Out of the Ashes: The Life, Death, and Rebirth of the “Safer” Cigarette in the United States

Abstract

From 1964 through the early 1980s, both federal and voluntary agencies endorsed the concept of “safer” cigarettes. Beginning in the mid-1980s, several factors, including revelations of tobacco industry malfeasance, the development of nicotine replacement therapy, and the reconceptualization of smoking as a chronic disease, led to “safer” cigarettes being discredited.

In the past few years, some public health professionals have begun to reconsider the viability of developing such products. The issue before us is stark: will a commitment to limiting the toll exacted by smoking preclude the tolerance of a product that while not safe may possibly be safer?

PUBLIC HEALTH AND MEDICAL professionals are currently divided over the idea of “safer” tobacco products. In 2001, the Institute of Medicine (IOM) released a report opening the door for endorsement of such products as a feasible component of a harm reduction strategy.1 On its heels came a National Cancer Institute (NCI) report that fueled enthusiasm for an approach embracing cessation. The NCI’s stance was decidedly hostile to “safer” cigarettes, raising provocative questions about the place of harm reduction within tobacco control.

Harm reduction represents an approach to risky behavior that places priority on minimizing damage rather than eliminating the behavior itself. Two related criticisms are most commonly made by its opponents. The first is that harm reduction “sends the wrong message” to society that drug use is acceptable and thereby undermines other messages that would reduce harm to a greater extent. As a corollary, critics charge that harm reduction activities encourage the initiation or continuation of potentially risky behaviors, and thereby perpetuate rather than attenuate harm. Thus, while individual harms may be reduced by efforts to make use safer, this reduction may be accompanied and even outweighed by an aggregate rise in harm.

These are the same concerns that have animated debate over “safer” cigarettes. For example, compensatory smoking behavior has been widely observed in the form of smokers who inhale more deeply and frequently, smoke closer to the butt, and plug the filter holes of low-tar, low-nicotine cigarettes to ingest a greater amount of nicotine. Many public health professionals have similarly claimed that the availability of allegedly safer filtered or low-tar cigarettes could provide a disincentive for otherwise motivated smokers to quit their habit; it could encourage others who might otherwise have been deterred from smoking because of health concerns to begin, and it could make relapse more likely.2

In the cases of both illicit substance use and smoking, the place of abstinence within a harm reduction framework has been the subject of some debate. One source, commenting on “the irrelevance of abstinence,” declared, “Although harm reduction is not inconsistent with the long-term goal of abstinence, harm reduction accepts the fact that the user will continue to use drugs while in a drug program or in the community.”3 But in the case of smoking, abstinence can have 2 meanings: abstinence from nicotine, the addicting agent in cigarette tobacco, and abstinence from cigarettes. Thus, it is the role of the so-called “safer” cigarette within the history of smoking and harm reduction for which we must account. While we discuss nicotine replacement therapies such as nicotine gum and the patch, which have come to fit comfortably within both the harm reduction and chronic disease models, we focus in this historical analysis primarily on “safer” cigarettes such as those with filters, lower yields of tar, and the newer smokeless alternatives. We argue that while an array of factors has shaped the history of the “safer” cigarette, it is the current understanding of the industry’s past deceptions and continuing avoidance of the moral implications of the sale of products that cause the enormous suffering and death of millions that makes reconsideration of “safer” cigarettes challenging.

A BURNING EMBER: PUBLIC HEALTH AND THE POTENTIAL FOR “SAFER” CIGARETTES

In the 1950s and 1960s, tobacco companies began manufacturing filtered, low-tar, and low-nicotine cigarettes. Consumers quickly adopted the new products, reflecting their interest in reducing the hazards of smoking.4 During the 1960s and 1970s, the public health community consistently viewed industry innovations with some optimism and were also involved in efforts to develop even “safer” cigarettes.5

Surgeon General Luther Terry, who issued the watershed 1964 report definitively linking smoking with cancer, saw “the development of better filters or more selective filters [a]s a promising avenue for further development.”6 In 1964, with the assistance of $1.5 million in congressional funding,7 the NCI and the Public Health Service (PHS) announced plans to “ ‘work closely’ with tobacco researchers from the Department of Agriculture” to try to develop new varieties of tobacco to determine whether they are “less hazardous, more hazardous or show no change from the present ones.”8 NCI head Kenneth Endicott said that the group’s “first and foremost” objective would be to reduce the danger of smoking.9 The NCI spent $6 million a year in pursuit of a safer tobacco product.10

