Tobacco and Public Health - TCSC Indonesia

664
GLOBAL TOBACCO CONTROL POLICY
Clearly, if nicotine dose is to be regulated, a better measuring system is needed. For
regulatory purposes a simple measure of the amount of nicotine in the cigarette
tobacco should suffice. However, if the smoker is to be informed of the dose he or she
is getting, something much more complex would be needed.
Until now the dose given to the smoker has been determined by the cigarette
manufacturer. The result is the carefully engineered (Kozlowski et al. 2001) modern
cigarette which is smoked in a compensatory way. The degree of compensation occurring
with this cigarette has not been meaningfully compared with the degree of
compensatory inhalation that occurred three and more decades ago. It is probably
greater. Clearly compensatory smoking delivers greater amounts of carcinogens and
toxins to the lung and one object of regulation should be to reduce this.
The intricacies of nicotine policy are discussed elsewhere and require consideration
of nicotine in cigarettes and nicotine available in other forms. It is enough to canvass
here the possible options for the cigarette. The first policy requirement is that nicotine
becomes the object of regulation. The options then become:
◆ Increase the amount of nicotine. Providing a ‘satisfying’ amount of nicotine (which
may mean an increase) has the advantage that it could be presumed to reduce compensation
and therefore carcinogen/toxin dose (Russell 1976). The disadvantage is
that it does nothing to reduce (and may enhance) dependence on the cigarette as a
source of nicotine. Regulatory authorities are unlikely to be comfortable with this
approach after several decades of struggle to reduce the dose.
◆ Allow the status quo. This has the disadvantage of leaving decision making to the
tobacco industry, leaves today’s level of compensatory smoking, and does nothing
to reduce the addictiveness of the cigarette.
◆ Reduce the amount of nicotine. First proposed in 1994 (Benowitz and Henningfield
1994) this has the potential to reduce the addictiveness of the cigarette and the disadvantage
that compensatory smoking might increase. It could only be done in
parallel with a determined attempt to provide more widely available and efficacious
NRT which might, used separately or together with cigarettes, replace the cigarette
as the prime delivery system for nicotine. Clearly a major requirement would be
a concerted comprehensive public education campaign. This option has possibilities
in the long term but remains in the realm of the theoretical until nicotine levels
in cigarettes are more universally captured by regulatory systems. The possibility of
‘more efficacious’ NRT being, or becoming, addictive, also needs to be faced.
Real control of dose and compensation
The above discussion of carcinogens/toxins and nicotine is aimed at reducing the
amounts of the substances available per unit dose of smoke and need to be based on
some form of standard measuring technique. The FTC system, or the various modifications
of it, allows comparison across brands for regulation of carcinogens and toxins