Tuesday 27 April 2010

Why do anti-smoking groups oppose tobacco harm reduction?

This morning I gave a speech at the 21st International Harm Reduction Conference in Liverpool. The topic I chose was 'Why do anti-smoking groups oppose tobacco harm reduction?' This is what I said...

For five centuries, opposition to tobacco has been founded on moral and religious objections to vice, as well as concerns over health. Under morality, we might include the claim that smoking was ungodly and sinful, that it was decadent and depraved, and that it was a habit suited only to ‘Red Indians’, Jews, blacks, Turks, Spaniards, or whichever racial group was out of favour at the time.

Under health, we could include virtually every disease in the medical textbook. Even confining ourselves to early modern Europe, we find references to deafness, blindness, hysteria, dyspepsia, impotence, infertility, paralysis and brain damage. The evidence underpinning these fears was, for the greater part of tobacco’s history, anecdotal at best, but even from the earliest days those who opposed tobacco did so on grounds that often had nothing to do with health.

From around 1700, rather by accident, the aristocracy of England and France engaged in a spontaneous experiment in tobacco harm reduction. Snuff came into fashion and smoking began to die out, amongst the upper classes at least. This should have pacified tobacco’s opponents for three reasons. Snuff did not fill the air with smoke, it did not carry the risk of starting a fire and it did not appear to be injurious to health. And yet it did not pacify them. Snuff was attacked as a vice - and an addictive vice at that - just as pipes had been. In the United States, similar moral objections were raised against chewing tobacco.

Today, the issue of health has become the dominant feature of the antitobacco movement, but the moral, and even puritanical, element is never far from the surface. In their efforts to ban smoking outdoors, Action on Smoking and Health (US) said such a ban was justified to prevent smokers from setting a bad example to others and listed smoking alongside swearing, drinking, gambling and the wearing of “scanty attire” as examples of unacceptable activities. Although smoking al fresco could not seriously be viewed as harmful to the health of others, it was still seen as sinful and offensive to the eye.

Similarly, Americans for Nonsmokers’ Rights - in a press release titled Electronic Cigarettes are NOT a safe alternative! - criticised the e-cigarette specifically because it mimics the act of smoking and because it contains nicotine. Only pharmaceutical nicotine products escape criticism, partly because they are marketed as a medicinal cure for a ‘disease’ and partly because they administer nicotine without providing pleasure. This has led to a somewhat inconsistent view of nicotine, described as being perfectly safe in pharmaceutical products but highly toxic in e-cigarettes, snus and other tobacco products. The EPA describes it as “acutely toxic (Category 1) by all routes of exposure (oral, dermal and inhalation)” while the MHRA says thats “nicotine, while addictive, is actually a very safe drug.”

Although the amount of nicotine delivered is comparable in all cases, the drug’s reputation as poison or medicine depends on how it is delivered and who is manufacturing it. Three industries are currently fighting for the nicotine market: the tobacco industry, the pharmaceutical industry and the e-cigarette industry. Each have a financial motive for denigrating alternative nicotine products. In the case of the pharmaceutical industry, this financial motive is shared by the various anti-smoking groups it directly and indirectly subsidizes.

This three-sided nicotine war is without historical precedent. Efforts to suppress alternative and/or safer tobacco products have traditionally been the preserve of the tobacco industry and the anti-smoking lobby. Initial opposition to cigarettes in the late 19th century came primarily from makers of chewing tobacco, pipe tobacco and cigars. It was from them that groups like the Anti-Cigarette League borrowed rumours of cigarettes being made in leper colonies and spiked with opium.

Attempts to bring a safer cigarette to market in the 1970s - in particular, by Liggett and Myers - were partly thwarted by rival tobacco companies closing ranks on those who, by introducing a safer alternative, would be implicating all existing brands as dangerous. In this, the tobacco companies found themselves on the same side as the anti-smoking movement, albeit for different reasons. By 1980, the consensus view amongst public health professionals was that any attempt to produce safer tobacco products would slow the quit rate.