In 1966, Senator Warren Magnuson, a Washington Democrat, requested that the surgeon general convene an ad hoc committee of scientists to produce a “Technical Report on ‘Tar’ and Nicotine” to address the benefits of labeling cigarette packages with tar and nicotine levels and to respond to a broader congressional interest in the development and marketing of less hazardous cigarettes. Although fearing that “promotion of a low ‘tar’ and nicotine cigarette might lull the consumer into believing that he could smoke this kind of cigarette without any accompanying risk,” the PHS concluded that continued warnings on packages and other educational initiatives “should minimize this likelihood.”11 At hearings before the Senate subcommittee where this report was presented, Dr Paul Kotin, a pipe-smoking PHS officer who had served as a modestly paid member on the Tobacco Industry Research Council’s Scientific Advisory Board for over a decade, confidently concluded, “It is our belief that a less-hazardous cigarette is within the limits of accomplishment.”12

Figure 1.

In the 1950s and 1960s, tobacco companies responded to popular concerns about the health hazards of smoking by seeking to convince consumers that new filtered cigarettes were safer, without actually conceding that smoking itself was dangerous. This 1960 magazine advertisement for Duke cigarettes illustrates the use of an implicit “harm reduction” approach to appeal to people who wanted to be able to smoke more safely.

Surgeon General William Stewart forthrightly identified the third prong of the Department of Health, Education and Welfare’s (HEW’s) approach to controlling smoking-related deaths as “to support the development of a less hazardous cigarette for smokers who never will be willing or able to give up smoking, and at the same time, to help create a climate of opinion so that when such a cigarette is developed it will be acceptable.”13 While relating it to the goal of cessation and abstinence, Stewart explained that the third aim of the HEW strategy was “to reduce the total exposure to cigarette smoke to such a low level of total dosage that the health risks are at a level which the average knowledgeable smoker might be willing to tolerate.”14

Figure 2.

Surgeon General Luther Terry announces the release in January 1964 of the first Surgeon General’s Report on Smoking and Health, a landmark document that helped to galvanize the modern antitobacco movement. Behind Terry are members of the scientific committee that compiled the report. Reflecting a widespread belief among public health officials of the day, Terry considered filters that might make smoking safer to be “a promising avenue for further development.”

Other supporters of less hazardous cigarettes who testified at this hearing included Ernst Wynder and Cuyler Hammond, who were among the first to establish the link between smoking and lung cancer in the 1950s, and George E. Moore of the New York State Department of Health’s Roswell Park Memorial Institute.15 Wynder was, by the late 1960s, perhaps the most vocal advocate of both low-yield and filtered cigarettes and of developing “safer” cigarettes. In 1968, he persuaded NCI director Endicott—a smoker who had tried unsuccessfully to quit16—to establish the Less Hazardous Cigarette Working Group (later renamed the Tobacco Working Group to appease the industry). The group contracted with outside laboratories and other tobacco industry scientists, underscoring the extent to which the NCI sought to cooperate with the tobacco industry.17

But profiting from the sale of tobacco products was viewed with deep skepticism. When Columbia University President Grayson Kirk (another pipe smoker) appeared at the 1967 congressional hearings on “safer” cigarettes to explain his university’s sponsorship of a safety enhancing cigarette filter, he noted that “Columbia University’s entrance into the field of cigarette smoking appears to have ‘surprised’ some of the university’s friends.” Surprise stemmed from months of conspicuous press coverage following Columbia’s rash announcement of a “development of far-reaching importance, which promises to benefit mankind by reducing the health hazard of cigarette smoking.”18 The university’s attempt to license what quickly became known as the “Columbia filter” was disastrous for the school. Tobacco stock prices soared as a result of the announcement, raising embarrassing questions—amid Columbia’s evasiveness regarding how much of a controlling interest they held in the product and their evidence regarding its efficacy—about the investments of the university and its trustees.19 Columbia withdrew from the endeavor and apologized the next year.20

