Reasonable people saying sensible things about low-risk alternatives to smoking (update)

Nicotine molecule
Warning: nicotine may induce authoritarian urges, warped judgements and loss of purpose

Updated 24 July 2013. Smokeless tobacco products, e-cigarettes and novel nicotine products have astonishing potential to reduce the expected one billion premature deaths from tobacco in the 21st Century.   Yet some health organisations are spreading misinformation, stoking up unwarranted fears and pretending there is much more risk and uncertainty than there really is.  So to provide some balance here is a collection of on-the-record quotes from researchers, experts and others who have grasped the important and disruptive significance of these developments. Enjoy!  

Professor Michael Russell anticipated this as early as 1991. The late great Mike Russell, then of the Imperial Cancer Research Fund, Health Behaviour Unit at the Institute for Psychiatry was one of the pioneers of insights into nicotine addiction and behaviour. He wrote the following in the British Journal of Addiction.

It is argued here that it is not so much the efficacy of new nicotine delivery systems as temporary aids to cessation, but their potential as long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic future target. Their relative safety compared with tobacco is discussed. A case is advanced for selected nicotine replacement products to be made as palatable and acceptable as possible and actively promoted on the open market to enable them to compete with tobacco products. They will also need health authority endorsement, tax advantages and support from the anti-smoking movement if tobacco use is to be gradually phased out altogether.

By and large it is the impurities in tobacco and its smoke which kill, while nicotine provides most of the pleasure, stimulation, and relief from stress. Conventional tobacco products will in future be regarded as archaic as the use of unrefined alkaloids in folk medicine appears now in comparison with the modem products of the pharmaceutical industry.

Note the important distinction he draws between an alternative to smoking and a temporary cessation aid…  Professional Russell also drew a critical distinction about underlying purpose – not moral objection to drug consumption, but the pragmatic purpose of reducing harm:

It will be assumed throughout that our main concern is to reduce tobacco-related diseases and that moral objections to the recreational and even addictive use of a drug can be discounted provided it is not physically, psychologically or socially harmful to the user or to others.

The idea of disruptive change to the cigarette industry is not just an idle public health fantasy… Bonnie Herzog of Wells Fargo Securities, one of the top US tobacco investment analysts, believes we are entering an era of radical change and innovation that may see consumption of e-cigs surpass cigarettes in 10 years. Quoted in Time magazine, Can Electronic Cigarettes Challenge Big Tobacco? (8 January 2013):

Consumption of e-cigs may overtake traditional cigarettes in the next decade … and they’ll only evolve and improve as time goes forward — at far less risk. The technology portion of it is sort of like Apple. This is just Version 1.

Professor John Britton, Chair Tobacco Advisory Group Royal College of Physicians, reported by the BBC on 11 February 2013

“Nicotine itself is not a particularly hazardous drug,” says Professor John Britton, who leads the tobacco advisory group for the Royal College of Physicians. “It’s something on a par with the effects you get from caffeine.

“If all the smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes we would save 5 million deaths in people who are alive today. It’s a massive potential public health prize.”

Dr David Halpern, Head of the Prime Minister’s Behavioural Insights Team (“The Nudge Unit”), reported in the Daily Telegraph 11 February 2013.

Then there are, as Halpern puts it, the “quirky” subjects. Smokeless cigarettes, for example. While many countries, unsure about their health risks, have moved to ban them, Halpern’s team thinks that’s a mistake. It’s far better, they argue, to ask smokers to adopt a similar behaviour that, while possibly not risk-free, is less dangerous than smoking proper, than to ask them to quit completely.

“If you give someone a decent alternative, it’s a lot easier,” says Halpern. “There are 10 or 12 million smokers in Britain, of which roughly half die from their habit. So even with a 20 per cent substitution, you’re talking about a million lives.”

The No 10 Behavioural Insights team had already endorsed the idea.  In its 2010-11 Annual Update discussed opportunities to reduce the burden of tobacco related disease:

exploring new products for people addicted to nicotine – products that deliver nicotine quickly in a fine vapour instead of as harmful smoke could prove an effective substitute for ‘conventional smoking’. It will be important to get the regulatory framework for these products right, to encourage new products, which smokers can use as safer nicotine alternatives, to be made available in the UK. A tenet of behaviour change is that it is much easier to substitute a similar behaviour than to extinguish an entrenched habit (an example was the rapid switch from leaded to unleaded fuel). If more alternative and safe nicotine products can be developed which are attractive enough to substitute people away from traditional cigarettes, they could have the potential to save tens of thousands of lives a year;

Professor Jean-François Etter, Head of the tobacco group at Institute of Social and Preventative Medicine, University of Geneva, and author of The electronic cigarette: an alternative to tobacco (January 2013 edition), in which he says:

The risk-averse regulation of nicotine causes thousands of deaths annually, because it artificially strengthens the position of tobacco, blocks safer products and innovations, obstructs the marketing of nicotine medications, builds high barriers of entry in the nicotine market, and otherwise distorts the market economy. The current legislation benefits mainly the tobacco and pharmaceutical industries, by eliminating competitors for nicotine supply.

… and states that the proposed EU directive would “essentially kill the e-cigarette market”:

In the European Union, a proposal to change the Directive regulating tobacco product was announced in December 2012. In this proposal, cartridges that contain more than 2 mg nicotine, e-liquids that contain more than 4 mg nicotine per ml, or e-cigarettes that result in blood nicotine concentrations of more than 4 ng/ml (nanograms per milliliter, a very low level, similar to level observed in non-smokers exposed to light levels of passive smoking) will need to be approved as medicinal products. If implemented in this form, this directive would essentially kill the e-cigarette market, and therefore have seriously adverse effects on public health.

… on demands for evidence of safety and efficacy to be provided to regulators:

It has been suggested that e-cigarettes should be authorized only after all the necessary safety and effectiveness studies are published, but this will result in a de facto prohibition of e-cigarettes for many years.

