January, 2016:
E-cigarette ads entice U.S. youth, could undo tobacco prevention efforts -CDC
http://www.reuters.com/article/usa-ecigarettes-idUSL1N14P13P20160105
E-cigarette companies are reaching about seven in 10 U.S. middle- and high-school students with advertisements employing themes of sex, independence and rebellion that hooked previous generations on regular cigarettes, a government study released on Tuesday said.
The marketing strategy could reverse decades of progress in preventing tobacco use among youth, warned the U.S. Centers for Disease Control and Prevention, which suggested tighter controls on e-cigarette sales to reduce minors’ access.
“The same advertising tactics the tobacco industry used years ago to get kids addicted to nicotine are now being used to entice a new generation of young people to use e-cigarettes,” said CDC Director Tom Frieden.
The CDC’s National Youth Tobacco Survey found that 68.9 percent of middle- and high-school students saw e-cigarette ads from one or more media sources in 2014, most commonly in stores but also online, on television and in movies or magazines.
E-cigarette use among this age group soared over the past five years, surpassing its use of regular cigarettes in 2014, according to CDC statistics. Spending on e-cigarette advertising also jumped, increasing to an estimated $115 million in 2014 from $6.4 million in 2011.
E-cigarettes contain cartridges that typically hold nicotine as well as other liquids and flavorings, and a heating element to create a vapor that the user inhales.
Many researchers believe e-cigarettes are less harmful than regular cigarettes, but the risks are still being studied.
“Youth use of tobacco in any form (combustible, noncombustible or electronic) is unsafe,” the CDC study said.
Exposure to tobacco at a young age may cause addiction and lasting harm to brain development, the agency reported.
Most states have passed laws banning the sale of e-cigarettes to minors, and the U.S. Food and Drug Administration’s proposal to regulate the products is under federal review. (Reporting by Barbara Liston in Orlando, Fla.; Editing by Colleen Jenkins and Lisa Von Ahn)
CDC: Youth exposure to electronic cigarettes ads contributing to use
http://wtop.com/health/2016/01/cdc-youth-exposure-to-e-cig-ads-contributing-to-use/
WASHINGTON — Children in the United States are seeing lots of ads for e-cigarettes — and the Centers for Disease Control and Prevention says that is one big reason why the use of e-cigs is soaring among the young.
A new CDC report says seven in 10 middle and high school students have seen these advertisements which — like cigarette ads of yore — use themes of sex, independence and rebellion to sell their products.
“The e-cigarette advertising we’re seeing is like the old-time Wild West; no rules, no regulations and heavy spending,” says CDC Director Tom Frieden.
Data from the CDC’s 2014 National Youth Tobacco Survey, found that 68.9 percent of teens and tweens saw e-cigarette ads from one or more media source. And those advertisements can have a great impact.
“Kids just pick up advertising messages really well and from young ages,” says Joanna Cohen, director of the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health.
She cites a key study conducted in the 1990s to prove her point. It showed that children as young as 3 years old recognized the Joe Camel cartoon figure more than they recognized Mickey Mouse.
Last year, researchers at Hopkins wrote of the potential health hazards of e-cigarettes. The report — published in the journal PLOS ONE — was based on a mouse study that found evidence that e-cigs may compromise the immune system.
Frieden says while there may be some limited benefit to short-term e-cigarette use for adults trying to wean themselves off regular cigarettes, the risk for kids is unacceptable.
He cites a possible impact on brain development, and notes that e-cigs still contain nicotine, which can be extremely addictive.
Government statistics show while cigarette smoking is down among teens, the use of e-cigs is way up. The CDC says e-cigarettes could reverse the trend, with many young people eventually transitioning to far more dangerous tobacco products.
“We are really excited that smoking rates are coming down among kids, but we have to keep working to make sure that they stay low,” says Cohen.
Maryland and Virginia are among the states that have already banned sales of e-cigarettes to minors, and similar legislation has been introduced in the District, but there has been no movement in the D.C. council.
But it may take much more than a ban to solve the problem, Frieden says.
E-cigarettes are readily available for anyone of any age to purchase on the Internet, and the CDC’s Frieden indicates an all-out awareness campaign may be needed.