Dr Gio Gori’s Less Hazardous Cigarette project, which was brought to a halt at the end of the '70s, was the last attempt to find a technological solution to a problem that many felt should be solved by behaviour modification. Thereafter, the doctrine of total abstinence took hold. The prevailing view was that the more dangerous tobacco was (or was perceived to be), the more people would quit. It consciously withheld safer alternatives from the individual in a bid to accelerate the quit-rate in the population. Reflecting on the new doctrine, Dr Gori said: “The new policy was - smokers shouldn’t be helped, smokers should be eliminated.”

At a time when governments were giving free syringes to heroin and free condoms to children, the ‘quit-or-die’ approach to tobacco raised ethical questions, and was only possible by an almost evangelical faith in the smokefree world to come. Total abstinence had previously been seen as a pipe-dream, but as the anti-smoking movement gathered pace in the 1970s, activists and governments came to believe it was possible within a generation. This was in-keeping with earlier reform movements, which invariably set their eyes on prohibition sooner or later. Just as the American temperance movement set out with a message of moderation and ended with complete prohibition, so the Anti-Cigarette League of the early 20th century went from a campaign that solely targeted ‘coffin nails’ to fighting cigars, pipes and chewing tobacco (which were the ‘less hazardous’ alternatives of its day). The Anti-Cigarette League’s absolutist slogan ‘A Smokeless America by 1925’ bears an uncanny resemblance to the Surgeon General’s equally ambitious of 1986: ‘A Smoke-Free America by 2000 AD’. Both serve as reminders that bringing
about total abstinence is easier said than done.

Four decades later, the ‘quit or die’ approach survives. Its political legacy can be seen in Britain’s ban on Skoal Bandits in the 1980s and Australia and Canada’s recent ban on e-cigarettes. It can be seen in Finland’s pledge to ban any safer tobacco product that might appear in the future. It can be seen in the ban on snus that is enforced in every EU country bar Sweden. Its impact on the health of populations, however, can only be seen by comparing Sweden’s significantly lower smoking rate and lung cancer rate to its EU neighbours.

In summary, modern anti-smoking activists oppose tobacco harm reduction because, like earlier reformers, they tend to be idealists. Even those who set out as pragmatists are liable to becoming more zealous once they become emerged in a worthy cause. Few activist groups of any hue avoid ‘mission creep’ for long. For the anti-smoking movement, the allure of prohibition - the only logical conclusion to its cause - could not be long resisted. To the anti-tobacco campaigner, the appearance of new tobacco products, even if demonstrably safer, innately feels like a step backwards. Their prohibition, on the other hand, feels perfectly natural and, since most alternative nicotine devices are niche products with relatively few users, they can be nipped in the bud with minimal resistance.

Tobacco harm reduction does not offer a Utopia, nor does it promise to rid the world of an addictive vice that some find intolerable. Nor, for that matter, does it hold the promise of destroying the tobacco industry; which is the stated goal of the most fervent activists, who have long convinced themselves that getting rid of the industry will get rid of the problem.

The oft-repeated mantra that 'if something is good for the tobacco industry it must be bad for public health' has come to be seen as a truism, and not without reason, but this logic can only be taken so far. Even the tobacco industry's fiercest critics must concede that no business benefits from killing its customers. When it comes to tobacco harm reduction, we might reflect that seeing the issue as good versus evil is more suited to lovers of comic books than to those looking for real-life solutions. If the tobacco industry - or any industry - can come up with less hazardous products, it should be seen as part of the solution, rather than part of the problem.

The future offered by harm reduction is not as tidy or pure as the vision offered by the idealists. Convinced that a tobacco-free world is within reach, a world of reduced harm seems pitifully unambitious. History provides many examples of anti-smoking crusades built on similar idealism collapsing under the weight of their own hubris, and no examples to the contrary. If they are aware of this inauspicious track record at all, today's crusaders would, I fear, reply with those famous last words: “This time it will be different.”


Lars Folmann said...

A century ago, it was the higest science, that mastubation would turn you blind and/or crazy. When it comes to tobacco smoking, it's clearly that medical science hasn't evolved since.

Witterings from Witney said...

Damn good post/speech Chris - will link to this later - with a comment or two.

DaveA said...

Balanced, erudite and a tour de force.