In a video published 26 May 2013, Professor Etter was forthright:

It would be a mistake I think to regulate these products as medications, and if they were regulated as medications this would limit access to the product too much and cause many deaths. …

Astonishingly, the most vocal opponents of e-cigarettes are people from the public health community, who perhaps don’t understand what is at stake, and just don’t like the product because it looks too much like a cigarette.  …

If regulators could let the market evolve without regulating it too much and without regulating it unjustly… because currently people who are addicted to cigarettes are condemned to use tobacco, these laws arguably kill millions of people. They are absurd because they block every competitor to cigarette makers. So there’s a need to let competitors to enter the nicotine market so more people will switch from smoking to e-cigarettes and this will save many lives.

He was also very critical of the approach of the WHO. See Some truth about e-cigarette regulation and the ‘appalling’ F-grade presentation of the WHO for more comments and analysis.

Professor Peter Hajek, in a Letter to The Times (£ – see text) on Friday 25th January, 2013 set out the risks of excessive regulation:

Sir, Hugo Rifkind (Jan 21) feels ambivalent about using electronic cigarettes and believes that there is no information available on whether they damage health. Several studies have analysed e-cigarettes. The most dangerous toxins present in conventional cigarettes are absent altogether, and the levels of suspect chemicals e-cigarettes do contain are an order of magnitude lower. Nicotine itself is probably safer than caffeine (smokers are killed by other chemicals they inhale with the smoke).

E-cigarettes are not a very good competitor to the conventional cigarettes yet, but if left to develop, they are likely to replace them within a few years and end the tobacco epidemic. Alarmingly, there is an effort under way to stop it. The UK wants to regulate e-cigarettes as a medicinal device. Medicinal licensing is an expensive process likely to be accessible only to big tobacco and pharmaceutical companies, and it is likely to fossilise e-cigarettes in their current “not-yet-very-good” state for two reasons: any changes to the product would trigger expensive licensing renewals, and neither the tobacco nor pharmaceutical industry will have much interest in allowing e-cigarettes to push conventional cigarettes and stop-smoking medications off the market. The case for regulating e-cigarettes as a pharmaceutical product is on a par with regulating coffee. It is even more absurd given that conventional cigarettes face no such hurdle. Legislation which cripples e-cigarettes will protect the market monopoly of the deadly conventional cigarettes and represent a serious disservice to public health.

Professor Peter Hajek
Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry

Professor Robert West, professor of health psychology and director of tobacco studies, at University College London’s department of epidemiology and public health, was quoted in The Guardian 4 June 2013 E-cigarettes: health revolution or fresh pack of trouble

 “We have such a massive opportunity here. It would be a shame to let it slip away by being overly cautious. E-cigarettes are about as safe as you can get. We know about the health risks of nicotine from studies in Sweden into the use of “Snus”, a smokeless tobacco. Nicotine is not what kills you when you smoke tobacco. E-cigarettes are probably about as safe as drinking coffee. All they contain is water vapour, nicotine and propylene glycol [which is used to help vaporise the liquid nicotine].”

The one potential problem West fears is “clever marketing”. Without regulation, he could see e-cigarettes being directed at teenagers through trendy product designs and celebrity endorsement.

“This is a danger. Regulators should monitor this. Their sale should be restricted to 18-year-olds and over. However, the use of e-cigarettes by children and non-smokers is basically nil at the moment. Fear of normalisation shouldn’t stop us transforming the health of smokers.”

But West points out in a later interview (BBC, 6 July 2013), that e-cigarettes may divert young people from starting to smoke:

“If those young people are people who would have smoked but instead they’re using e-cigarettes, then that’s a huge public health gain. If they’re people who would never have smoked but they’ve taken up e-cigarettes, frankly in public health terms it’s not really an issue – it’s like drinking coffee or something, there’s no real risk associated with it.

And the interview continues:

As for the idea that e-cigarettes undo the work to de-glamorise tobacco smoking, West, who has done consultancy work for nicotine cessation medication, says the public health opportunity provided by e-cigarettes lies in their remaining trendy. “The opportunity here is for something that’s seen in a different light,” he says.

“We never got communities of people really enthusing about nicotine patches or nicotine gum. You didn’t get a sort of nicotine gum users’ group, in which they’d rave about the gum and sort of say: ‘This sort of gum’s so much better, and I make my own gum,’ and stuff like that.”

Finally pointing out that it is ‘nuts’ for countries to ban them:

Ninety per cent of e-cigarette users are also smoking, he says, indicating that the devices are being used as a quitting aid. Countries that have banned them are, in his view, “nuts”.

Professor Peter Hajek is Professor of Clinical Psychology, Head of Psychology, Director of Tobacco Dependence Research Unit at the Wolfson Institute of Preventative Medicine. On this blog he says

E-cigarettes should be left to evolve into an alternative to smoking as a consumer product. Overzealous regulation (let alone bans) will protect the market monopoly of the deadly conventional cigarettes. Public health strategists should view the growing interest in e-cigarettes among smokers as a grass-root harm reduction movement and a potential end-game of the tobacco epidemic.

Hajek’s presentation to the UK National Smoking Cessation Conference (28 June 2013) is well worth a look: here.  It gives a good sense of the limitations of smoking cessation medications.

Professor Lynn Kozlowski, Dean, School of Public Health and Health Professions, University at Buffalo, State University of New York.  His article: 9 things to think when you think about e-cigarettes, on the Huffington Post 24 June 2013 is quotable in its entirely and a terrific antidote to the dreadful dogmatic and evidence-free positions coming from official bodies like WHO.  Here are a couple of extracts:

Smokers should try e-cigs to completely replace cigarettes. Given the variety of e-cigs, one should ask around and explore Web forums and videos for advice on brands. The goal is to stop smoking forever and use e-cigs as long as needed.