He suggests states may want to use some of the money they received as part of a big settlement with tobacco companies in the late 1990s. But such action may have to wait until the Food And Drug Administration announces a long-awaited formal proposal to regulate e-cigarettes as a tobacco product.
Health agency takes on advertising for electronic cigarettes
http://6abc.com/health/health-agency-takes-on-advertising-for-electronic-cigarettes/1147363/
The nation’s lead public health agency is focusing its attack on electronic cigarettes on the issue of advertising, saying too many kids see the ads.
The Centers for Disease Control and Prevention released national survey results Tuesday indicating 7 in 10 youths see e-cigarette ads, mostly in stores.
CDC officials worry such ads will lead more kids to try them and, perhaps, regular cigarettes.
The report says the e-cigarette ads use many of the same themes used to sell tobacco cigarettes and other tobacco products.
CDC Director Dr. Tom Frieden says, “The same advertising tactics the tobacco industry used years ago to get kids addicted to nicotine are now being used to entire a new generation of young people to use e-cigarettes.”
In 2014, e-cigarettes became the most commonly used tobacco product among young people, surpassing tobacco products.
Ad spending on electronic cigarettes has risen from $6.4 million in 2011 to an estimated US$115 million in 2014.
There are bans on TV commercials and some other types of marketing for regular cigarettes but there are no restrictions on advertisements for e-cigarettes. Most states, though, ban the sale of e-cigarettes to minors.
The report doesn’t prove advertising is actually causing more kids to pick up e-cigarettes and a trade group said the survey is flawed
Tobacco Giants Eye Lucrative $50 Billion Marijuana Market
http://thelibertarianrepublic.com/tobacco-giants-eye-lucrative-50-billion-marijuana-market/
Big tobacco is positioning itself to muscle into the growing marijuana business if the drug wins nationwide legal status, according to a Daily Caller News Foundation investigation.
Four states and the District of Columbia have already approved some level of legalization for possession of small amounts of marijuana, and 10 other states may have ballot measures in 2016 that give voters further opportunities to legalize possession.
Big tobacco, despite its conservative image since the 1970s, has been closely eyeing the marijuana market which venture capitalists regard to be worth $50 billion in annual revenues.
Tobacco companies are now on a buying spree of e-cigarette companies — the producers of smoking devices called vaporizers marijuana users prefer because vaporization can offer a higher high.
In 1970, Philip Morris covertly sought government research funds from the Department of Justice (DOJ), then overseen by Attorney General John N. Mitchell, a close friend and ally of President Richard Nixon. The funds were to be used to study the drug, according to documents obtained under litigation by the University of California, San Francisco (UCSF).
After approaching DOJ’s Bureau of Narcotics and Drug Abuse with a secret offer to conduct marijuana research, Philip Morris received formal bureau approval, although the company insisted it be done on a “confidential basis” to avoid public awareness.
“We can hardly refuse this request under any circumstances,” stated an unsigned 1970 Philip Morris memo to executives obtained by UCSF’s Center for Tobacco Research & Education.
“We are in the business of relaxing people who are tense and providing a pick up for people who are bored or depressed,” the tobacco memo added. “The human needs that our product fills will not go away. Thus, the only real threat to our business is that society will find other means of satisfying these needs.”
Philip Morris, now known as Altria, was so enthusiastic over the prospects of cashing in on marijuana that in 1993 it sought the French trademark and intellectual property rights for the name “Marley,” named after Jamaican celebrity Bob Marley, an avid and well-known advocate for the drug.
Reynolds America’s Jacob McConnico told TheDCNF there are no marijuana plans underway at his tobacco company. “None of Reynolds American’s operating companies is evaluating entering the U.S. market with commercial brands of marijuana,” he said.
Altria did not respond to TheDCNF’s request for comment.
“I would deny it, too,” replied Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford School of Medicine. “If that were my intention, I would deny it at this moment,” he told TheDCNF.
Humphreys is a giant in the drug abuse and reform movement. He sat on California’s highly publicized “blue ribbon” marijuana policy commission as a steering committee member that was headed by California’s pro-legalization Democratic Lt. Governor Gavin Newsom. Humphreys was also a senior advisor to Obama at the White House Office of Drug Control Policy.