Support for or opposition to safer products did not fall out along predictable ideological lines. Supposedly safer tobacco products (typically overplayed by the press as “safe”), like the Columbia filter, had their critics, but the sharpest attacks came from those who most wanted to see the development of a safer product.21 And tobacco’s strongest opponents did not necessarily oppose safer products. Research initiatives into harm reduction continued to enjoy support even from antitobacco activists like Maurine Neuberger, Democratic senator from Oregon, who sponsored the legislation requiring warning labels on cigarette packages and advertising.22 She also supported national antismoking educational programs.23 Nonetheless, in 1965 Neuberger backed federal legislation allocating $5 million for research into safer products.24

Some influential voluntary organizations such as the American Heart Association took complementary stances through the 1960s and 1970s.25 While expressing concern that they might derail efforts to encourage people to stop smoking or not to start at all, the American Cancer Society said in 1967 that it had “long urged measures to reduce the tar and nicotine in cigarettes smoked by individuals who are unable or unwilling to give up smoking.” It called on tobacco companies to make greater efforts to develop less hazardous cigarettes and felt “strongly that frank scientific discussion about the possibilities of developing cigarettes that will be less harmful and still satisfying to smokers is an important aspect of our efforts. . . .”26 The American Cancer Society’s Cuyler Hammond called for the removal of high-tar brands from the market after concluding that smokers of low-tar brands enjoyed a lower rate of lung cancer and heart disease.27

Nevertheless, by the late 1970s, the federal government was beginning to show caution about the supposed benefits of “safer” cigarettes and was stepping up smoking cessation efforts. Caution may have stemmed in part from the well-known 1978 controversy generated by Gio Gori, deputy director of the NCI’s Smoking and Health Program—previous home of the Tobacco Working Group. Although the working group had been formally terminated in 1977, the National Institutes of Health continued to hope to “be able to call on [industry representatives] to consult with the Smoking and Health Program in its future endeavors,” indicating the continuing close relationship between government and industry.28 In a much-criticized article in the Journal of the American Medical Association, Gori and Cornelius Lynch attempted to quantify “less hazardous” levels of smoking by calculating the number of cigarettes one could theoretically smoke for each brand without exceeding “critical levels” for 6 “major toxic smoke components.”29

A month before the study was published, the Washington Post reported Gori and Lynch’s results under the front-page headline, “Some Cigarettes Now ‘Tolerable,’ Doctor Says.”30 The public relations fallout from this reporting was tremendous.31 Gori hit the front page again the following day in what was now termed a “smoking dispute.” Gori found himself under sharp attack not only by NCI director Arthur Upton but also the surgeon general, the head of the National Heart, Lung, and Blood Institute, and HEW Secretary Joseph Califano, who said simply that everyone was “very disturbed” and “there is no such thing as a safe cigarette.”32

The federal reaction was precipitated primarily by reporting that termed cigarettes “safe”—which had elicited sharp public health reproofs since the 1960s. Despite the media’s role in misrepresenting Gori’s position, Gori was more reckless in his comments than other early advocates for harm reduction.33 In retrospect, he remains controversial—like Kotin, who not only worked directly with the tobacco industry and placed enormous faith in its ability to conduct useful research but also disparaged the “wild-eyed evangelists” in the federal laboratories 34—because of his indirect connections to the tobacco industry during his tenure at the NCI and direct connections after departing. Accordingly, Gori’s advocacy has been used to discredit the genuineness of the federal harm reduction effort, just as the strong and swift public health reaction to Gori has been used to paint a picture of intolerance to harm reduction.35

But Gori was no outlier in the field of public health at the time. For instance, the University of Michigan’s prominent health economist Kenneth Warner, while rejecting Gori’s methods, referred to his “motivation” as “beyond reproach: “I applaud Dr Gori’s continuing efforts to develop and promote less hazardous smoking materials and behaviors.”36 Earlier that year, even Califano, in his 1978 announcement of his department’s sweeping antismoking program in which he judged smoking “public enemy number one,” found a place for “research aimed at creating a less hazardous cigarette.”37