E-cigs are much safer than cigarettes. We don’t need clinical trials to know that a large rock falling on a person is much more dangerous than a small rock falling on someone. Compared to cigarettes, reduced risks of e-cigs are obvious. The number and level of toxins are much lower in e-cigs. It is easy to be less dangerous than fire-causing, carcinogenic, smoke-generating cigarettes.

Safer does not mean safe. Many popular products are unsafe — bicycles, alcohol, aspirin, acetaminophen, off-label prescription drugs, and on-label prescription drugs, as examples. Consumers and regulators need information on comparative risks, not just on whether a product is safe or not safe.

Premature death and disability from cigarettes justified public efforts to reduce smoking. Personal distaste, disapproval, or disgust of smokers or vapors may spur some, but major harm to health should be the bedrock of public health efforts.

Cultural commentators have valuable perspectives on this.  Lionel Shriver, author of We Need to Talk About Kevin, writes in the The Guardian, 5 January 2013. She blends a straightforward understanding of the science with a searing attack on the motivation of prohibitionists:

If electronic cigarettes became a socially acceptable norm, lung cancer and emphysema rates would plummet. The trouble is that smokers have been demonised medically and morally: not merely bad for public health, but bad, full stop. E-cigs neatly separate the rational, research-backed concern for the health consequences of tobacco from a purely cultural revulsion for a “filthy” habit marking you as evil.

You want real evil? What’s truly evil is attempting to deny people addicted to a profoundly damaging substance the opportunity to transfer that addiction to a product most medical professionals rate as 99% harmless. The gathering European opposition to electronic cigarettes is the result of kneejerk cultural prejudice, puritanical vindictiveness, corporate collusion, and the unconscionable greed of tax authorities that won’t be able to heap the same punitive, confiscatory, opportunistic duties on a product that doesn’t hurt anyone.

David Sweanor, Adjunct Professor of Law, at the University of Ottawa draws a distinction between moral quest and pragmatic public health mission [Smokers’ Angel interview]

Some part of the opposition to nicotine products comes from the same moral absolutism that we see in other abstinence-only efforts on issues concerning such things as alcohol and sexual activity. Actually, on a very wide range of issues there is a tension between those on a moralist/absolutist quest (usually tied to ideas on the perfectibility of mankind) and those on a pragmatic public health mission. It would wrong to characterize those on a moral quest as being public health advocates, and this is true whether looking at abstinence-only campaigns on sex, on alcohol, on illicit drugs or on nicotine. Campaigns based on making better people rather than making people better are driven by moral concerns rather than public health concerns.

… and he is withering about demands that products should be ‘safe’…

Everything has risks, so simply pointing out that something is ‘not safe’ shows a person to be either ignorant or disingenuous. The key issue in looking at safety is that it is a relative concept; we need to look at safety of any activity compared to some alternative. Rather than the unattainable standard of ‘safe’ we should be thinking in terms of ‘safer’. Despite the risks associated with soccer, I would, for instance, prefer my children play soccer rather than play with live hand grenades.

… and a view from sociologists. Dr Kirsten Bell of University of British Columbia & Dr Helen Keane of the Australian National University, writing in the International Journal of Drug Policy (2012): Nicotine control: E-cigarettes, smoking and addiction [authors’ full text] on the distinction between addiction and harm – and the confusion this has caused.

E-cigarettes expose the artificial boundaries placed upon ‘good’ and ‘bad’ nicotine and their hostile reception needs to be understood in relation to this. They also challenge the equation between addiction and harm, suggesting the potential for nicotine addiction without the harms of smoking and many of its pleasures. By unabashedly foregrounding pleasure, these products contest its construction as the ‘enemy’ of public health and make explicit the moral underpinnings of contemporary notions of health, disease and addiction.

Action on Smoking and Health (London-based) has produced a reliable and honest guide in its E-cigarette Fact sheet – updated June 2013 – this from the summary:

  • Nicotine containing products (NCPs) such as e-cigarettes are evolving and there is increasing evidence to suggest that some if not all products provide effective nicotine delivery.
  • There is little real-world evidence of harm from e-cigarettes to date, especially in comparison to smoking.
  • E-cigarettes are used by both smokers and ex-smokers, but there is little evidence of use by those who have never smoked or by children
  • ASH supports regulation to ensure the safety and reliability of e-cigarettes but, in the absence of harm to bystanders, does not consider it appropriate to include e-cigarettes under smokefree regulations.

The main thing wrong with this ASH statement is its unfathomable and evidence-free support for regulating e-cigarettes as if the were medicines: the arguments for this are weak and the arguments against it are strong, not least because e-cigarettes are not medicines, and there are plenty of applicable regulations already in force that would do the job.

Deborah Arnott, Chief Executive of ASH, told The Guardian on 4 June 2013 that there is no evidence for gateway effects and usefully sets out why e-cigarettes are appealing. But curiously, she believes that smokers should try a less effective but regulated route first.  If that approach means people are less likely to switch, then the risks from ‘unregulated’ products* would need to be astonishingly high before it made sense to use a less effective product:

“There is no evidence that they get people into smoking by acting as a gateway. Behavioural psychologists tell us that substituting behaviour is easier than extinguishing behaviour. The sucking, shape, finger feel, and act of exhaling – all this helps the transition away from real cigarettes more easily than gum or patches. However, e-cigarettes aren’t regulated and we would always recommend in the first instance that smokers try licensed nicotine replacement therapies.”

*Note: e-cigarettes are not unregulated.

Professor Ann McNeil, Addictions Department, Kings College London, writing in the Royal College of Physicians publication, Fifty years since Smoking and health on the 50th anniversary of its ground breaking 1962 report (p.31):

… despite the controversy, harm reduction offers a potentially important alternative approach in tobacco control that should be explored and exploited rather than dismissed. For harm-reduction strategies to succeed and become mainstream, we need to see a radical change in policy from government and regulators, that will: encourage innovation in alternative nicotine products; regulate them permissively to guarantee purity and acceptable safety standards without stifling innovation; impose more proportionate regulation and controls on smoked tobacco products to further discourage their continued use; inform health professionals and the public about this new strategy; and monitor performance and effectiveness when in place.