Humphreys said big tobacco has a distinct advantage in marijuana production. “On marijuana, who knows better how to grow a plant that you dry up, wrap up in paper and smoke,” he told TheDCNF. “They’re the masters of that worldwide and have wide brand recognition.”
Jonathan Caulkins, a professor at Carnegie Mellon University’s Heinz Center and co-director of RAND’s Drug Policy Center, told TheDCNF he believes the tobacco industry is privately looking at the legalization movement.
“If you’re specifically in the tobacco industry, of course you should be paying great attention,” Caulkins said. “It would be unfair to your shareholders if you didn’t at least watch with interest and probably should have several analysts working full time trying to think of different scenarios of how this could play out,” he said.
Dr. Stanton Glantz of the UCSF School of Medicine and the American Legacy Foundation Distinguished Professor of Tobacco Control told TheDCNF, “They certainly would deny it if you asked them, but the reality is that tobacco firms are very well positioned.”
“They know how to make the product very well and very efficiently,” Glantz said. “More important, they know how to engineer the product to maximize the addictive potential, which is something that the current marijuana enterprises probably aren’t as good at.”
Glantz, who was also a key figure in the litigation effort that released 80 million pages of internal tobacco industry documents, said “it would be a very, very very small step for them to dive into the marijuana with both feet if they wanted to.”
The documents show big tobacco has toyed with marijuana cigarettes for at least a half a century.
“Since at least 1970, despite fervent denials, three multinational tobacco companies, Phillip Morris (PM), British American Tobacco (BAT, including its US subsidiary Brown & Williamson [B&W]), and RJ Reynolds (RJR), all have considered manufacturing cigarettes containing cannabis,” the UCSF researchers concluded.
Glantz asserted tobacco companies “have the financial resources, product design technology to optimize puff-by-puff delivery of a psychoactive drug (nicotine), marketing muscle, and political clout to transform the marijuana market.”
As noted previously, big tobacco is also buying up American e-cigarette companies with fervor. The devices called vaporizers can be used with either tobacco or marijuana.
In the last three years, Altria Group acquired e-cigarette company Green Smoke for $110 million and Lorillard acquired Blu Ecigs for $135 million and Reynolds America launched its own e-cigarette vaporizing brand, called Vuse.
Last April, Japan American Tobacco agreed to acquire Logic Technology Development, LLC, the third largest e-cigarette company offered in American convenience stores.
“For e-cigarettes, there is a huge crossover in e-cigarette use between marijuana and tobacco,” Glantz told TheDCNF.
A 2003 University of Florida study found that two out of three marijuana users follow the drug with mentholated cigarettes, which can extend the high.
Caulkins said he believes “it will be quite possible in the marijuana legalization market, we might move away from combustion-related products and moving heavily into ‘vaping’ based products.
Norway under pressure to ban sale of tobacco to adults
http://www.independent.co.uk/life-style/health-and-families/health-news/norway-under-pressure-to-ban-sale-of-tobacco-to-adults-a6795971.html
Medics say access to tobacco is ‘not a basic human right’
Norway’s biggest medical organisation wants to ban the sale of cigarettes to adults.
In a drive towards a smoke-free society by 2035, the Norwegian Medical Association (NMA) is pressing the government to back its proposal for a ban on tobacco sales to citizens born after the year 2000.
Marit Hermansen, the president of the NMA, told Norwegian newspaper Aftenposten that access to cigarettes was not a basic human right.
“We have long had the policy of phasing out smoking by 2035. This is a measure to achieve this goal. We want a tobacco-free generation,” she said, according to The Local.
“It shouldn’t be forbidden to smoke, but we want young people to not get started with tobacco.”
They hope the proposed legislation will mean future generations are unable to buy tobacco in Norway when they reach 18 years old, which is the current age limit. Given the choice of 2000, the law would technically come in to until 2018.
“The [health] minister has said that the main objective is to hinder young people from beginning to smoke,” Ms Hermansen told Aftenposten.
“That means that when the new generations come of age, they won’t be able to buy tobacco in Norway.”
