Category Archives: Standardised cigarette packaging

Further up the garden path

I wrote about the Population Assessment of Tobacco and Health (PATH) Study on 17 June 2017 ( Here is another paper about it in, where else, Tobacco Control (July 2017).

It’s written by a no less than forty-one American authors from thirteen different institutions. The conclusion of this astonishing collaborative effort confidently asserts that

…the PATH Study will contribute to…the evidence base to inform FDA’s regulatory mission…and efforts to reduce the Nation’s burden of tobacco-related death and disease.

This interesting idea set me musing why they seem only concerned to reduce tobacco-related death and disease rather than eliminate them.

The paper helpfully starts by putting the problem in perspective by commenting on the  Surgeon General’s Report on smoking and health from 1964.

It has been over 50 years since the Surgeon General of the USA first concluded that ‘cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action’.

Some kind of remedial action does seem to have happened because, we are informed, ‘Cigarette smoking prevalence has been halved since publication of 1964 Surgeon General’s Report’. This good news, however, is somewhat tempered by the shocking fact that ‘tobacco use…[still] cause[s] over 480,000 annual US deaths’. Further, we are reminded that ‘Scientific evidence [shows] that smoking causes at least 15 types of cancer, as well as numerous chronic diseases including heart disease, stroke, lung diseases and diabetes’.

In response to this dire situation the Surgeon General’s Report of 2014 merely ‘highlighted the need for continued implementation of comprehensive tobacco control programmes and policies’. Better than nothing I suppose. But fear not – we are also told that

The Food and Drugs Administration (FDA) now has regulatory authority over the manufacturing, marketing and distribution of tobacco products to protect the Nation’s health.

Considering the nearly half-million annual US tobacco related deaths, the Nation’s health is clearly in need of protection. To help it achieve this vital aim it’s a relief to know that the FDA now has within it a Center for Tobacco Products (CTP) that has been ‘charged with regulating tobacco products’. And the way it is supposed to do this is by ‘weighing potential benefits and harm to current, former and never users of tobacco products’. And what might these potential benefits be?

Now, where does the PATH Study come into all this?

The PATH Study’s research focus is most clearly illustrated in its eight overarching objectives

One of these, which are also referred to as ‘primary objectives’, is to

Characterise the natural history of tobacco dependence, cessation and relapse.

And when the characterisation is complete, then what?

We already have voluminous research on the effects of smoking. To what end is it hoped further research will lead? The paper makes repeated reference to ‘regulation’. What does this mean? That it is acceptable for some people under some circumstances to smoke? That in the unlikely events that people under the age of, say, 18 never start to smoke, that tobacco products including e-cigarettes are never sold near schools, that marketing is restricted to adults who wish to use tobacco products, that smoking and vaping in public indoor spaces nevermore occur, that cigarettes products are only sold in plain packs festooned with horrible pictures and dire health warnings, then our tobacco regulators can give themselves a pat on the back and go home?

If this imaginary scenario were by some miracle to become reality, there would still be millions of adult smokers in all countries of the world except Bhutan.

So that’s all right then.

Text © Gabriel Symonds

Danger! Never Smoke While Using Oxygen!

Here is some good news for those unfortunate patients suffering from a serious condition  known as chronic obstructive pulmonary disease, or COPD. It’s a complex disorder but the main features are shortness of breath with cough, phlegm and chest tightness as the lungs are progressively damaged; the result may be fatal. The biggest risk factor for getting COPD is cigarette smoking so it’s obvious what a smoker should do if he or she has been given this  diagnosis.

Easier said than done! Or so it may appear. Here we have the absurd situation where smoking is literally killing these patients and they may say they can’t stop. Well, unless someone has a death wish – and respiratory failure is not a pleasant way to die – I don’t believe someone can’t stop smoking. I have had a number of patients with the COPD under my care and when they  realised the state they were in, even if they didn’t want to avail themselves of my method of smoking cessation, they just stopped. It’s similar to the situation of a smoker who gets a heart attack: they usually quit forthwith.