Professors Ann McNeill and John Britton publish a commentary in The Lancet, 1 June 2013,  Nicotine regulation and tobacco harm reduction in the UK,  (paywall):

Most of the 10 million people in the UK, and 1 billion worldwide, who smoke tobacco do so because they are addicted to nicotine. However it is the many other constituents of tobacco smoke, rather than nicotine, that kill half of all smokers. Conventional approaches to smoking cessation have at their core the idea that stopping smoking involves stopping nicotine use, which many smokers feel unable, or unwilling, to do. Harm reduction provides an option for these smokers to substitute cigarettes, preferably completely, with a less hazardous nicotine source. Proof of concept is provided from Sweden, where snus, a form of smokeless tobacco, has provided a socially acceptable and widely available lower-risk option to cigarettes and contributed to exceptionally low smoking prevalence and lung cancer mortality

David Sweanor (University of Ottawa); Philip Alcabes City University of New York); Ernest Drucker (Columbia University) focus on the idea that it is faster and easier to reduce harm, than to reduce the use of the drug – if these things can be done independently.  Writing in an editorial in the International Journal of Drug Policy 2007: Tobacco harm reduction: how rational public policy could transform a pandemic.

We can reduce tobacco related death and disease far more rapidly than we can reasonably expect to reduce nicotine use by focusing on the fact that people smoke for the nicotine but die from the smoke. Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century.

Professor Riccardo Polosa (video), Department of Medicine, University of Catania, Italy in a highly quotable interview, June 2013 with Paul Bergen discusses the e-cigarette smoking cessation study he was part of – and much else….

E-cigs encourage smokers to spontaneously do something good for their health. An efficient, attractive, adequately priced, and widely available product has the potential of becoming a major strategic weapon for the success in the fight against tobacco worldwide.

…typically the act of smoking is also often coupled with the sense of guilt that derives from the knowledge that smoking and combustion are bad for someone’s health. A much safer product that can reproduce the experience of “smoking without smoking” is a revolutionary opportunity for smokers that now can pursue abstinence without giving up the pleasure that derives from their smoking behavior. That is why I am convinced that with the development of newer more attractive products that can replicate a personalized smoking experience will make important weapons for the success in the fight against tobacco.

Dr Konstantin Farsalinos, Onassis Cardiac Surgery Center, Greece, in a wide-ranging interview with Paul Bergen – on the imperative of having an open mind.

For some reason, several scientists do not accept harm reduction as a useful strategy. I have to respect but at the same time disagree with their opinion. Harm reduction would be useless if we could provide smokers with highly successful means of smoking cessation. However, we know that more than 4 out of 5 smokers are unable to quit with currently available medical products. What shall we do with them? We know the effects of smokeless tobacco in harm reduction; Sweden has the lowest rate of lung cancer in males, mostly due to the use of snus instead of regular cigarettes by that population. Now we see a new product in tobacco harm reduction, the only one that does not contain tobacco and the only one that deals with both the behavioral and chemical addiction to cigarettes. We have to study it.

Farsalinos was decisive in his critique of a bizarre WHO claim that e-cigarettes are more dangerous than smoking because they are ‘unfiltered’: WHO discredits e-cigarette by suggesting that tobacco cigarettes are safer because they have a filter (5 July 2013).  The whole article is quotable, but he draws a wider lesson for those interpreting data and giving advice:

We are reaching a point where several e-cigarette consumers are discouraged from using them. There is a high chance that these people will relapse to smoking (some have already done that). Someone may be held responsible for the adverse effects on their health in the future. Scientists should remember that they have the ethical and legal responsibility to inform the society about the truth and the scientific data available. This should be done without misinterpreting the results and without introducing personal ideology or preference in order to distort the truth.

Professor Martin Jarvis of University College London, and a leading international authority on nicotine psycho-pharmacology, says of snus [Feb 2013 here]:

“The evidence of a pronounced health benefit from oral tobacco is very strong and can no longer be ignored. The consumption of nicotine through snus in Sweden has greatly reduced smoking, and that in turn has caused a significant reduction in the cancer, cardiovascular disease and lung damage caused by smoking. It makes no sense scientifically or ethically to deny access to this much less dangerous alternative to cigarettes to smokers elsewhere in Europe.

Dr. Karl Erik Lund is an Oslo-based expert on tobacco and public health. He notes that similar effects are appearing in Norway [Feb 2013 here]:

“Northern Europeans have a greater tradition and culture of using smokeless products and oral snus, and compared to other countries health has benefited as a result.  In Norway we are having a similar experience to Sweden, with smoking rates now around 16 percent, mainly due to oral tobacco use.  There is no reason to ban snus in countries that want it in Northern Europe,  just because other countries in the European Union don’t realise or don’t want the benefits?

Professor Karl Fagerström is an internationally renowned Swedish expert in nicotine and one of the pioneers of nicotine replacement therapy (NRT). He points out:

“Snus has proved more successful at helping people to quit smoking than NRT in Sweden because it meets the smoker’s need for a strong nicotine ‘hit’ in a way that is a more effective substitute for smoking.  It is no good just hoping everyone will quit completely – just look at the rest of Europe, where average smoking rates are twice as high as Sweden. If we can meet the need for nicotine with products that create much lower risks, then we will see great improvements in health. This could be smokeless tobacco, or it could be new devices like e-cigarettes, but we have to have a harm-reduction approach to nicotine as well.