The emphasis will be on denying access to the substances, rather than criminalising use, she added according to The Nordic Page.
In 2013, about 32 per cent of the Norwegian population were smokers – a steady decline from 36 per cent in 2008.
Among young people, seven per cent had reported that they smoked daily, the Nordic Page reported.
Yet despite the NMA’s hopes, health spokespeople for the Conservative, Labour, Centre and Christian Democrats parties in the country told Aftenposten the idea was not currently feasible.
In the UK, meanwhile, eight percent of 15-year-olds smoked regularly in 2014 – a significant decline compared to the 20 percent who were smoking eight years earlier.
Cancer burden with ageing population in urban regions in China
Cancer burden with ageing population in urban regions in China: projection on cancer registry data from World Health Organization.
https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/92697-cancer-burden-with-ageing-population-in-urban-regions-in-china-projection-on-cancer-registry-data-from-world-health-organization.html
China is facing the challenges of an expanding ageing population and the impact of rapid urbanization, cancer rates are subsequently increasing. This study focuses on the changes of the ageing population and projects the incidence of common ageing-related cancers in the urban regions in China up to 2030.
Cancer incidence data and population statistics in China were extracted from the International Agency for Research on Cancer.
Due to improving longevity in China, continuous and remarkable increasing trends for the lung, colorectal and prostate cancers are expected.
The rate of expanding ageing population was taken into account when predicting the trend of cancer incidence; the estimations of ageing-related cancers were more factual and significant than using the conventional approach of age standardization.
The incidence rates of lung, colorectal and prostate cancers will continue to rise in the future decades due to the rise of ageing population. Lifestyle modification such as cutting tobacco smoking rates and promoting healthier diets as well as cancer screening programs should be a health system priority in order to decrease the growing burden of cancer-related mortality and morbidity.
British medical bulletin. 2016 Jan 01 [Epub ahead of print]
Kelvin K F Tsoi, Hoyee W Hirai, Felix C H Chan, Sian Griffiths, Joseph J Y Sung
E-cigarettes: effective cessation tools or public health threat?
L. Clancy1 and K. Babineau1
From the 1TobaccoFree Research Institute Ireland, Focas Research Institute, DIT, Kevin Street, Dublin 8, Ireland
Address correspondence to Prof Luke Clancy, TobaccoFree Research Institute Ireland, Focas Research Institute, DIT, Kevin Street, Dublin 8, Ireland.
email: lclancy@tri.ie
In a short time, electronic cigarettes have become a multi-billion dollar industry. Since their introduction to the market, prevalence of ever-use among smokers in the USA appears to have increased from 2% in 2010 to >30% in 2012, and the rate of increase appears to be similar in the United Kingdom, Ireland and other Western countries according to a special Eurobarometer survey in 2014.1 The e-cigarette market is estimated to be worth over $3 billion. However, there is no consensus on the role of e-cigarettes and their contribution to the provision of smoking cessation (SC) services, nor to global tobacco control.
At the Conference of the Parties to the WHO Framework Convention on Tobacco Control in September 2014, the secretariat presented a report outlining the current facts concerning ecigarettes, put forth an opinion on these devices, and offered considerations on options for regulation.2 This was on the tail of two contrasting letters to Margaret Chan, Director General of the WHO, submitted by scientists from many disciplines including tobacco control, public health, epidemiology, pharmacology and the clinical sciences (Letters to Dr Chan; June 2014). One letter stated that e-cigarettes offer huge prospective gains by reducing the prevalence of cigarette smoking and subsequently, the harm done by smoking. Those in favour of this position therefore requested support for the introduction and widespread availability of e-cigarettes. The other letter cautioned restraint, citing the possible damage that e-cigarettes could have on tobacco control.
For those favouring the widespread proliferation of ecigarettes, the main considerations appear to be the efficacy and safety of e-cigarettes with regards to SC and potential for harm reduction. For those cautioning restraint the main consideration seems to be the possible effects these products may have on broad tobacco control measures such as smoking prevalence among children and young people, the possibility of relapse among ex-smokers, the impact on smokefree laws, the effects on advertising and sponsorship and the feared influence of the tobacco industry. Although both groups are, of course, concerned about all these issues, the discourse suggests that priorities may be somewhat different for different scientists.