Nuff said.

Anonymous said...

I've proposed the idea that the legal age to purchase tobacco could be raised by 12 months EVERY 12 months. So in 2030 the legal age might be 35 if such a scheme was introduced in say 2013. Current legal age smokers would always be legal so have nothing to fear. Non smoking teenagers would never attain legal age.

BUT at any time any person over 18 but below the legal age could obtain a "pass" by registering as an addict. Few would do so however unless they were in fact addicted or habituated because there would likely be some stigma or obligation.

OK so that's "my" bright idea. But I'm sure it's been thought of before. So why have I never seen it proposed in the media? Is it because neither the revenue hungry governments or the rabid anti-smokers really want to see a decline in smoking?

Anonymous said...

The anti smokers offer an ideal of lifestyle austerity.
Austerity is in at the moment amongst a good half of the population, well even amongst that group many pretend to be so when not.
Austerity is not a strong instinct in homo sapiens.
Just watch em go at a party.
Anti smokers.
Their doomed because they have a weird view on life.
I think they probably whip themselves with stinging nettles instead.
Just look a the lines of po faces at the "rallies" they hold.

Anonymous said...

Once more Chris Snowdon uses a Straw Man to try to make his argument.

Unless he now considers that the RCP and ASH UK don't fall into his category of "anti-smoking activists".

Despite what Snowdon might have us believe, they have both stated that they support tobacco harm reduction measures.


Anonymous said...

28 April 2010 07:52
No they fall into the category of the anti smoking industry mate.
It's all about getting funds to expand their quango (fake charity)

Anonymous said...

So what's the difference between "anti-smoking activists" and "anti-smoking industry"?

And where does this leave the RCP?

Unrepentant Smoker said...

This is where the RCP and others are exposed for their vested interests.

Competing interests of UKCTCS staff

John Britton chairs the Royal College of Physicians Tobacco Advisory Group and is a member of the board of trustees of Action on Smoking and Health

Peter Hajek undertakes consultancy for and has received research funds from a number of companies developing and manufacturing smoking cessation products.

Paul Aveyard has accepted hospitality from the pharmaceutical industry. He has done consultancy and research work in smoking cessation for Pfizer, McNeil, and Xenova Biotechnology that has led to payments to him and his research account.

Linda Bauld is vice-chair of the Cancer Research UK Tobacco Advisory Group and serves as Scientific Adviser to the Department of Health on tobacco control.

Tim Coleman has, within the last 5 years, done occasional consultancy work for companies that manufacture NRT products (Johnson and Johnson, Pierre Fabre Laboratories). He has also advised a Public Relations company on the strength of the evidence for using Nicobloc as an aid for smoking cessation.

Robert West undertakes research and consultancy for companies that develop and manufacture smoking cessation medications. He has a share of a patent for a novel nicotine delivery device. He is a trustee of QUIT. His research is funded mostly by Cancer Research UK.


Unrepentant Smoker said...


1. Britton J, McNeill A, Aveyard P, Bauld L, Hastings G, Hajek P, West R The UK Centre for Tobacco Control Studies. UKCRC £5,000,000, 2008-2013.

2. Aveyard P, West R Rapid reduction versus abrupt quitting for smokers who want to stop soon: a randomised controlled non-inferiority trial. British Heart Foundation £151,701 2008-2010 (Award number PG/08/047/25082)

West R Contribution to the Smoking Toolkit Study. Department of Health £164,000 2008-2009..

Unrepentant Smoker said...



3. West R, Vangeli E. An in-depth investigation of the causes and process of relapse to smoking. Cancer Research UK. £39,000, 2006-2008.