Now there has been a new study, reported in the journal Thorax in May 2017, undertaken by six researchers from the UK, Germany, The Netherlands and the USA, that shows, apparently, that giving the drugs varenicline or bupropion to smokers with COPD – those who by implication are unable to quit on their own in spite on of this serious diagnosis – is safe, in that these drugs ‘do not appear to be associated with an increased risk of cardiovascular events (heart attacks and strokes), depression or self-harm (suicide attempts) in comparison with (so-called) nicotine replacement therapy.’

Smoking is a voluntary activity. Yet the orthodox approach of medical workers involved in the care of these patients is that they can only offer nicotine products or drugs to help them stop killing themselves. But even if they use these drugs or nicotine products they still have to stop smoking!

It’s not generally realised that offering drugs or nicotine products as smoking cessation ‘aids’ is inherently discouraging and may make quitting more difficult. This is because these treatments imply that it’s too difficult to quit on your own. Even if you’re suffering from COPD, and obviously the smoke is going into the very place where the trouble is, namely, the lungs, there’s an unspoken collusion that these poor people can’t stop without medical intervention.

Psychologically this is a disaster: it gives the patient an in-built excuse for failure. Like all smokers, even though dying from this smoking-induced disease is a real possibility, they still don’t really want to stop. They can say, therefore, that they tried the drugs or nicotine products and they didn’t work, so in a sense they have permission to carry on smoking!

What, then, should be done?

First of all, it is a ludicrous situation, is it not, that people with a potentially life-threatening illness largely caused by smoking, are able to go into any corner shop or supermarket and buy a pack of cigarettes, no questions asked. Pictures of diseased lungs and patients with breathing holes in their throats (tracheostomies) do nothing to put off those COPD patients who continue to smoke. It is, therefore, not lack of information about the harmful effects of smoking that is the reason many people start or continue smoking.

Why, then do they do it?

Children and teenagers start smoking because they see other people smoking, either older people whom they wish to emulate, or their peers whom they wish to impress. Horrible pictures on the packs make very little impression. ‘Lung cancer happens to older people – it doesn’t apply to me.’ Or they think of themselves as invulnerable – which is understandable and even normal at that age. The ‘graphic health warnings’ may even act as an incentive to  smoke, as a dare. What is absurd is that cigarettes are on sale at all.

There’s a glaring inconsistency in that cigarettes, in packs emblazoned with warnings not to smoke, are nonetheless freely available. I have even had young people say to me, ‘If cigarettes were really so dangerous they wouldn’t be allowed!’ This is a good point, but how do you respond to it? By saying that government is either lying or being irresponsible?

And why do older smokers continue to smoke in spite of knowing the dangers? Because they are addicted to the nicotine in cigarettes. This statement, however, is not an adequate answer to the question. We can put it succinctly like this: the only reason smokers smoke is because they believe they are unable to quit.

Text © Gabriel Symonds

The Great Smoking Paradox

The scholarly journal with the curious name of Tobacco Control, on the cover of the May 2017 issue shows a picture of an inflated balloon with a map of the world on it about to be burst by a lighted cigarette. The wording is ‘Tobacco threatens us all’ and ‘Say No to Tobacco’, among other slogans.

The dire situation of tobacco threatening us all is elaborated in the leading editorial:

…tobacco use is not merely a threat to individual health…[it] is associated with increased poverty and food insecurity…land formerly used to grow food crops is converted to tobacco growing…tobacco continues to be produced using child labour in unsafe conditions…tobacco is an environmentally destructive industry. In addition to deforestation for tobacco growing and curing, heavy use of pesticides contributes to water and soil pollution…the potential negative effects of leachate from billions of discarded cigarette butts on marine life.

