Orange Barn Door

Guest Post: Finding a Way for Healthier Generations

Recently in JAMA, Bill Dietz and colleagues outline a three-part recommendation to address the long-term consequences of preventable chronic health conditions. They focus, rightly, on smoking and tobacco, physical activity, and nutrition as components of the two leading causes of preventable suffering and premature death. These are important recommendations for healthier generations.

We see strengths in their recommendations but also some substantial limitations. The limitations include an almost exclusive focus on youth that ignores adults who are currently bearing the unnecessary burdens of suffering and early deaths.

On tobacco, Dietz et al promote a promising policy intervention – increasing the minimum purchase age for tobacco. But their entire posture on dealing with “tobacco” is to treat all tobacco and nicotine products as if they present the same risks to health. In fact, in their closing summary bullet points, they go further and highlight the need to reduce the harms from “nicotine products” and “nicotine addiction.”

The harms from tobacco come from the inhalation of smoke. The Surgeon General was clear on that point in 2014. The UK Royal College of Physicians declared in April 2016: “Provision of the nicotine that smokers are addicted to without the harmful components of tobacco smoke can prevent most of the harm from smoking.”

The UK Centre for Tobacco and Alcohol Studies put forward an important, fundamental point in a recent rebuttal to a WHO position paper on vaping. Public health leaders should view products that deliver nicotine without smoke much more as opportunities to reduce the disease burden than as a threat to the status quo in tobacco control policy.

As examples of that kind of thinking, experts have called for pursuit of differential minimum purchase ages across nicotine products as well as differential taxation according to different risks. These ideas would strengthen the recommendations by Dietz et al.

On physical activity and nutrition, the recommendations in JAMA focus exclusively on programs to prevent obesity, and such steps are critical to minimize the health and fiscal impact of obesity in the latter half of this century. But the authors offer absolutely no guidance that would help adults who currently have obesity. Obesity moves in families.

We are certain that it is not that the authors do not want better health and well-being for these adults. But we are flummoxed as to why they embrace no ideas that could help. Evidence-based approaches to improve health now are abundant. The Diabetes Prevention Program is an obvious example.

We know that patience is a virtue, but when it comes to improving health and well-being, count us among the very impatient!

Click here for the paper by Dietz et al. Click here for more on tobacco harm reduction from the Royal College of Physicians, here for more from the UK Centre for Tobacco and Alcohol Studies, and here for more from WHO.

Today’s post comes from our friend Joe Gitchell, who has devoted his career to behavioral health and especially nicotine and tobacco policy.  By way of disclosures, he tells us:

My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and digital vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to GlaxoSmithKline Consumer Healthcare on smoking cessation and NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication an option for which has been sold to Niconovum USA.

Orange Barn Door, photograph © WineCountry Media / flickr

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November 9, 2016

4 Responses to “Guest Post: Finding a Way for Healthier Generations”

  1. November 09, 2016 at 10:57 pm, John Shierholz, M.D. said:

    I am concerned that Mr. Gitchell’s position as a consultant for RJ Reynolds Vapor Company and his financial interest in a nicotine medication leads him to minimize the well-documented increasing use of vaping products by our youth. While vaping may be less toxic than inhaled tobacco smoke, the nicotine in vaping products is addictive. We need laws that help us decrease the use of vaping products by our youth.

    • November 10, 2016 at 3:03 am, Ted said:

      Thanks for taking the time to read and comment, John. I am concerned that bias against harm reduction will lead to more people harmed by tobacco smoke.

  2. November 11, 2016 at 3:57 pm, Joe Gitchell said:

    Dr. Shierholz – thank you for raising two thorny and relevant issues: 1) the impact of my financial interests on my judgment, and 2) how to contextualize youth use of nicotine products?

    On #1, you should be concerned. I am concerned, too. Factors such as earning a living and status definitely bear on judgment. Please continue to be skeptical. I appreciate your willingness to engage on the issues, allowing my disclosures to be part of the beginning of the discussion, not the end of our interactions. I would encourage you to read this article for more context on the issues of conflict of interest:

    On #2, I would invite you to complete the thought-experiment survey available at this link: Clive sets up a number of challenging trade-offs that do not have “right” answers but certainly stimulate consideration.

    If you would like to set up a time to discuss more of these issues directly, I would be happy to do so.

    Take care,

  3. November 12, 2016 at 11:21 am, Allen Browne said:

    Treating obesity in adults can have long reaching results.
    Women with obesity cause epigenetic changes in their children prior to birth. Epigenetic changes in utero have been demonstrated in the case of ACE’s to last 2-3 further generations. A chance for generations of improvement by treating adults with obesity. It seems like a good investment.