4. West R. Contribution to Smoking Toolkit Study. Pfizer Consumer Healthcare. £150,000, 2006-2011.

5. West R, Wardle J Smoking cessation: population and clinical approaches. Cancer Research UK. £2,850,000, 2007-2012 (Award number C1418/A7972)

6. West R, Contribution to Smoking Toolkit Study. Pfizer £170,000, 2007-2008

7. West R, Contribution to Smoking Toolkit Study. GlaxoSmithKline. £50,000, 2008.

8. Ussher M, Aveyard P, Evans P, Hucklebridge F, Ibison J, Reid F, Steptoe A, West R The effect of hydrocortisone on desire to smoke and tobacco withdrawal symptoms Cancer Research UK £34,885, 2007-2008 (Award number C8641/A8419)

Ussher M, Aveyard P, Coleman T, Marcus B, Barton P, Manyonda I, Lewis B, West R A pragmatic randomized controlled trial of physical activity as an aid to smoking cessation during pregnancy National Insitute for Health Research, Health Technology Assessment.£1,182,613, 2008-2011

Anonymous said...

Replying to anon 07.52: I have just looked at the ASH UK document. It recommends the use of drugs and nicotine gum rather than ecigs and its general tone is not one of support for the use of ecigs; and suggests that ecigs should and will soon be "regulated": presumably renamed nicotine inhalers, altered in appearance and the price of the refills increased to reflect the fact that "harmless" nicotine is even more expensive than printer ink. (Compare the price of chewing gum (45p) with that of nicotine gum (£14). How do the ecig companies manage to sell dilute nicotine solution for next to nothing? Chinese children stirring the ingredients with dirty planks of wood? I don't think Chris uses a Straw man. I've read nothing to suggest that ASH UK shouldn't be included among anti-tobacco activists for whom saving lives is of little importance. Go to the CRUK wesite and compare the rate of lung cancer for Swedish males with those of every other developed country. Compare the prevalence of smoking (15%) among Swedish males with that in the rest of Europe. And finally, after reading on the various anti-smoking websites that Snus causes oral and pancreatic cancer, go to the cruk website and compare the rates of those cancers in Sweden with the rates in the rest of Europe.

Dr Evil said...

ASH is a fake charity. It runs on government grants. If it raised all the cash on its own, then fine! But a bunch of whiners trying to create government policy, funded by the government is most certainly not fine!

Christopher Snowdon said...

Anon 07.52

If you're going to post links then at least read what's on them. The RCP webpage is classic example of the anti-smoking movement opposing tobacco harm reduction: they support the ban on snus and oppose smokeless tobacco. ASH are currently more ambivalent about the e-cig than their American namesake, but we'll see if they man the barricades if and when the MHRA bans them (clue: they won't).

You seem to be mistaking support for NRT as support for less hazardous tobacco products. It isn't - NRT isn't a tobacco product, for a start. The reasons for the anti-smokers' support of NRT are outlined in the speech.

jredheadgirl said...

Great post Chris! It's time that we demand the introduction of reduced risk tobacco products. It is our choice and our bodies after all. Who are they to deny us of our health, simply because we smokers partake in something that the anti-smokers do not approve of. Indeed, in addition to being about corruption and money, it has once again become a moral crusade, which ironically, is anything but moral. The question that we need to ask ourselves is this: How many smokers have needlessly fallen ill as a result of this suppression of science? Can you imagine if the study of AIDS medications where to be suppressed as a way to discourage behavior? THAT would be morally reprehensible; this is no different.

Thanks again for Chris for your clarity and forward thinking.

Anonymous said...

CHRIS as usual you nailed it,now for your next piece how about the history of the repeal of prohibition and the reasons it finally failed.......thats the one I wanna read.......''GLOAT''

Chip said...

Note the absurd doublespeak of the RCP statement. First they say "Opening up the EC market to tobacco companies would invite abuse by allowing them to market to children and through smokeless products also promote smoked cigarette brands." Then, just a few paragraphs later, they say "If you make smokeless tobacco products more available won’t non-smokers start using them? The evidence from Sweden suggests that this is unlikely. A small percentage of young people will take it up but the hazards to society are far less than through smoking."

So which is it? Will legalizing snus cause every youth in the UK to immediately become addicted or won't it?

In the 2 months since I switched to electronic cigarettes my health has improved dramatically. E-cigs WORK. I have had zero desire to go back, and if these so-called public health advocacy lobbies actually had any interest in improving public health, they would be shouting from the rafters that all smokers should switch as I have. Unfortunately, they are far more interested in lining their pockets with public money that might dry up if an actual solution to the problem of smoking was made widely available.