But by the following year, in the preface to his 1979 report on smoking, Surgeon General Julius Richmond wrote that although some research suggested that low-tar and low-nicotine cigarettes might be less hazardous, it was not based on currently available products.38 He further noted that smoking machines that measured tar and nicotine levels could not account for the ways living people actually smoked and that flavor additives might represent unknown hazards, concluding, “until these scientific and behavior issues are resolved, there can be no final assessment of the public health benefits of our present search for less hazardous cigarettes.”39

Indicative of the unsettled state of opinion, however, the Surgeon General’s Report of 1981 gave less equivocal advice: “Overall, our judgment is unchanged from that of 1966 and 1979: smokers who are unwilling or as yet unable to quit are well advised to switch to cigarettes yielding less ‘tar’ and nicotine, provided they do not increase their smoking or change their smoking in other ways [italics added].”40 The report made this recommendation despite concerns that “the new cigarettes being produced today” may “introduce new risks through their design, filtering mechanisms, tobacco ingredients, or additives,” underscoring the extent to which harm reduction, even as late as 1981, remained a viable part of the federal antismoking campaign.41

SNUFFED OUT: NICOTINE REPLACEMENT AND A TREATMENT MODEL FOR SMOKING

Whereas the 1960s and 1970s had seen major agencies and organizations like the PHS and the American Cancer Society setting policy regarding “safer” cigarettes, new groups began to enter the policy arena in the 1970s and 1980s. Grassroots advocates outside of the more formal public health community would begin to exert a strong influence on public attitudes on smoking, relying on a more vehement antismoking and anti–tobacco-industry rhetoric. The American Medical Association (AMA) would also forcefully weigh in on the debate over safer tobacco products for the first time. The new players, new tone, new frameworks, and new products would help to move public health away from tolerating safer tobacco products.

During the 1970s and 1980s, a gradual yet profound shift occurred in the politics of tobacco control in which the protection of nonsmoking bystanders, rather than smokers themselves, moved to the center of policy goals.42 The 1972 Surgeon General’s Report was the first to include a reference to the potential health hazards of environmental tobacco smoke,43 and over the next 2 decades the newly emergent nonsmokers rights movement reframed the cigarette debate as one of harm to others. Grassroots organizations such as Group Against Smokers’ Pollution (GASP) and Americans for Nonsmokers Rights successfully pushed for federal, state, and local laws banning smoking in a wide range of public places; smoke-free workplaces and nonsmoking sections on airplanes, interstate buses, and restaurants began to become commonplace.44 In the early 1980s, studies began to appear in scientific journals demonstrating the health hazards of environmental tobacco smoke,45 and in 1986 the surgeon general and the National Research Council issued reports devoted to the subject that gave an official imprimatur to a social movement that had already effected major changes in public perception.46

The strategy of delegitimizing the habit and ridding the public sphere of smoke was in tension with efforts to develop a safer cigarette—if the two were not irreconcilable. On the heels of this movement, a newly endorsed addiction framework would throw into question the concept of safer cigarettes and, indeed, harm reduction. Smoking had long been known to be a hard habit to break, and the tobacco industry identified nicotine as the addicting agent in tobacco as early as 1962.47 The landmark Surgeon General’s Report of 1964 focused not on the addictive but rather on the toxic nature of nicotine.48 The report, while noting that it was difficult to stop smoking, stressed that “the tobacco habit should be characterized as an habituation rather than an addiction.”49 The report concluded that “Nicotine substitutes or supplementary medications have not been proven to be of major benefit in breaking the habit.”50

In the 2 decades following 1964, however, enormous strides would be made in developing effective nicotine replacement therapy (NRT). The Food and Drug Administration approved nicotine gum in 1984 and 4 forms of the nicotine patch, a transdermal nicotine delivery system, in 1991 and 1992.51 In some instances, NRT was explicitly framed as a harm reduction strategy, but in most cases it was viewed as a temporary, short-term tool for smoking cessation.52

The 20th report of the surgeon general, issued in 1988, formally classified nicotine as “addictive.” It cautioned against “alternating use of the substitute with use of the traditional tobacco product.” It stressed that nicotine gum was “recommended as a temporary treatment aid” and was not to be used indefinitely. It was already becoming apparent, however, that some people were growing dependent on the gum, but the report merely stated that “it is not clear to what degree such use may be necessary for some people to avoid relapse to tobacco use.”53

The watershed period in the shift away from support for safer cigarettes would come in late 1987 and 1988, when internal industry documents began to come to light. Millions of pages of previously secret tobacco industry documents revealed a long history of deception and manipulation on the part of the industry regarding the safety of cigarettes. The documents further underscored the self-imposed practical and political constraints preventing the industry from developing and marketing safer products.