Dr Lars Ramström, Institute for Tobacco Studies, Stockholm, Sweden points out that oral tobacco has been a very successful aid to quitting smoking in Sweden. Writing in the journal Addiction in 2011, he says:

Quitting smoking by taking up snus use can result either in quitting all tobacco use or in moving from high-risk to low-risk tobacco use. Even in the latter case, the risk reduction is so large that the benefit cannot be offset by any reasonably conceivable reduction of the rate of quitting all tobacco use. This is illustrated by a study suggesting that, for example, male 40-year-old smokers who switch to snus will be expected to save 4.3 years of life that would have been lost by continued smoking, almost as much as 4.5 years if quitting all tobacco use.

Professor Michael Kunze is an eminent physician at the Medical University of Vienna. Dr Kunze commented [Feb 2013 here] and takes the view of the patient trying to deal with entrenched addiction:

“I see many patients in their 30s and beyond whose lives are at grave risk from smoking, whose health is deteriorating, and who are miserable about their smoking. It is too easy just to tell them to quit, because many are simply unable or unwilling to give up the nicotine.  Doctors need to be able to discuss new approaches and put the health of the patient before everything else. That means talking honestly about smokeless tobacco or e-cigarettes as an option.  Banning much safer tobacco products helps no-one who is at risk from cigarettes.

Dr Jacques Le Houezec is managing editor of an authoritative source on the treatment of tobacco dependence. He says it is unethical to ban a safer alternative to cigarettes [Feb 2013 here].

“Everyone involved needs to think more carefully about the ethics of denying an addicted smoker access to a smokeless tobacco product that is far less harmful than cigarettes. We know there is strong evidence of substantial health benefits for individuals and at population level from the Sweden experience and also no signs of significant gateway effects – if it is a gateway, it is an exit from smoking, not an entrance.  There are no precedents for allowing a dangerous product like cigarettes on the market, whilst banning much safer alternatives, and as Europeans we should not just do this.

Dr Nigel Gray, one of the world’s most experienced tobacco control experts, from his keynote presentation at the Society for Research on Nicotine and Tobacco, 14th March 2013 notes that when a tobacco company does the right thing, it is punished by regulators… (with apologies to Greece, but not to economists).

One tobacco company–Swedish Match –  took the evidence seriously and abandoned the cigarette market in favour of low nitrosamine snus, for which they established a standard. For their pains snus was banned from the European Union by a  bizarre bureaucratic decision presumably made in a in Brussels basement by a committee of Greek economists, despite the efforts of a significant group of scientists who attempted to enlighten them.

Scott Ballin, Director of the Alliance for Health Economic and Agriculture Development (AHEAD) reminds us that the idea of eliminating tobacco is a seductive illusion.

It is (especially in the developing world) shortsighted to think that we can wave a magic wand and ‘tobacco’ will disappear off the face of the earth. I also like to remind people that its not the tobacco or nicotine that causes the most significant harm to society but rather how that tobacco is grown, cured, processed, manufactured, and used that determines the risks and relative risks. Burn something and inhale it into the lungs and one can expect serious damage. Take it in a non-combustible form (whether it is tobacco based or nicotine based) and the risks are significantly reduced.

Dr Gilbert Ross MD is the Executive Director and Medical Director of the American Council on Science and Health (ACSH), a consumer education-public health organisation, says in a Marmot’s Hole op-ed on 12 November 2012:

…misguided or agenda-driven government officials and public health experts worldwide are condemning the best hope for mitigating its damage  — electronic cigarettes and certain low-risk tobacco products that have the potential to reduce the risk caused by smoking.

[…] Prohibiting the safest form of nicotine delivery will increase, not stem, the tsunami of cigarette-related death. Truly informing smokers about reduced-risk nicotine products, such as e-cigarettes and smokeless tobacco, and increasing access to these products is the best way we have to save millions of lives.

Professor Jonathan Foulds, Professor of Public Health Sciences & Psychiatry, Penn State University, College of Medicine – on this blog (November 2012)

Around a billion people are addicted to nicotine in deadly cigarettes and many have no immediate plans to quit. Young people will also continue to try dangerous and addictive products. We believe it is preferable that, if people become addicted to cigarettes or decide to try tobacco, they can use a product that is markedly less harmful than cigarettes. […] We should not delay in allowing snus to compete with cigarettes for market share, and we should be prepared to accurately inform smokers about the relative risks of cigarettes, snus, electronic cigarettes, and approved smoking-cessation medications. In light of all the available evidence, the banning or exaggerated opposition to snus and e-cigs in cigarette-rife environments is not sound public-health policy.

Professor Ron Borland is Nigel Gray Distinguished Fellow in Cancer Prevention at Cancer Council Victoria (since 2004). Also a Professorial Fellow in both the School of Population Health and Department of Information Systems at the University of Melbourne. He commented on this blog:

I have come to the conclusion, that even in the most successful countries, that we will not effectively end the epidemic of tobacco-related harm within the next generation just using the range of strategies currently being used.

I believe in adopting a comprehensive range of strategies, and that this must include consideration of harm reduction strategies along with those currently used. […]. The death and disability toll from cigarette smoking is far too high not to be doing all that we can.

The rise of a consumer movement, as I understand almost entirely consisting of ex-smokers, supporting the use of e-cigarettes is the first social-level evidence that there might now be substitutes for cigarettes that will be readily taken up by smokers.

Professor Michael Siegel, Department of Community Health Sciences, Boston University School of Public Health [Smokers Angel interview].

I don’t believe there is a conspiracy against the electronic cigarette. I just think there is a lot of ideologically-driven, dogmatic thinking in the tobacco control movement, and that rigid thinking can get in the way of sound public policy. We’ve seen this happen in other areas of public health. Now, the abstinence-only approach seems to be getting in the way of sound policy in tobacco control.

Also, Siegel’s blog is a quote-mine. And Carl Phillips’ blog too.  Oh, and Brad Rodu’s Tobacco Truth.

