A remarkably self-regarding letter is published in The Times (London) today. The writers are reacting with hostility to the outstanding Royal College of Physicians report, Nicotine without smoke: tobacco harm reduction, and the very positive editorial in The Times (Vaping Vindicated) that followed its launch.
In my view, their letter is truly dreadful, but it is also very revealing. In this post, I take a look at the arguments they make.
Update 2 May: my reply published in The Times.
Here is the letter… I have added cross-references in square brackets to the original [..] to help readers navigate to my comments.
Letter – Vaping regulation
Sir, Once again, England seems out of step with medical and public health organisations in the rest of the world , and even the rest of the UK, in its calls to encourage use of e-cigarettes (“Vaping Vindicated”, leader, Apr 28). In particular, it contrasts with the call, a few days earlier, by 31 leading US health groups for the Food and Drug Administration to strengthen regulation of these products .
An earlier report from Public Health England  was heavily criticised  for, among other things, its selective use of evidence, for example by failing to cite a major review noting concerns about the safety of these products . Inexplicably, the Royal College of Physicians report ignores a recent review of 38 studies, published by The Lancet , finding that e-cigarettes are associated with a lower probability of quitting. Similarly, it suggests that “snus” (oral tobacco) has been effective in reducing smoking in Sweden, a view not supported by scientific evidence . While remaining open to the possibility that e-cigarettes may be effective as part of individually tailored smoking cessation interventions, it is premature to encourage their widespread use .Professor Martin McKee, President, European Public Health Association;
Professor Walter Ricciardi, Past President, European Public Health Association;
Dr Natasha Azzopardi Muscat, President Elect, European Public Health Association;
Professor Mike Daube, Curtin University, Perth, Australia;
Emeritus Professor Simon Chapman, University of Sydney, Australia;
Dr Martina Poetschke-Langer, German Cancer Research Center;
Professor Esteve Fernandez Munoz, University of Barcelona;
Professor Pekka Puska, former Director, National Institute for Health and Welfare, Finland
Examination of this letter
 What distinguishes the Royal College of Physicians report from the work of other “medical and public health organisations” is that the RCP has meticulously argued its case over a 200-page assessment put together by a team of experts that are from the top tier of tobacco and nicotine research. Where is the equivalent from the European Public Health Association? Come on, show your working! You can find all manner of mad, bad and dangerous statements from opinionated and over-confident doctors, health and medical organisations. What you will never find is a credible case to back what they are saying. So yes, in that sense, the RCP is “out of step”.
 This refers to an evidence-free lobbying letter signed by crypto-prohibitionist American anti-vaping groups. It does not contain a scientific assessment or even a single credible policy argument. These groups want to force a massively onerous FDA authorisation process on vaping products that was waived for thousands of cigarette products, which now have unfettered access to the market. Most informed commentators think this will just wipe out the vast majority of the vaping industry, and I suspect that is why these 31 groups want it. Quite why they want to protect the cigarette trade in this way remains a mystery. Quite why they want to regulate the e-cigarette market in a way that suits the tobacco companies e-cigarette business model is another unsolved puzzle.
 This must refer to PHE’s excellent E-cigarettes: an evidence update commissioned from genuine experts in the field, Professors Ann McNeill and Peter Hajek. No equivalent has been put together by their critics and it stands as a fine piece of work that should embarrass its equivalents in other countries.
 PHE was mainly criticised by a small cabal of anti-scientific academic activists centred around Martin McKee, who appears to me to know nothing at all about these issues and refuses to debate with those who do. You can see the complete destruction of McKee’s vacuous arguments by the brilliant Zvi Herzig here > Response to McKee and Capewell. As for other criticism, the BMJ and Lancet editors just embarrassed themselves as you can see in my ten point take-down of the BMJ’s infantile ‘investigative journalism’ here: Smears or science? The BMJ attack on Public Health England and its e-cigarettes evidence review.