In the 1960s, for example, Liggett had developed a supposedly safer cigarette, which reduced tumors in mice up to 100%. Liggett placed development and marketing of the cigarette under the stewardship of its lawyers, who understood that such an endeavor amounted to conceding the hazards of smoking and risked opening the company to litigation. Ultimately, Liggett suppressed its research and the product. And, indeed, when lawyers for Rose Cipollone—a woman who had smoked for 40 years—argued in a landmark 1988 trial that Liggett was liable for the death of their client, they cited, among other charges, Liggett’s failure to market its “safer” cigarette.54 In a remarkable and absurd exchange during deposition—outrageous for its obvious duplicity, tragic for its illumination of how the industry’s decision to suppress the hazards of smoking dramatically limited the potential development of safer products—Liggett’s chief executive, Kinsley V. Dey, Jr, found himself denying any knowledge that smoking causes cancer while acknowledging his company’s efforts to produce a cigarette that reduced the incidence of tumors in mice. Cipollone’s lawyer asked, “It had nothing to do with the health and welfare of human beings, is that correct?” Dey concurred, opening himself to the conclusion that the company had invested nearly $15 million “to save mice the problem of developing tumors.”55

At a moment when a public sense of outrage and betrayal began to take hold, RJ Reynolds, in the fall of 1988, announced that it would test market Premier, a new smokeless tobacco product that the company advertised as providing “cleaner enjoyment.”56 Reynolds claimed its product’s “smoke substantially reduces many of the chemical compounds that the critics of smoking have been complaining about.”57 The AMA, joined by the American Public Health Association and state health departments where the product was to be test marketed, attacked the cigarette on the grounds that RJ Reynolds was trying to market it as a safer product; interestingly, however, given the role that NRT would assume in providing nicotine free of the hazards of smoking, their attack hinged on the argument that it represented a “new and hazardous system intended to deliver the drug nicotine.”58 The AMA then led the charge for the Food and Drug Administration to regulate Premier, which RJ Reynolds eventually withdrew because of the poor consumer response to a smokeless product.59

The significance of the effort to regulate Premier as a drug delivery device lay in the new prominence of medicine in the fight against tobacco. Slow to respond to the threat of smoking in the 1950s and 1960s,60 the AMA’s stance on Premier and other tobacco-related issues in the mid-1980s reflected widespread acceptance of the bold assertion made in the New York State Journal of Medicine in 1985 that the profession was in part to blame for the illusion that a safer cigarette was feasible. The AMA took up the charge: “It is imperative that physicians realize that there will never be a ‘less hazardous’ cigarette.”61

By the 25th anniversary of the surgeon general’s landmark 1964 report, the PHS had also grown cold on less hazardous tobacco products as opposed to pharmaceutical nicotine replacement products. C. Everett Koop’s 1989 report stated, “The development of the low-yield cigarette has also necessitated an enrichment of the flavor ‘bouquet’ in the smoke either by tobacco selection or by addition of natural or synthetic flavor compounds. These facts and the practice of smoking low-yield cigarettes more intensely make it difficult to evaluate whether these new types of cigarettes are in fact less hazardous to the smoker.”62 This report cast public health successes in terms of smoking cessation and reduced initiation, not reduced consumption or consumption of alternative products. Finally, it described the popularity of filtered and low-tar cigarettes not as a viable strategy for reducing the hazards of smoking but merely as an uninformed “public’s principal behavioral response to concerns about the health hazards of smoking.”63 Ironically, at the very moment that public health officials were embracing an abstinence-only approach to tobacco, they were increasingly asserting that harm reduction for injection drug use was appropriate in the context of the AIDS epidemic.

