Tobacco and Public Health - TCSC Indonesia

as these correlate quite well with tar (Hoffmann and Hoffmann 2001). Much of this
potential benefit was lost because of compensation, although the relative decline in the
risk of squamous cell carcinoma (Cox and Yesner 1979; Rimington 1981; Johnson
1988; el-Torky et al. 1990; Stellman et al. 1997a, b), and some of the decline in risk seen
in earlier studies (Bross and Gibson 1968; Wynder et al. 1970; Hammond et al. 1976;
Hawthorne and Fry 1978; Wynder and Stellman 1979; Rimington 1981; Lubin 1984;
Stellman 1986; Stellman and Garfinkel 1989) and among men under 50 in the United
Kingdom (Peto et al. 2000) may well be attributed to this factor. Conversely the
increased relative risk of adenocarcinoma is presumably an outcome of changes in
cigarette composition with nitrosamines a likely factor in this.
The campaign for reduction in tar (and nicotine) yields has been used by the
tobacco industry as way of reassuring smokers who are contemplating quitting
(Kozlowski and Pillitteri; Shiffman et al. (a); Shiffman et al. (b)). ‘Light’ cigarettes are,
in fact, not light, as compensatory smoking is facilitated by the designs to an extent
that inhalation of carcinogens and toxins may be as great with these brands as with
regular cigarettes (Djordjevic et al. 1995). It is therefore not surprising that ‘harm
reduction’ as represented by attempts to make the cigarette constituents less harmful
has been the object of scepticism. Harm reduction by use of nicotine replacement
therapy (NRT) as an aid to reducing smoking in those who cannot quit is dealt with
elsewhere (Chapter 43).
General principles
NIGEL GRAY 767
In principle, a consumer product should be as safe as possible and in the case of a drug
should deliver as precise a dose as possible. Contaminants (in this case carcinogens and
toxins) should be minimal with upper limits set. Additives should also be demonstrably
safe. The cigarette is unique in that it cannot be made safe. However, the dose of
drug (nicotine) delivered could certainly be made more precise and upper limits could
certainly be set for the contaminants which are much lower than presently seen on the
market. New measurement systems are certainly needed.
Some fundamental questions arise here.
◆ Should limits for carcinogens and toxins be set as low as possible? Can it possibly be
justified to add, or allow, higher levels of, carcinogens for ‘flavour’ or other purposes?
◆ The real purpose of the cigarette is to deliver nicotine. It is proven as the fastest (and
most addictive) nicotine delivery system yet known (Gourlay and Benowitz 1997).
Should the dose per cigarette be standardized as far as is practical?
◆ Should the nicotine dose be ‘satisfying’ without the need for deep and frequent
inhalation which brings with it a larger dose of contaminants?
◆ If a ‘satisfying’ dose is to be delivered, how should this be measured for regulatory
purposes.