Chris Davies MEP – a UK European politician – in an excellent exercise in democracy actually asked the people he represents (whatever next?!). Here’s the consultation response with many excellent informed views from constituents.  Davies and his colleague Rebecca Taylor MEP wrote to the UK medicine’s regulator, the MHRA (letter June 2013):

We believe that insisting that electronic cigarettes should be classified as a medicinal product makes no sense, unless conventional cigarettes are also required to be registered in the same way. The truth is that users of e-cigarettes are not ill and do not consider themselves to be, so they do not require a medicinal product. If our objective is to save tens of thousands of people from tobacco related deaths each year, then persuading smokers to switch to electronic cigarettes, at least as a first step, must be better than letting tobacco kill them.

Peter HajekJonathan FouldsJacques Le Houezec David Sweanor & Derek Yach writing in The Lancet: Should e-cigarettes be regulated as a medicinal device? July 2013

In conclusion, since electronic cigarettes are a recreational consumer product that are competing with much more dangerous cigarettes, which are not regulated as medicines, mandatory medicinal regulation is not required for public safety and can harm public health by restricting the ability of electronic cigarettes to compete with cigarettes in the marketplace. Excessive regulation of electronic cigarettes would protect the market monopoly of cigarettes and have the potential consequences of disease in and death of millions of smokers who were prevented from moving on to the next generation of electronic cigarettes. For the first time in the history of the tobacco control movement, a realistic possibility is emerging that the tobacco problem might get resolved, and that this could happen with minimal or no government involvement or expenditure. Regulators of medicines should hold their fire.

I’ll finish by abusing editor’s privilege and post one or two from me… Clive Bates, former Director of Action on Smoking and Health (London-based) from 1997-2003 (note: not necessarily the views of ASH today):

“The main effect of banning snus or over-regulating e-cigarettes is to prop up the cigarette market in Europe.  It’s easy and trivial for politicians and bureaucrats to look tough by banning something, but the effect of banning snus and heavy-handed regulation of e-cigarettes will be more cigarettes sales, more smoking, and more death and disease.

The following from an interview with me on ‘the ashtray blog’:

On harm reduction:

The idea of ‘harm reduction’ is always controversial – whether it is needle exchanges for intravenous drug users, contraception for teenagers, or even cycle helmets. There are people who think that promoting anything other than quitting smoking completely is somehow an unacceptable compromise. But this takes no account of real human behaviour and that fact that what matters is what people actually do, not what you want them to do.

On the attitude of some health groups:

I’m incredibly frustrated by some of the health groups. They’ve taken a cavalier attitude to the evidence and ethics of harm reduction, and seem to show no empathy or concern for the people they are supposedly trying to help. It is as if they value their anti-tobacco industry credentials more than doing something about cancer, lung and heart disease. If you swear a fight to the death with Big Tobacco, you will be treated kindly by politicians, the media, funders and the public. But if you care about health, and I mean really care, there are some tougher choices and trade-offs to make about reducing the harm caused by tobacco.

It is hugely frustrating to see so many people whose job is supposedly to protect health going to work and doing exactly the opposite. Prohibitionist rhetoric and practice has never served society well in practice.

On whether one product better than others?

I think the same arguments apply to e-cigarettes, vapour devices, NRT, non-combustible tobacco. They are all vastly less hazardous as a way of consuming nicotine and, unlike smoking, have negligible risks or risks that are not out of line with other lifestyle risks we routinely accept. Which do I prefer? Whichever works for each smoker.

My concern is not whether these alternatives are dangerous – they aren’t. My concern is whether they can quickly gain market share from cigarettes. The challenge from a health point of view is to get as many smokers, especially those over 40 years old and looking like they may be smoking for life, to switch. So I think we need a broad range of alternatives available to suit individual tastes and motivations.

On the perils of excessive regulation:

This is an area where market forces could drive strong pro-health innovation as makers of these products seek to win market share from smoking. There will be an instinct to regulate, and in doing so to be excessively restrictive – but we must be so careful. Too much caution or excessive regulation of these alternatives would throttle the market and would in effect amount to protective regulation for the cigarette market. So my message to those health interests who want very strict regulation of new nicotine products is: “beware what you wish for, because if you get what you want, you will be doing the dirty work of the cigarette vendors for them”.

On truth and the importance of social media:

I am still optimistic. The truth is the truth, and it will out. Social media make a powerful vector for the truth, challenging the handed-down wisdom of these authorities whilst sharing knowledge and building confidence of smokers below the radar of most health professionals.

Over to you…  can you sum it up in a smart savvy plain English quote or two…? Have a go in the comments…

30 thoughts on “Reasonable people saying sensible things about low-risk alternatives to smoking (update)”

  1. So why did ASH UK want ecigs taken off the market after a year (2010 consultation) and why did Deborah Arnott attack ecigs on the grounds they are made in China? Watch this video from 17.45 to the end and then decide whether you think ASH’s idea of regulation will make ecig use more expensive and less enjoyable; or even exist in its current form. These people managed to get an smoking ban in all non-residential buildings by lying. I don’t trust them an inch.

  2. Jonathan, what you say is true. However people and even organisations can change, and perhaps it is better to look at what they are doing today rather than dwelling on the past. Although we understood the issues clearly at least three years ago, this is not true for many others; and they deserve praise for changing their opinion as a result of clear evidence that this was advisable. It takes a lot to do a public U-turn, and personally I think praise is the better approach. Things are changing very rapidly in terms of recognition of the role THR can play; two years is a long time.

    The next step is to advance the fact that no additional regulation is required, certainly in the UK. There is no problem to fix, therefore no regulation is needed. Too many medics still appear to think that the best approach to consumer products is to hit them with a ton of regulation; but the best way of fixing the smoking mortality issue is simply market self-control of e-cigarettes, since there are demonstrably no health problems to resolve. The market will remove useless products and promote good ones. The market removes risky products and promotes better ones. In the case of a product with no recorded issues, and here, in an environment where consumer product regulation is more strongly enforced than probably anywhere else, this is all that is required.