Figure 3.

In 1989, RJ Reynolds withdrew its newly developed Premier “smokeless cigarette” amid attacks from public health groups and a tepid response from consumers. Without acknowledging that smoking was dangerous, Reynolds claimed the product would reduce smokers’ exposure to some of the chemical components of cigarettes

Over the next several years, additional disclosures would lead to the tobacco industry being increasingly reviled. The introduction of Joe Camel in 1988 drew widespread condemnation,64 and over the course of the 1990s protection of youths moved to the center of the tobacco control agenda. This focus resulted in Food and Drug Administration Commissioner David Kessler’s reframing of smoking as a “pediatric disease” and culminated with the agency’s ultimately unsuccessful attempt to regulate cigarettes as nicotine delivery devices. During this period, preventing the initiation of smoking assumed greater salience as a policy goal than mitigating the harm to current smokers; the 1994 Surgeon General’s Report, Preventing Tobacco Use Among Young People, exemplified this stance in its claim that “When young people no longer want to smoke the epidemic itself will die.”65 As with the issue of environmental tobacco smoke, the focus on youth—with its ultimate goal being the complete elimination of smoking from society—was irreconcilable with the idea of safer cigarettes.

With this history now as backdrop, what Kenneth Warner would describe as a solid “ ‘zero tolerance’ philosophy” regarding harm reduction involving safer cigarettes would take hold.66 The new availability of NRT did little to change this stance. In 1996, the Food and Drug Administration approved Nicorette gum for sale over-the-counter. The next year, Nicotrol and Nicoderm CQ, 2 forms of the patch, were approved.67 In both instances, over-the-counter sales met with the support of the public health and medical communities.68 Over-the-counter availability of NRTs forced the medical, public health, and research communities to investigate the likelihood and consequences of long-term NRT and of using both the patch and nicotine gum in combination with each other and with cigarettes.69 But acknowledgment that some people would use NRT for long periods of time did not constitute an endorsement of harm reduction.

In 1996, the Agency for Health Care Policy and Research and the American Psychiatric Association (APA) offered the first clinical care guidelines for treating smoking, both of which included offering NRT.70 The APA guidelines incorporated the 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification of nicotine dependence and withdrawal as disorders, noting that half of smokers aged 20 to 30 years, as well as half of all smokers who attempted to quit, met the criteria for dependence.71 The guidelines, therefore, discussed “more intensive therapies.” And they clearly identified all forms of tobacco as potentially leading to dependence.72

The APA, while not dismissing harm reduction, emphasized the areas of uncertainty about the potential consequences of such an approach: “Whether harm reduction (e.g., switching to low nicotine cigarettes or cutting down on the number of cigarettes smoked) is an acceptable goal is debatable because the health benefits from these actions are not well documented, compensatory behaviors occur, and patients may consider harm reduction as a ‘safe haven,’ which will undermine later cessation attempts.”73 By this time, internal industry documents had made the public health and medical communities aware that the industry had also suppressed the evidence related to compensatory smoking.74 Although the public health community had speculated as early as 1972 about the possibility that smokers would inhale more deeply, smoke more cigarettes, or nullify in other ways any potential benefits of filtered and lower-tar cigarettes,75 it was not until 1980 that a published scientific study confirmed this fear.76 The tobacco industry, however, had cultivated public health support for low-tar and filtered cigarettes even as they sat on empirical studies conducted a decade before. It was in this context that the APA guidelines embraced “long-term abstinence” as “the ultimate goal of the treatment of nicotine dependence.”77

In 2000, a PHS panel, drawing on widely respected scholars across an impressive array of leading schools, institutions, and agencies,78 dramatically reframed tobacco dependence as “a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved.”79 The panel equated tobacco dependence with “high blood pressure, high cholesterol or diabetes.” Drawing an analogy to psychiatric patients, its chair explained that good practice sometimes requires “keeping them on medication for the rest of their lives because I know it saves their lives. We have the exact same circumstances here.”80 In framing the guidelines in this fashion, the panel offered long-term treatment using nicotine replacement as a companion to cessation. They did not allow that some patients simply might not want to quit or might want only to cut back.81

Nonetheless, over-the-counter availability, because it enabled people to use NRT products however they chose, also set the stage for a harm reduction approach as an alternate strategy—one that would also include “safer” cigarettes despite the posture of the medical treatment guidelines.

