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Where there's smoke

The good news is that someday soon there may be a significantly ``safer" cigarette. For public health advocates, that's also the bad news.

ONE OF THE MORE interesting things about the quest to create a safer cigarette--an ongoing, multimillion-dollar effort on the part of the world's leading tobacco companies--is that no one involved will actually use the words ``safe" and ``cigarette" in the same sentence, except to say that such a product does not exist.

It's no surprise, of course, to hear Stephen Brody, the lawyer who helped lead the Justice Department's landmark racketeering case against the tobacco industry, describe cigarettes as ``virtually the only consumer product that kills you when used as intended." More striking is to hear David Howard, a spokesman for RJ Reynolds--maker of Camel and Winston--repeat, mantra-like, several times over the course of an interview, that ``there is no such thing as a safe cigarette."

The term preferred by both tobacco companies and those who would regulate them is the more ambiguous ``Potentially Reduced Exposure Product," OR PREP for short. Coined in a 2001 Institute of Medicine report, it describes products that cut down on a tobacco user's exposure to carcinogenic or otherwise toxic byproducts. And tobacco companies today are offering up a profusion of PREPs.

Philip Morris, the world's leading cigarette manufacturer, is at work on a $350-million tobacco research center, due to open next year in Richmond, Va., and dedicated in large part to PREP research. The company already has a top-secret reduced-exposure research program, called the Smoke Constituent Reduction (SCOR) program. The company won't comment on it, but the new Marlboro Ultra Smooth cigarette, now being test-marketed in Tampa, Atlanta, and Salt Lake City, is reported to be the first product to result from SCOR research.

Last year, a small manufacturer called New Century rolled out its Fact cigarette, featuring a patented, chemically treated filter that blocks several of the carcinogens in cigarette smoke. And RJ Reynolds, Philip Morris's biggest rival, has launched the Eclipse--a cigarette-shaped nicotine delivery system that heats, rather than burns, tobacco--after several years of test-marketing.

The tobacco industry's interest in the reduced-exposure market, amounting as it does to an admission of the dangers of traditional cigarettes, would seem to mark a major departure from decades of public denials of the health risks of smoking. But many public health experts and tobacco control advocates claim to have have seen this tactic before.

Two weeks ago, a federal district judge in Brooklyn ruled that a class-action lawsuit against the cigarette industry, claiming that it fraudulently advertised ``light" cigarettes as less dangerous than regular cigarettes, could go forward. And in August, Judge Gladys Kessler of the federal district court in Washington, D.C., in her ruling in the government's racketeering case, ordered the tobacco companies to stop labeling their cigarettes ``light" or ``low tar."

Pending appeal of Kessler's ruling, the ``light" cigarette remains, for now, on the shelves. But industry critics suggest that the PREP may simply be an updated replacement, a marketing ploy meant to attract and keep customers who, worried about their health, might otherwise quit smoking. Tobacco companies, for their part, respond that they are simply trying to provide a safer product for the tens of millions of American smokers who are unable to stop. Each side, in its own way, is trying to answer the question of whether the world, lacking a safe cigarette, is ready for a merely safer one.

. . .

There are 45 to 50 million American smokers. According to a recent surgeon general's report, 70 percent of them want to quit and every year, roughly half of those try. Mostly they fail.

Nicotine, in short, is seriously addictive. And yet --aside from interfering with fetal development if used by pregnant women --it is not terribly bad for you. The major health risks from smoking--the dramatically higher rates of lung cancer, emphysema, heart disease, and stroke--stem not from the nicotine but from other chemicals in cigarette smoke. In theory, then, it should be possible to design an addictive but mostly harmless cigarette. Even Greg Connolly, director of the Tobacco Control Research and Training Program at Harvard's School of Public Health and a leading industry critic, concedes the possibility: ``I think in our lifetime we can probably figure that one out, but I think in our lifetime we'll get to Mars, too."

Tobacco smoke is a vastly complicated mix of 4,000-plus chemicals, and while scientists have linked certain of them definitively to certain diseases, they're still unsure how they all interact with one another. Even if a tobacco treatment process or a filter technology such as those being experimented with in today's PREPs managed to reduce some toxicants without raising others, it's unclear how much better off that would make the user. As Connolly puts it, ``We don't know if [smoking a PREP] just means that the consumer jumps from the seventh instead of the 10th floor."

Meanwhile, according to Michael Cummings of the Roswell Park Cancer Institute, the consensus among tobacco control advocates is simple: ``If you light it, it is bad."

Cigarette companies, limited by law from making health claims for their products, can only respond indirectly. Peggy Roberts, a spokesman for Philip Morris, offers that her company has spent $2 billion on risk reduction in the past decade and that, alone among major tobacco companies, it has pushed for Food and Drug Administration regulation of tobacco so it can start making explicit health claims for its products.