    It is also worth pointing out that the consumer alert system that the ecig community has in place is demonstrably far more efficient than the pharmaceutical regulatory system, in terms of removing problematic products. As an example Chantix/Champix/varenicline has killed hundreds and ruined thousands of lives: the FDA admit to 272 deaths, and they have received over 10,000 serious incident reports; ecigs have killed no one, and are the subject of 47 incident reports at the FDA, which after investigation by Prof Rodu he described essentially as inconsequential. The very idea of something that killed a single person remaining on sale in the e-cigarette market is extremely unlikely; that something as lethal and dangerous as Chantix might remain on the market is frankly preposterous. Thus, consumer protections and the community publicity machine are provably hundreds of thousands of times safer than the pharmaceutical regulatory system.

    Someone needs to make this point forcefully to those medics who are still blundering around asking for pointless and unnecessary regulations for e-cigarettes. Let them clean up their own product area first – perhaps then they might conceivably have the right to tell us what to do.

    Currently the situation is the same as a serial drunk driver who has killed half a dozen people, telling a perfectly safe driver how to drive.

    1. Some care needed and ideally a citation when quoting views of the FDA. They may have recorded a certain number of death in varenicline users, but that doesn’t mean they attribute those deaths to the product. Given people die all the time, some users would be expected to die while using the product. Their statements on varenicline are here. Having said that, there are clearly grounds for concern about cardiovascular risks and neuropsychiatric harm.

      1. Point taken.

        Two separate clinical studies show a risk for cardiac event; 1 in 28 and 1 in 30. If these are correct it means that just in 2010, just in the USA, then over 60,000 Chantix patients experienced a ‘cardiac event’ as a result of its use.

        It doesn’t seem like a GRAS or ‘acceptably safe’ product to me; but perhaps I am overly sensitive to feelings of resentment at propaganda bombardment :)

      2. The FDA’s assessment on adverse cardiovascular events is here. I can’t draw the same interpretation from this. That doesn’t of course mean you are wrong.

      3. It doesn’t seem a good principle to accept the FDA’s published views on the safety of certain medicines or e-cigarettes at face value. Their materials on e-cigarettes are clearly blatant lies (by disinformation, omission, misrepresentation, selective choice and every other trick of propaganda) if you know the facts; their position on varenicline does not seem to reflect the scale of its impact.

        As the most obviously regulatory-captured government agency in the world, believing what the FDA say on issues related to income is simply not sane.

    2. Chris, you said,

      “Jonathan, what you say is true. However people and even organisations can change, and perhaps it is better to look at what they are doing today rather than dwelling on the past. Although we understood the issues clearly at least three years ago, this is not true for many others; and they deserve praise for changing their opinion as a result of clear evidence that this was advisable. It takes a lot to do a public U-turn, and personally I think praise is the better approach. Things are changing very rapidly in terms of recognition of the role THR can play; two years is a long time.”

      It is now June 12th. Here is Arnott’s response, in the MHRA press release about regulating ecigs as medicines. So sad as it is, I was right.

      “ASH strongly supports the MHRA decision to regulate e-cigarettes and other novel nicotine products – we think this is both proportionate and necessary. Regulation will ensure that e-cigarettes meet the same standards for quality, safety and efficacy as medicines while remaining as readily available to smokers as they are today. Crucially it will also ensure marketing of e-cigarettes and other such products is controlled to prevent their promotion to children and non-smokers”

  3. Hmm… Useful quotes that point up the issues?

    Carl Phillips’ are crackers:
    “On average, three months’ continued smoking causes more harm than a lifetime’s use of a low-risk THR product.”
    [from emails with him]

    “Nicotine consumption has about the same implication for health as coffee and fries.”
    [I particularly like that one as there are different ways of interpreting it, if someone is trying to nail you to the floor – but the general message is clear enough]

    Or Brad Rodu:
    “Modern epidemiologic studies show that today’s oral tobacco products have such a low risk for oral cancer that it cannot be reliably identified.”
    [slightly paraphrased from emails with him]

    Or these, from an ecig community group sec. you may know:-
    “Sweden is the world leader in reducing smoking mortality, and is so far in advance of any other developed country that comparison is pointless; but the tobacco control industry – based in countries with a massively worse problem, by the way – is not only trying to tell them how to go about it, they are even trying to increase smoking in Sweden (by attempting to ban flavours in Snus, which are an integral part of the system).”

    “Once smoking prevalence is reduced to around one-fifth of the population in a developed country where efforts are made to reduce smoking from the typical level of 40% or higher, no further significant reduction can be made by using the methods generally used for reduction to that level; only THR is proven to work past the 20% mark.”

    “Nicotine is a natural and normal part of the diet, and in all large-scale tests to date, every subject has tested positive for it. A closely-related compound, nicotinic acid, is a vitamin (B3)*. Vitamin B3 or ‘niacin’ seems to have some effects on the metabolism in common with nicotine – the cognitive function improvement and stress reduction effects, for example. Trying to make out that nicotine is some sort of alien, dangerous or toxic chemical is going beyond the disingenuous – it is an outright lie.”
    * In some plants, nicotinic acid is a metabolyte of nicotine

    More on application :)

    1. These are good – ideally looking for words on the record that I can link to… I like the one about Sweden… Too true! The one about 20% would be disputed in California, Australia and New Zealand… though I think they have weaknesses in survey techniques.

      1. The 20% Prevalence Rule excludes AUS and NZ by its terms (they had very low smoking prevalence in the first place, 25% for AUS for example). I think they will reach their own reduction plateaus, although we don’t know where it will be for countries like this that had low smoking prevalence in the first place.

        Regarding CAL, I have no idea what rules or principles apply to areas within a country, it is not covered by the 20% rule.