OUT OF THE ASHES: THE REEMERGENCE OF “SAFER” CIGARETTES AND THE CLASH OF 2 MODELS

In the late 1990s, as pharmaceuticals and tobacco companies began to develop potentially safer alternatives to smoking including the patch, gum, lozenges, and modified cigarettes, some public health thinking on harm reduction began to shift. As Michigan’s Ken Warner, who is widely respected within the tobacco control community, noted in 1997, “When I first broached this idea [of safer cigarettes] three or four years ago, the public health community’s reaction was one of horror.”82 But while some public health professionals were becoming more receptive to harm reduction, the contribution of the tobacco industry to the new range of products clearly complicated thinking and made consensus difficult to achieve.83

Foremost among these products was Eclipse, a new brand of smokeless cigarette that heated rather than burned tobacco. RJ Reynolds introduced the cigarette in 1996, claiming that it offered “less risk of cancer and certain other diseases, such as chronic bronchitis and emphysema.”84 Eclipse was rejected by several leading health organizations. The American Cancer Society, citing “the tobacco industry’s long history of deception,” argued that the “use of a product such as the nicotine skin patch is the best option for those who feel that they must have nicotine from some source.”85 Both the American Heart Association and the American Lung Association stated that “there is no such thing as a safer cigarette.”86 The head of the American Heart Association was most emphatic: even “talking about a safer cigarette is like playing Russian Roulette, sooner or later you’re going to hit the chamber with the bullet in it [italics added].”87

But Henry Waxman, Democratic representative from California who chaired the House Subcommittee on Health and the Environment—one of the proclaimed “heroes of the antitobacco” movement and also a strong supporter of harm reduction for intravenous drug users in the context of the HIV epidemic88—proved more receptive. Eclipse, he said, may be “safer, relatively speaking. That is impressive and could be a big advantage.” Without endorsing the product, an independent scientific investigation called for further investigation on the basis of its findings that, among a group of smokers very unlikely to stop, Eclipse increased rather than decreased motivation to stop while reducing the number of cigarettes smoked per day by 85%.89 According to a report in American Medical News, many participants at a Georgetown University conference on tobacco dependence in 1998 concluded that addicted smokers should not be denied less hazardous cigarettes.90

In response to the proliferation of nicotine-laced and cigarette-based products,91 the Food and Drug Administration requested the formation of an IOM panel to review the evidence on their safety and efficacy. The IOM had on more than one occasion endorsed the concept of harm reduction in the case of needle exchange.92 Its committee on smoking and harm reduction published its final 600-plus-page report in 2001 after a year-long process of reviewing evidence on tobacco control and harm reduction. Key to the panel’s conclusion that harm reduction was “feasible and justifiable” was the observation that “approximately 10–15% of the adults in the United States are expected to be regular users of tobacco in 2010, and they will continue to suffer the increased incidence of harmful and lethal consequences. Among this group are many who cannot or will not stop using tobacco, and it is to this group that effective programs and products of harm reduction should be directed.”93

Most dramatically, then, the report accepted such tobacco industry products as “safer” cigarettes as legitimate harm reduction tools, not only nicotine delivery products. The report was straightforward regarding concerns that the IOM was recommending nicotine dependence and possibly continued use of tobacco products for some. The report stated, “There is little agreement in the tobacco control field that public policy should encourage products that maintain nicotine addiction,” but it continued, “Worrisome as harm reduction might be to those who have studied the history and disappointments of low-yield cigarettes, [potential reduced-exposure products] are currently available and likely here to stay.”94

The IOM report was received favorably by the tobacco industry. An RJ Reynolds spokesman stated, “We are pleased that the Institute of Medicine believes that reduced-risk cigarettes should be part of a sound public-health policy.”95 But the public health and medical communities have given it a more mixed reception. Gio Gori, in a commentary in the American Journal of Public Health, argued that “the [IOM] report has hardly been noticed by the public health community, because it implies a policy shift that many would find uncomfortable.”96 But the IOM’s Kathleen Stratton, who coedited the report, claimed that it was enjoying a “slow, steady life” and that public health professionals were using it as a starting point to examine potential strategies for tobacco harm reduction.97