Depressing reading. But in the last sentence they come to the point:

Eliminating the tobacco threat by implementing tobacco control measures…

Just a minute. How can you eliminate the tobacco threat by tobacco control measures? The only way you can eliminate the tobacco threat is by eliminating tobacco.

If tobacco is merely ‘controlled’, as opposed to being eliminated or abolished, it implies that there are some circumstances or situations where tobacco use in some form or other is legitimate or acceptable. And what circumstances or situations would those be? This is a continuation of the discussion of the problem of ‘regulating’ nicotine products mentioned in my post of 20 May 2017,

The regulation/prohibition problem can also be considered from the perspective of a group of parents afflicted by the loss of a child through drug use. Understandably they want to do something to prevent further deaths from this cause (BMJ 2017;357:j1876). Two such parents ‘blame their daughters’ deaths not on the illegal substances that they had taken but on the laws that did nothing to save them’ and ‘[They want] not only just to decriminalise the taking of heroin, cocaine and cannabis but also to regulate their supply.’ One of these mothers says of her daughter, ‘She wanted to get high, but she didn’t want to die.’

There is no safe way of taking addictive drugs – it’s a contradiction in terms. And why, I wonder, should a teenager want or feel a need to ‘get high’ anyway? The best ‘high’ one can possibly have is the experience of normal good mental and physical health – with one’s mind unclouded by chemical poisoning of the brain. No amount of regulation of addictive drugs will make them safe to use, nor will it significantly reduce the number of users within a reasonable time.

To see this in proportion, in Britain in 2015 there were nearly 2,500 deaths from illegal drugs; the number of tobacco-related deaths per year is 96,000.

The same confused thinking is evident in the debate about tobacco – I promise I am not making this up:

[Smoking is] a severe psychiatric disease that can only be solved by a complex, multi modular, and individual treatment including consideration of socioeconomic status/factors.

Thus sayeth Dr Detlef Degner, a psychiatrist at the University of Göttingen in Germany. This extraordinary statement appeared in The British Medical Journal (25 May 2017) as a comment on an editorial about the advent of standardised cigarette packaging in Britain. The editorial that gave rise to this comment is headed ‘Standardised packaging for cigarettes’ and has the Oh-so-clever subtitle, ‘Undressing a pack of wolves in sheep’s clothing’.

The writer, one Professor Joanna Cohen, is affiliated with the Institute for Global Tobacco Control whose mission is ‘to prevent death and disease from tobacco products’. So far so good. But the Institute proposes to do this ‘by generating evidence to support effective tobacco control interventions’, as their website circularly puts it.

After reminding us that ‘Tobacco industry products are responsible for six million deaths every year’, Professor Cohen laments that ‘There is no magic bullet to end the tobacco epidemic.’

But there is! The notion of tobacco control is based on the premise that tobacco is here to stay. Herein lies the problem. Allow me to repeat: you cannot prevent death and disease from tobacco products by controlling them; they need to be abolished.

A further contradiction is evident by Professor Cohen saying in her editorial, ‘Tolerating attractive packaging of a deadly product is indefensible.’ Indeed, but it defensible to tolerate the selling in any form of a deadly product?

As she points out, Big Tobacco are not merely going to stand by and do nothing while tobacco control measures are introduced; they do everything they can to delay and obstruct. And even if all current tobacco control measures were instituted tomorrow, there would still be left a substantial number of smokers for decades to come.

Why is there so little mention of tobacco abolition? Because it would drive smoking underground? Maybe it would but then there would be vastly fewer smokers. Because governments would lose revenue? Apart from huge savings in health costs from abolishing tobacco, governments have never lacked ingenuity in devising new ways of taxation.

It is not as if there is anything new in this. Readers of this blog will be well aware that I have called repeatedly for tobacco to be banned as the only realistic way to stop the smoking epidemic.

In order to bring this about the first step is for smoking to be seen for what it is: legalised drug addiction.

Text © Gabriel Symonds