  4. First I will say its good to see sensible people in the UK and US and Canada. As smokers we were aways be looked as tho we had 3 heads, the media, propaganda and ANTZ have created this.Rightfully so smoking is bad. Now as users of something alien to them, e-cigs, something that looks like a cigarette, exhaleing what looks like smoke in their minds it must be just another form of a cigarette with smoke and now that BT is on the bandwagon it makes it worse. We have to break that misconseption of the public. The health officials that are quit or die probably wont ever get on board with THR,they do have their own agenda and some get money from BD to further there agenda. In the general public everyone was told over and over nicotine is poison and bad and is part of smoking. There again opinion of nicotine needs to be changed. California still thinks it cause birth defects. Where we know there is no proof in this. BT has got to be the worse representive of THR, they are in peoples mines the devil, and whatever they say can not be trusted. To have e-cigs in the same breath with BT is a bad thing for E-cigs in the end IMHO. We have also been taught that chewing tobacco or any of the smokeless tobaccos cause cancer which we know is not true. But because the BT is behind them nobody is going to trust anything they say. We need more respected important sensible people on board talking loud and clear to change public opinon, then maybe the health organizations will open their collective eyes and see this for what it is. THR is the way of the future I believe if not lot more WILL loose their lives.

  5. I used to smoke about 40 cigarettes a day and did that for almost 30 years. I have been using e-cigs for 10 months and am feeling very much healthier and am also saving around £400 each month.
    I can’t see how the governments of this world can effectively ban e-cigs by using
    legislation and keep any credibility. I’m no scientist ( i’m a joiner ) but from what i have read most experts in this field say e-cigs are a much safer alternative to smoking tobacco
    The very fact that they are trying to legislate/ban e-cigs , in my opinion, makes them no better than murdering, drug dealing gangsters fighting to keep their profit margins up.

  6. I think it could fit to to add this:

    “We are reaching to a point where several e-cigarette consumers are discouraged from using them. There is a high chance that these people will relapse to smoking (some have already done that). Someone may be held responsible for the adverse effects on their health in the future. Scientists should remember that they have the ethical and legal responsibility to inform the society about the truth and the scientific data available. This should be done without misinterpreting the results and without introducing personal ideology or preference in order to distort the truth.”

    From my blog, commenting on WHO official’s statement about e-cigarettes and absence of a filter!
    Available at:

  7. Could I just recommend Prof Hajek’s presentation at UKNSCC (don’t be put off by the topic).It is the most wonderfully subversive review of current ‘aids’ to smoking cessation that I’ve seen

    He accurately assesses the ineffectiveness of NRT,the ‘fossilising’ role of medicines regulation,the existence of hard-to-reach ‘hard-core’ smokers and suggests that ecigs can achieve the ‘I have a dreamers’ tobacco-free world in 10 years.

    A masterpiece

  8. wow, just wow. I concur with previous comment. This is a masterpiece. The most important bits of e-cigarette related information put together in one easy to read and understand article. Pure joy. Thank you:)

  9. You won’t use this one, but here goes, anyway:

    “We have the best politicians that money can buy, and they will forcibly defend our freedom to buy cigarettes, become ill and die.”
    – Chris Price

  10. Hi Clive, first up let me say I am an avid reador of counterfactual I think it’s the best blog around on the subject of e-cigarettes and legislation about e-cigarettes there is around.

    Secondly I am presently the owner of a website selling vaping supplies online, just to declare my bias ahead of time.

    I was recently replying to a post on an internet forum about the costs to the UK Govt from smoking.

    As I understand it smoking is a net drain on the UK economy of some £4billion annually. Based upon figures from a Policy Exchange report (2010) in which they estimate the annual cost to be £13.74billion.

    The goverment takes in £9billion or so in tobacco excise revenues, the difference being £4billion and change.

    If everyone currently smoking switched to e-cigs about £3billion in costs carry over, time lost to ‘vape-breaks’ and costs of fires caused by e-cigs (some small % of batteries/chargers will cause house fires).

    The government would lose out on £9bn revenue from tobacco excise but would gain with lower costs to the NHS, increaed income tax from longer living, more productive citizens.

    Without raising a ‘sin tax’ on e-cigs the budget is about £2bn better off. Undoubtably there will be some kind of ‘sin tax’

    Apart from the overwhelming and science based case for not regulating e-cigs as medicines, isn’t there also good reason economically for the UK Government to support the new e-cig market rather than beat it out of existence with overbearing, unneeded regulation, which will in fact cost them money in the longer term?

  11. Mark, the UK gov probably clears over £20bn annually from smoking. Everywhere you look there are little income channels that add up (employment of people in retail: income tax; VAT from OTC medicines bought by smokers; etc), but the biggie is the huge savings on pensions, healthcare for the elderly, social support, and every other expense saved from the years that smokers die early. I don’t know of any reliable source for an average reduction in lifespan for all smokers on average, but for continuing smokers it’s 10 years. I’d guess that gov saves £10bn annually (it would be nice to see this worked out properly by an independent). The cost of treating sick smokers is peanuts compared to the savings they make from smokers dying early.

  12. The best way to quit msoking is by using the alternative smoking products that will help you in quiting smoking habit easily and don’t cause any bad effects.

  13. Hi Clive
    I’m just writing a note on sustainable consumption and I wanted to make reference to a most excellent note I think you wrote about the interval in time between medics saying smoking is not the most healthy of activities back in the 1950s to the eventual ban in the 2000s. I’ve just spent a hapless half hour googling various permutations of the words “Clive Bates smoking slowness of public policy change taxes advertising ban” and uncovered you’re more prolific on the topic than Stephen King is on scary stuff. Hope you and Catriona well and congrats on your canonisation (I thought she’d get that gong before you)

  14. It is always wise to read and research widely on matters to do with health not all people have good intention. For example above some of these so called “health organizations” have some ill intentions that they would want to benefit from these. Thanks its an eye opening article.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.