Almost immediately following the IOM report, the NCI released its own report, Risks Associated With Smoking Cigarettes With Low Machine-Measured Yields of Tar and Nicotine.98 The NCI explained that its monograph “complements” the IOM report, but its emphasis fell more heavily on discrediting low-tar cigarettes and underscoring the duplicity of the tobacco industry.99 Concluded one of the report’s papers, “The reality that many smokers chose these products as an alternative to cessation—a change that would produce real reductions in disease risks—makes this deception an urgent public health issue.”100 The NCI report thus confirmed for many that the only reasoned objective remained total cessation: “If you are concerned about your health, quitting is your only choice [italics added].”101

CONCLUSION: THE FEASIBLE AND THE IDEAL

The coincidental timing of the 2 apparently contradictory messages embodied in the NCI and IOM reports underscores the diversity that exists within the tobacco control movement and the field of public health more generally. Over the last 4 decades, a wide range of organizations and individuals, representing different political and ideological views, have entered the arena of tobacco control. Some, appalled by the enormous toll of smoking-related death and disease and the malfeasance of the tobacco industry, view “safer” cigarettes as a misguided diversion of effort from the only appropriate goal of cessation. A vocal segment of this group further views—with just cause—the tobacco industry as evil, as liars incapable of corporate responsibility.102 Compromise with an industry characterized as displaying “a callous disregard for life” is impossible.103

Without apologizing for the sins of the tobacco industry, others espouse a more tolerant pragmatism toward smokers that accepts the use of nicotine and tobacco, like the use of psychoactive substances more generally, as inevitable. The position of the latter group reflects the influence of the harm reduction movement, with its grassroots philosophy that originated with drug users themselves and thus views abstinence-only messages of any sort as ineffective and moralistic.104

The IOM report has faced the dilemma presented by the possibility of “safer” tobacco industry products by endorsing harm reduction only “as a component of a comprehensive national tobacco control program that emphasizes abstinence-oriented prevention and treatment [italics in original].” The NCI report declined to address what might be theoretically possible and rejected the low-tar and nicotine products that key federal and voluntary agencies had hung their hopes on from the 1960s through the 1980s.

But given the history and current terrain of tobacco control in the United States, we must confront the moral dilemma directly: prioritizing the reduction of harm, however great or minimal, may necessitate some level of cooperation with the tobacco industry and will certainly prove lucrative for it. And despite any breakthrough innovations in “safer” tobacco products, the tobacco industry will continue to be responsible for an enormous toll of morbidity and mortality worldwide. The careful evaluation studies that will be necessary before adopting any particular harm reduction tool may ultimately give us a good indication of whether the risks outweigh the benefits. But the most vexing question will be philosophical rather than empirical. In the end, we will have to make a moral judgment regarding what is feasible and what is ideal.

Underscoring the difficulties of recommending a tobacco product in light of the current understandings of industry behavior, one official with the PHS during the era when it was cautiously recommending safer cigarettes claimed, in 2001, “If we’d had one single piece of evidence that the industry had . . . then we would have changed” the advice on low-tar cigarettes.105 On the one hand, the comment speaks to a profound sense of betrayal: health officials had attempted to collaborate with the tobacco industry to find a safer product only to learn that the industry had not cooperated in good faith. But on the other hand, while it is important to remember that certain advocates for safer tobacco products were cozy with the tobacco industry, history also shows that there is a long tradition of surprisingly broad support within the public health community for harm reduction when it comes to smoking, which was eroded for the reasons we have discussed.

The later history of tobacco industry deception and manipulation was an important factor contributing to the erosion of public health support for harm reduction; indeed, its own labyrinth of lies made the industry a dishonest partner in the pursuit of supposedly safer products, which must give us pause. But while knowledge of this deception and its consequences now makes the reemergence of the “safer” cigarette unacceptable to many, it neither invalidates the earlier public health quest for harm reduction nor dictates the course we must take.