So what does the evidence say? On the whole, it remains inconclusive.
With regard to the potential efficacy of e-cigarettes as a smoking cessation tool, two randomized controlled trial (RCT) studies suggest that e-cigarettes may be helpful. One study found that e-cigarettes containing nicotine are as effective as nicotine patches for smoking cessation when used as directed.3
In this study [n¼657], one group of participants received vouchers for nicotine patches by post and were encouraged to use them, while the other groups were given e-cigarettes—one with and one without nicotine. In another RCT [n¼300], smokers were randomized to three groups (patches, e-cigarettes with nicotine, e-cigarettes without nicotine). This study found that at 2, 4 and 12 weeks, there was a statistically significant difference between the two groups with e-cigarettes containing nicotine and the group with non-nicotine containing devices. However, there was no difference between the groups with regard to the overall reduction in the number cigarettes smoked at 24 or 52 weeks.4 In addition to these, there are many other small-scale trials, some of which show positive and some of which have negative results which may be considered inconclusive. These studies often address particular aspects of efficacy which are of concern (e.g. efficacy in key sub-populations), but they do not resolve the overall question of the efficacy of e-cigarettes for cessation. An interesting ‘real world’ study which was part of the continuing English Smoking Toolkit Study found that ecigarette users had a better quit rate than those who used ‘over the counter’ nicotine replacement products, or than those who succeeded in quitting without any form of nicotine.5 The survey reports high e-cigarette use among ex-smokers, which raises questions regarding the role of e-cigarettes in maintaining abstinence or as a gateway to relapse.
The approach to establishing safety has included demands for accurate information on e-cigarette contents and basic ingredients, which was initially very limited but is now increasing thanks to labelling by makers and analysis by independent scientists.
However, the wide range of available devices (some estimates exceed 500 variants) reduces confidence that the contents are reliably known. For the purpose of this article, only nicotine containing devices are relevant to this discussion.
Within these products, the main constituents are reported to be nicotine, propylene glycol, glycerine and flavours which of course when vaporized are released as particles of varying sizes which have not been well characterized. Particle size may be a consideration in itself, distinct from the actual composition of the particles. All of these substances have toxicity and when vaporized are inhaled into the lungs and released into the atmosphere.
The relevance of animal studies showing potential toxicity from e-cigarettes are uncertain but to date, they are thought to be low.6 At least two human-based studies show acute but mild toxicity on lung function: one demonstrates an increase in airway resistance with active e-cigarette usage7 and one indicates a decrease in FEV1/FVC ratio, but only in passive exposure to e-cigarettes.8 It is too soon to be confident about long-term toxicity. A knowledge of the constituents indicates that the effects may not be severe, with one estimate suggesting that in comparative terms it may be as little as 5% that due to cigarette smoking.9 However, this estimate is based on a modelling study where the inputs for the effects of e-cigarettes are reported to be largely unknown for these relatively new devices.
The possible long-term effects on tobacco control are also largely unknown. Prevalence studies referred to earlier suggest that adolescences and young adults are using e-cigarettes in increasing numbers.10 Most studies find that young people who use e-cigarettes also use tobacco products, though there are instances where young people try e-cigarettes without having tried tobacco.11 The possible gateway effect to cigarette smoking is not resolved. Studies conducted in the UK have not shown a link to date but research from the USA is starting to indicate that e-cigarettes may serve as a gateway in some circumstances. 12, 13
The effects that e-cigarette use may have on smokefree laws are no less complex. Many purport that the vapour released from e-cigarettes is harmless and therefore should not be banned in indoor/public places. However, the possibility that the vapour may be confused with smoke has led some authorities to ban ‘vaping’ where smoking is banned with the aim of ensuring continued support for Article 8 of the WHO FCTC and avoiding the confusion that e-cigarette use in public may affect attitudes and implementation of smokefree laws. Countries contemplating policies towards the tobacco ‘endgame’ (e.g. Ireland, Finland, Scotland, New Zealand and Singapore) are also grappling with the policy implications that e-cigarettes may have on smokefree legislation.14
Perhaps the greatest challenge that e-cigarettes may pose for tobacco control would be the actions and reactions of the tobacco industry. With the e-cigarette market, we see a revival of the difficulties that marketing, advertising, sponsorship and promotion of cigarettes posed for tobacco control and that were subsequently reflected in WHO FCTC Article 13. Perhaps even more concerning is the threat posed by the consequences of ownership of a large and seemingly increasing proportion of the e-cigarette industry by the tobacco industry, which directly challenges implementation of WHO Article 5.3, requiring governments to refuse the tobacco industry access to policy formation in public health and is regarded among the most important of tobacco control measures. It seems possible that the proposed provisions of the Transatlantic Trade and Investment Partnership (TTIP) may also be used to threaten TC. In the European Union, multinational corporations may try to use TTIP to challenge the EU Tobacco Products Directive regulations on e-cigarettes, further muddling the already unclear circumstances surrounding the right of Member States to legislate for public health of their citizens.