 This ‘major review’ probably refers to Pisinger C, Døssing M. A systematic review of health effects of electronic cigarettes. Prev Med (Baltim) 2014;69C:248–60. This review was comprehensively flawed and any reasonable assessment would have ignored it because it didn’t really say anything. The basics of toxicology were overlooked throughout, namely that the “dose makes the poison” and that you can’t say anything meaningful about risk without quantifying exposure. After much whining because they couldn’t really find a ‘smoking gun’, the authors of this study boldly concluded: no firm conclusions can be drawn on the safety of ECs. However, they can hardly be considered harmless.
In contrast, the Royal College of Physicians has made evidence-based judgements about relative risk based on studies of toxic exposure compared to smoking, and made a carefully-expressed, cautious and proportionate statement about risk that does not claim complete safety and acknowledges uncertainty:
Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.
The importance of this type of clarity cannot be overstated – smokers and vapers need a clear steer to help them gauge the difference in risk between smoking and vaping, and so to make informed choices. In this, they have been badly let down by public health histrionics all the way through funders, agencies, universities, journals, press offices and the media. Commendably, the RCP follows PHE in trying to help the public anchor their perceptions of risk closer to reality, and to cut through the blizzard of bullshit that comes from the anti-vaping faction in public health.
 This reference draws on one of the worst pieces of work ever published in the history of science: Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med 2016. This “meta-analysis” was subject to heavy criticism from the moment of its publication, see Expert reaction to meta-analysis looking at e-cigarette use and smoking cessation. For example, Professor Robert West, Professor of Health Psychology at University College London, commented:
Publication of this study represents a major failure of the peer review system in this journal.
A pre-publication version of this meta-analysis was severely criticised in evidence to the U.S. Food and Drug Administration by experts at the Truth Initiative, which describes itself as “America’s largest non-profit public health organization dedicated to making tobacco use a thing of the past“. In the Truth Initiative submission to FDA, the examination of the methodological issues begins on page 8 and the following comment appears on page 12, referring to this meta-analysis subsequently published in The Lancet Respiratory Medicine.
While the majority of the studies we reviewed are marred by poor measurement of exposures and unmeasured confounders, many of them have been included in a meta-analysis that claims to show that smokers who use e-cigarettes are less likely to quit smoking compared to those who do not.  This meta-analysis simply lumps together the errors of inference from these correlations. As described in detail above, quantitatively synthesizing heterogeneous studies is scientifically inappropriate and the findings of such meta-analyses are therefore invalid.” (emphasis added)
This criticism is both apt and fatal, and cannot be addressed with bluster or a ‘sensitivity analysis’.
 The authors indulge in an extraordinary and utterly inexplicable denial about the snus experience in Sweden. That would be the same Sweden where the adult smoking prevalence is an outlying 11% compared to EU average of 26% as measured in the one survey that covers all the European Union. That’s the same Sweden where the only marked difference between it and other countries is snus use (see chart below and explanation here).
And as for saying this is ‘a view not supported by scientific evidence‘. Really? Again, where is their case? For real science, see for example (a small subset of the literature):
- Foulds J, Ramstrom L, Burke M, et al. Effect of smokeless tobacco (snus) on smoking and public health in Sweden — Foulds et al. 12 (4): 349 — Tob Control.: 2003 [link]
- Ramström L, Wikmans T. Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report. Tob Induc Dis 2014;12:14. [link]
- Ramström LM, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control 2006;15:210–4. [link]
- Stegmayr B, Eliasson M, Rodu B. The decline of smoking in northern Sweden. Scand J Public Health 2005;33:321–4; discussion 243. [link]
- Rodu B, Cole P. The burden of mortality from smoking: comparing Sweden with other countries in the European Union. Eur J Epidemiol 2004;19:129–31. [link]
The final citation in this list estimates “Almost 500,000 smoking-attributable deaths occur annually among men in the EU; about 200,000 would be avoided at Swedish smoking rates“.
And here’s something for the Finnish letter-writing anti-snus extremist Pekka Puska to reflect on next time he declares snus has no public health value. When the ban on snus in the EU started in 1992, it applied to Finland but not to Sweden or to Norway – creating a natural experiment. Look what happened… (see full posting by Brad Rodu: The Swedish Snus Experience Isn’t Finnished)
Oh dear, an absolutely foreseeable slowing in the rate of decline in smoking emerged in Finland compared to Sweden and Norway. That does not prove the snus ban caused the slow-down, of course. But it should be enough for Professor Puska to spend the rest of his days haunted by these trends and the possibility that his clumsy evidence-free opposition to snus has ended the lives of many of his Finnish compatriots prematurely.
