Correspondence
Nicotine Addiction in Young People
N Engl J Med 1995; 333:1225-1226November 2, 1995
- Article
To the Editor:
Dr. Kessler (July 20 issue)1 correctly identifies the obvious problem of increasing nicotine addiction among adolescents but fails to recognize the sociopolitical condition that has created this circumstance and likewise misses the opportunity to champion the measures that might effect a genuine solution.
He proposes to “convince” young people of the hazards of nicotine abuse but says little about convincing legislators that they should enact stricter, enforceable regulations governing the marketing and sale of tobacco products. I suspect Dr. Kessler understands that the tobacco industry has a substantial voting bloc in Congress and accepts the futility of instituting change in this way.
Keeping children away from cigarettes, as Dr. Kessler suggests, is a posture of passivity. This approach represents a simplistic and ineffectual treatment for a social disease that requires aggressive intervention, a “solution” as unrealistic as attempting to eradicate the battered-child syndrome simply by convincing children to avoid abusive adults. The responsibility for choosing to use nicotine, a deadly product, cannot be left to the adolescent. Definitive government intervention is the only realistic means to control this epidemic.
Unfortunately, there is no moral imperative on the part of those who could solve this national health problem. The bottom line is economics. The author asserts that the removal of cigarettes from the marketplace will lead to “serious adverse effects on those addicted.” This is not a compelling argument to justify the continued production and distribution of products known to be carcinogenic. The real reason cigarette sales will continue is that the tobacco industry is a multibillion-dollar conglomerate that supports the economies of a number of states, generates substantial tax revenue for the country, and sustains the political lives of many influential members of Congress. Even President Clinton, as recently as July 26, 1995, considered changing his support of the proposal by the Food and Drug Administration (FDA) to have nicotine reclassified as a drug in exchange for concessions by the tobacco industry related to their marketing practices.2 Is this not pandering at the highest level? Objectively, nicotine is an abusable and addictive substance.3 Yet those in our government, who ostensibly function in the best interest of the people and are the only force capable of curtailing the distribution of this poison, possess neither the motivation nor the strength of character to stand up against big business, irrespective of the long-term consequences.
As advocates for children, the medical establishment cannot make deals. Although I agree with Dr. Kessler's basic intention, I must propose a more radical stance. Cigarettes kill people. When used as intended, nicotine produces dependence and ultimately results in disease and death.4 Compensatory legislation will have no effect. Real progress will occur only when we enact laws that treat the marketing of tobacco products to young people as the felony of child abuse.
4 ReferencesRobert F. Perry, M.D.
PeeDee Clinic, Wilmington, NC 284031
Kessler DA . Nicotine addiction in young people. N Engl J Med 1995;333:186-189
Full Text | Web of Science | Medline2
CNN/Headline News. July 26, 1995.
3
Slade J ,Bero LA ,Hanauer P ,Barnes DE ,Glantz SA . Nicotine and addiction: the Brown and Williamson documents. JAMA 1995;274:225-233
CrossRef | Web of Science | Medline4
Cotran RS, Robbins SL, Kumar V, eds. Robbins' pathologic basis of disease. 4th ed. Philadelphia: W.B. Saunders, 1989.
To the Editor:
Dr. Kessler may be heartened to learn that he is not the first government official to have to deal with the addictiveness of tobacco and its subsequent health effects. King James I of England, in his A Counterblast to Tobacco, 1 stated in the early 1600s:
Many in this kingdom have had such a continual use of taking this unsavory smoke, as now they are not able to forbear the same, no more than a long drunkard can be long sober. . . .
. . . [I]s it not both great vanity and uncleanliness, that at the table . . . men should . . . sit . . . making the filthy smoke and stink thereof . . . when very often men that abhor it are at their repast?
Surely smoke becomes a kitchen far better than a dining chamber, and yet it makes a kitchen also oftentimes in the inward parts of men, soiling and infecting them with an unctuous and oily kind of soot, as hath been found in some great tobacco takers that after their death were opened. . . .
. . . It is a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless.1 ReferencesClifford B. Saper, M.D., Ph.D.
Beth Israel Hospital, Boston, MA 02215Author/Editor Response
Dr. Kessler replies:
To the Editor: I agree with Dr. Perry that nicotine addiction among young people is a very serious problem requiring meaningful public health measures that go beyond simply “keeping children away” from cigarettes. Since most adults begin smoking as teenagers, preventing children from smoking is the best public policy. On August 10, 1995, the FDA proposed a variety of restrictions on access to tobacco products by young people, as well as several measures affecting tobacco advertising, marketing, and promotion that can, over time, reduce the tremendous appeal and allure of these products for young people. Any regulations, once final, will have the force of law.
As Dr. Saper illustrates with his quotation from King James I, tobacco use has been a serious problem for many generations. I believe that realistic, reasonable, and meaningful policies can prevent future generations from becoming addicted to cigarettes and smokeless-tobacco products.
David A. Kessler, M.D.
Food and Drug Administration, Rockville, MD 20857