Melissa Mowbray-D'Arbella, the CEO of Filligent, the Hong-Kong-based biotechnology company that created the filter that is used in the new Fact cigarette, believes asking for a harmless cigarette misses the point. She quotes World Health Organization statistics that more than a billion people worldwide will be addicted to cigarettes by 2010. She wants to offer more choices to those people than ``quit or die."

``I want to make it perfectly clear, this is about harm reduction, not elimination," she insists. ``Cigarettes are deadly, they kill. Smoking a cigarette is like playing Russian roulette with four chambers full, maybe five. All we're trying to do is reduce the number of bullets."

Of course, as in any gamble, the better the odds, the more tempting it might be to try it. Any reduction in individual risk, PREP skeptics say, has to be balanced against the resulting increase in the number of smokers.

``Does that mean people not quitting who otherwise would have quit? Are kids starting who might not otherwise have started?" asks Danny McGoldrick, the director of research at the Campaign for Tobacco-Free Kids. If more people are smoking but fewer of them are dying from smoking, how much of an improvement is that?

. . .

For tobacco control advocates, all of this has a familiar ring to it. Light cigarettes--like Marlboro Lights, Camel Lights, and Vantage--were introduced in the early 1970s as a purportedly less dangerous alternative to regular cigarettes ``If 'tar' and nicotine has become a concern to you, you may consider changing to a cigarette like Vantage," one ad discreetly suggested.

But the lower nicotine levels meant that people just smoked more of them, and sucked the smoke in further, and the new cigarettes proved just as lethal.

``I worry about another generation of health-concerned smokers lost, as in 'lights,"' says Mitch Zeller, who was director of the Food and Drug Administration's Office of Tobacco Programs under the Clinton administration. Millions of smokers who might have quit, he believes, simply switched to light cigarettes and went on to die from smoking-related diseases. PREPs, he fears, are just another attempt ``to keep smokers smoking."

Cigarette companies don't deny that they'd like to hold onto their clients in a domestic cigarette market that, while still highly profitable, has been shrinking for decades. (Overseas, where there are fewer limits on marketing, American tobacco companies have been expanding rapidly.) ``We're in the business of making cigarettes," says Roberts of Philip Morris, ``we have shareholders in a parent company that expect us to be in that business, and to be successful in that business. The development of potentially reduced exposure products not only makes sense for public health--it also makes good business sense."

Of course, few industry critics would argue that a truly harmless cigarette would not be a welcome development. But the question of how harmful we should allow tobacco products to be is a contentious one.

Witness the division among tobacco control advocates over smokeless tobacco. This summer, Philip Morris and RJ Reynolds both introduced, in limited markets, smokeless, spitless, oral tobacco pouches, aimed, they said, at smokers. US Smokeless Tobacco, producer of Skoal and Copenhagen snuff, introduced a similar product. Another company, Star Scientific, has for a few years been marketing two brands of tobacco lozenges.

Smokeless tobacco is, it's widely agreed, far less dangerous than smoking: A recent National Cancer Institute-funded study concluded that the risks of most smokeless tobacco products are on the order of 90 percent less than those of smoking. Smokeless tobacco does increase one's risk of mouth cancer, but far less than smoking does, and, being smokeless, it does not present the sort of pulmonary or cardiovascular risks of cigarettes.

This has led some medical academics, like Brad Rodu, professor of medicine and endowed chair for tobacco harm reduction research at the University of Louisville, to suggest that getting smokers to switch to smokeless tobacco, even if they don't then go on to quit tobacco altogether, would represent a major step forward. He cites the example of Sweden, where use of a finely cut moist snuff called snus (rhymes with ``goose") is widespread among men. Sweden's male adult smoking rate, and its smoking-related mortality rate, meanwhile, are among the lowest in the world. Some in the tobacco industry are skeptical that cigarette smokers will give up all the rituals and pleasures of smoking, but Rodu cites studies that show otherwise.

The idea of swapping one carcinogen for another, however, still sits uncomfortably for some. Dorothy Hatsukami, director of the Tobacco Use Research Program at the University of Minnesota, worries that more user-friendly oral tobacco might simply be a gateway to smoking for nonsmokers, or a way for smokers to tide themselves over until their next cigarette. ``We're really at an infancy stage in terms of our knowledge of these products," she says.

Yet Ken Warner, director of the University of Michigan's Tobacco Research Network, believes that even full information won't solve what he sees as a uniquely knotty public health dilemma. ``I've been working on tobacco policy issues for 30 years now," and the issues that arise around PREPs, ``are the most perplexing I've faced."

Drake Bennett is the staff writer for Ideas. E-mail drbennett@globe.com

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