This denial of the snus experience in Sweden is at an anti-vaxxer level of delusional scientific obfuscation. No one should take these letter-writers seriously on vaping or tobacco harm reduction (or perhaps anything else?) following this. Their comments on snus show they either simply don’t understand anything about it or they are unwilling to grasp what is both obvious and scientifically established beyond reasonable doubt. But why? Another mystery – perhaps because it destroys the foundations of their anti-nicotine and tobacco zealotry. A tobacco product marketed by a tobacco company does more for health in Sweden than tobacco control? That can’t be right… can it?
…open to the possibility that e-cigarettes may be effective as part of individually tailored smoking cessation interventions
Oh, thank you. No doubt, millions of vapers worldwide are breathing a sigh of relief. But alas…
…it is premature to encourage their widespread use.
I guess vapers will have to bear that with equanimity and just “vape on”…!
To control freaks everywhere: sorry, that’s not how vaping or tobacco harm reduction works. One of the best aspects of the RCP report is that it recognises this, I guess to the dismay of these writers.
For the benefit of those who are stuck in this Patient > Illness > Treatment > Cure mindset, Gerry Stimson explains it very well here: Public health should step aside. Vapers are now leading the fight against smoking.
For the benefit of any joyless and confused elders of public health, Sarah Jakes explains the importance of ‘pleasure’ in tobacco harm reduction: Vapers just wanna have fun. Enjoy!
As these writers don’t even understand how snus has worked in Sweden, it’s no surprise they are confused about vaping, which is nothing to do with them and their ‘smoking cessation interventions’. In Britain, there are 8.8m smokers and 2.2m vapers of which 850,000 are ex-smokers – another 720,000 are both ex-smokers and ex-vapers (data). This has happened without any official smoking cessation interventions, without taxpayers’ money and without any state coercion. It happened in the teeth of public health opposition (now happily reversed in the UK) and against a backdrop of misleading anti-vaping propaganda, of which this letter is just the latest miserable instalment.
While remaining open to the possibility that e-cigarettes may be effective as part of individually tailored smoking cessation interventions, it is premature to encourage their widespread use.
That has a familiar ring to it… the idea that giving a little protects your credibility. Here’s British American Tobacco discussing it confidentially in 1978 (emphasis added in red)
“we can move our position on causation to one which acknowledges the probability that smoking is harmful to a small percentage of heavy smokers . . . On balance, it is the opinion of this department that . . . we should now move to position B, namely, that we acknowledge ‘the probability that smoking is harmful to a small percentage of heavy smokers’ . . . The ideas suggested above are in some cases a radical departure from our current practice although nearly all of them have echoes in our overall policy and attitudes. The problem to date has been the severe constraint of the American legal position. This problem has made us seem to lack credibility in the eyes of the ordinary man in the street. Somehow we must regain this credibility. By giving a little we may gain a lot. By giving nothing we stand to lose everything.”
BAT Notes on group research and development conference, Sydney, 1978: Mar. (Restricted.)
I know this must be right because the source is: Francey N, Chapman S. ‘Operation Berkshire’: the international tobacco companies’ conspiracy. BMJ 2000;321:371–4. [link]
Update: The Times publishes my reply
I’m not the only one noticing these similarities it seems:
I will return to this question with an analysis of their credibility shredding position on snus. But in the meantime, here’s a clue: snus is banned in every country except one on this chart (data).
The worst letter of 2016? It’s definitely a contender
Three of writers of this letter to The Times (McKee, Chapman and Daube) won my “Worst Letter of 2014” award for a deranged letter they wrote to The Lancet, trying to mock a vaper, Lorien Jollye for having the impertinence to disagree with them based on her actual lived experience. That was a clear winner in 2014. But new one is very strong: a real contender for the 2016 award.
Has anyone else got any useful insights?
Of course, the court jester of public health thinks it’s all great and the writers are “global gurus”. Nurse!
— Simon Capewell (@SimonCapewell99) April 30, 2016