing of new nicotine delivery products.

The threat posed by these products has not of course been totally removed. The companies involved are seeking new bases in other countries, e.g. in Eastern Europe, and there is a danger that modern marketing and packaging may be used to recruit new users in traditional markets in Asia and elsewhere. There may also be further attempts to produce new nicotine delivery products. However experience at national and international levels provides valuable guidance for governments and health authorities wishing to prevent the introduction of new tobacco or nicotine products.

Control Strategies

The following strategies are based on the recommendations of the 1987 WHO Study Group on Smokeless Tobacco Control, and on subsequent experience at national and international levels.

1. Control of smokeless tobacco and new nicotine delivery products should be an integral part of national tobacco control programmes.
2. In countries with no established use an opportunity exists to prevent these products from coming on the market. Wherever possible the manufacture, importation, sale and promotion of smokeless tobacco products should be prohibited. The sole exception to this would be products containing nicotine (or commercially manufactured nicotine) used only for the purpose of helping people to stop smoking. These should be treated as controlled substances. A ban on new products should be part of any comprehensive tobacco control legislation. Failing this existing public health, drug, consumer protection or safety legislation may be used, or amended. In some cases new legislation may be introduced.
3. In countries where the use of new products is already too well established for a comprehensive legal ban to be feasible, control measures should be introduced, as follows:

• A ban on promotion, or where this is not possible, strict controls.
• Taxation at a level sufficient to act as a disincentive, and at a similar level to other tobacco products.
• Strict controls on exports.
• A ban on subsidies for production.
• Priority for the promotion of substitute crops.
• A ban on duty-free sales.
• Prohibition of sales to minors, and sales from vending machines.
• Prominent health warnings.
• Prohibition or strict control of use in public places.
• Government control of analysis and regulation of harmful constituents.
• Appropriate health education and information programmes.
• Appropriate cessation programmes.

International Action

International and non-governmental agencies should include new tobacco and nicotine products in their tobacco control programmes, and liaise with relevant agencies at national and international levels to ensure exchange and dissemination of information and control strategies. Particular attention should be paid to countering marketing strategies by transnational tobacco companies.

Health and Tobacco Control Professionals

Experience in several countries has shown how health and tobacco control experts can promote action by governments. The key elements of a successful campaign are:

• 1. Involvement of medical, dental and other key health professionals.
• Example: In the UK the campaign against smokeless tobacco was led by the medical and dental professions. The UK government's scientific and medical advisers expressed concern about the introduction and marketing of the product.
• 2. Access to reliable information on, e.g. the health effects of new products and their addictive properties; prevalence and consumption; the manufacturers' marketing strategy; the appeal of the product to vulnerable target groups, e.g. children; success of other countries in controlling the introduction of new products.
• Example: US evidence on the successful industry strategy to attract young users of oral snuff had a powerful effect on several other governments.
• 3. A central information and coordination point to ensure rapid response to new developments, dissemination of information and strategy advice, effective use of media and campaigning networks, and the ability to sustain a lengthy campaign.
• Examples: The UK campaign coordinated by ASH Scotland involved a very large number of organizations and individuals, and lasted for over two years, before resulting in a government decision to ban oral snuff and other new tobacco products.
• 4. International liaison to give timely information about industry tactics, and enable national campaigns to build on experience in other countries.
• Examples: Information from the USA enabled the Hong Kong government to prepare and implement a ban on moist snuff before it was introduced, and the European Commission built on the experiences of the UK and Irish governments in introducing a Europe-wide ban.
• 5. Information exchange and liaison at government and expert levels by international agencies, both official (e.g. WHO) and non-governmental (e.g. UICC, etc.).
• Example: The report of the WHO Expert Study Group on Smokeless Tobacco in 1987 summarized the available information, and recommended action to member governments. UICC and many other agencies have played a vital role in spreading information and expertise.
• 6. Presentation of the issues in simple terms, to generate media interest, build mass public support, and persuade governments to act.
• Examples: In the UK sustained media coverage of the campaign was ensured by the way in which key issues were framed, e.g.: a new cancer threat, the exploitation of children, and government funding for a foreign company making a hazardous product. In Sweden, on the other hand, smokeless tobacco use is not perceived as a health hazard, and the need for action has not been publicly argued.

Conclusion

All tobacco and nicotine use is hazardous or potentially hazardous to health. The need for decisive action at international, national and local levels to prevent or control the introduction of new tobacco and nicotine delivery systems has been demonstrated. The experience of several countries can be used as a guide to the introduction of successful control strategies.

Further Reading

1. World Health Organization: Smokeless Tobacco Control, Technical Report Series, 773. WHO, Geneva 1988.
2. Raw, M., White, P., McNeill, A.: Clearing the Air: A Guide for Action on Tobacco. British Medical Association, London 1990.
3. US Department of Health & Human Services: "The Health Consequences of Using Smokeless Tobacco". A report of the Surgeon General, Washington 1986.
4. Slade, J.: The Demise of a Nicotine Delivery System. In the Proceedings of the Seventh World Conference on Tobacco and Health, Perth 1990.
5. International Agency for Research on Cancer: Tobacco Habits Other Than Smoking: betel, quid and areca-nut chewing; and some related nitrosamines. Vol. 37. Lyon, IARC l985.
6. Hatsukami, D., Nelson, R., Jensen, J.: Smokeless Tobacco: Current Status and Future Directions. British Journal of Addiction, Vol. 86 No. 5, 1991.
7. West, R., Krafona, K.: Oral Tobacco: Prevalence, Health Risks, Dependence Potential and Public Policy. British Journal of Addiction, Vol. 85 No. 9, 1990.

March 1993

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