Data to support or refute these growing hopes for, or concerns regarding, e-cigarettes are yet not available and will likely not become available during this rapidly evolving situation.
History, however, suggests caution. Both in Europe and the USA, efforts by scientists to collaborate with the tobacco industry in the 1950s, 1960s and 1970s to find safer nicotine delivery devices had the net effect of only delaying the inevitable conclusion that the tobacco industry’s aims are incompatible with public health.15, 16 Will history repeat itself with this new, sophisticated, less toxic device or will public health learn the lessons from history and reject the extravagant hopes placed in a technology which, at its most benign can be seen as another nicotine replacement therapy with unpredictable prospects of success?
Funding
The authors, Prof Luke Clancy and Dr Kate Babineau are employed and funded by Tobacco Free Research Institute Ireland (TFRI), Dublin.
Conflict of interest: None declared.
References
1. TNS Opinion & Social. Special Eurobarometer 429. Attitudes of Europeans towards tobacco and electronic cigarettes. 2015 [Online]. http://www.thehealthwell.info/node/870442.
2. Conference of the parties to the WHO Framework Convention on Tobacco Control. Electronic nicotine delivery systems, including electronic cigarettes, Moscow. http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_Report-en.pdf (13–18 October 2012, date last accessed).
3. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382:1629–37.
4. Caponnetto P, Campgna D, Cibella F, Morjaria JB, Caruso M, Russo C, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One 2013; 8: e66317.
5. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 2014; 109: 1531–40.
6. Hajek P. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014; 109: 1801–10.
7. Chorti M, Poulianti K, Jamurtas A, et al. Effects of active and passive electronic and tobacco cigarette smoking on lung function. Abstracts/Toxicol Lett 2012; 21: 64.
8. Vansickel AR, Cobb CO, Weaver MF. A clinical laboratory model for evaluating the acute effects of electronic cigarettes: nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomark 2010; 19: 1945–53.
9. Grana R, Benowitz N, Glantz SAE-. cigarettes a scientific review. Circulation 2014; 129: 1972–86.
10.Cooper M, Case KR, Loukas A. Ecigarette use among Texas youth: results from the 2014 Texas Youth Tobacco Survey. Addict Behav 2015; 50:173–7.
11.Babineau K, Taylor K, Clancy L. Electronic cigarette use among Irish youth: a cross sectional study of prevalence and associated factors. PloS One 2015; 10: e0126419.
12.Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study. JAMA Pediatr 2014; 168: 610–7.
13.ASH. Electronic cigarettes (also known as vapourisers). A Briefing. 2014. http://www.ash.org.uk/files/documents/ASH_715.pdf
14.Beaglehole R, Bonita R, Yach D, Mackay J, Reddy KS. A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040. Lancet 2015; 385: 1011–8.
15.Berridge V. Marketing Health. Smoking and the discourse of public health in Britain, 1945-2000. Oxford University Press, Oxford, 2007.
16.Parascandola M. Lessons from the history of tobacco harm reduction: the National Cancer Institute’s Smoking and Health Program and the “less hazardous cigarette”. Nicotine Tob Res 2005; 7: 779–89.