Snus: they knew all along (part 2)

While doing some research recently, I came across a letter in a library archive written by Dr Richard Peto to Dr. B. MacGibbon. Peto was, and is, a highly respected epidemiologist who worked closely with Richard Doll on smoking and health.

The letter is dated 28th June 1984. Two months earlier, the Daily Mail had run a story about Skoal Bandits, an American form of snus made by US Tobacco Inc. who were due to build a factory in Scotland. Shortly thereafter, ASH's director David Simpson started a moral panic about this smokeless tobacco product which ultimately resulted in the EU ban on oral tobacco (1992). See Chapter 4 of The Art of Suppression for the full story.

I do not know who Dr. B. MacGibbon was or why Peto was writing to him, but Peto begins by recommending that some research into the saliva concentrations of snus users be conducted "fairly urgently". He continues...

I have given some further thought to the question of how many cancer deaths would be likely to be caused each year if one-third of the British population were to become habitual tobacco suckers.

Then, basing his figures on data from the US and UK...

This suggests that if about a quarter of the British population took to dipping 100 gms of tobacco a week, then in the long run “only” some 500-1000 excess deaths/year would result (see Appendix [which is a couple of studies, including the influential study by Deborah Winn looking at women in North Carolina - CJS]).

Maybe Skoal Bandits would be worse than SE US snuff, or maybe (especially if you take the advice in the first part of this letter! [ie. to carry out research "fairly urgently" - CJS]) they would be less hazardous. In any case, no matter what epidemiological studies you mount, you probably won’t get even a preliminary answer this century, so as a practical basis for action I suggest you assume that the adoption of Skoal Bandit-like products by a quarter or a half of the British population will cause about 1000 cancer deaths a year. In contrast, tobacco smoking currently causes about 100,000 British deaths a year!

This may be wrong – they could be carcinogenic, and the Asian experience with oral cancer suggests that they could be a lot more carcinogenic than I’ve estimated, but in any case you have most of what you need for political action, viz:

• The risks are not zero
• The risks can probably be reduced by immediately commissionable laboratory research;
• The risks are much, much less than those of cigarette use.

The final thing you need is to know whether they will help avoid tobacco. No proof is possible, but it is noteworthy that among women in North Carolina, where both products have been widely available for decades,

• The proportion of smokers among snuff-dippers is only one-third as great as that among non-dippers, and
• Even among those dippers who smoke, mean cigarette consumption Is significantly lower than among non-dippers who smoke.

I suspect that, no matter what the risks might be, Skoal Bandits and allied products would be allowed to be sold [alas, this prediction was wrong - CJS]. Fortunately, however, the above arithmetic suggests that this may well do more good than harm. In any case, one should try to avoid producing a situation where the warnings or statements about Skoal Bandits etc. are so strong as to divert attention from the much more serious hazards of tobacco smoking.

He concludes by saying:

"The real message is that there is a hazard, but that it’s much less than that of smoking, and that a widespread shift to such products could probably save a lot of lives."

As I mentioned recently, Peto was not alone in seeing the harm reduction potential of snus. In 1985, the addiction expert M.A.H. Russell published a letter in the Lancet, estimating that 49,000 premature deaths would be prevented by a switch from cigarettes to Skoal Bandits. Unfortunately, and not for the last time, the voices of scientists were drowned out by those of activists who were itching for prohibition.

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Snus: they knew all along

Brad Rodu reports on a study recently published in Nicotine & Tobacco Research which shows that Norwegians who believe snus to be dangerous tend not to use it to give up smoking. Nothing surprising about that, of course. What is worrying is that 35% of those surveyed believed that using snus was as dangerous - or more dangerous - than smoking (in fact, it is over 95% safer). This is a troubling statistic, though perhaps unsurprising since many Norwegian doctors remain ignorant of the gulf in potential harm between cigarettes and snus.

The study, by Dr Karl Lund, also found that 32% of ex-smokers used snus to quit, whereas only 14% used pharmaceutical nicotine medication. From this, we can draw the conclusion that if smokers were not ignorant about snus's risk profile, many more Norwegians would be ex-smokers.

Still, at least the people of Norway - having wisely chosen to remain outside the EU - are able to buy snus if they want to. The same cannot be said of we Brits who helped to introduce the EU ban in the first place (see The Art of Suppression. You've read it by now, right?)

The harm reduction potential of snus in tobacco control can seem like a relatively new discovery. It is easy to believe that a clueless anti-smoking movement stamped the product out without realising the possibilities it had for smoking cessation. It was, after all, not until 2004 that Brad Rodu and Philip Cole published the study showing that 200,000 premature deaths could be prevented by adopting a Swedish culture of snus use.

This is not quite true. As early as 1985, the addiction expert M.A.H.Russell had tested snus (Skoal Bandits in fact) and wrote to The Lancet saying:

Our results suggest that this new product could help people trying to give up smoking. It might be cheaper than nicotine chewing gum and would not require a prescription. If all smokers in Britain switched to sachets about 50,000 premature deaths per year might eventually be saved at an annual cost of less than 1,000 deaths from mouth cancer.

This was at a time when snus was believed to cause mouth cancer, a belief that has been known to be false for over a decade. Nevertheless, Russell based his figures on the core principle of harm reduction and understood that 50,000 minus 1,000 still left 49,000, and that this was better than the prohibitionist, quit-or-die fairytales that were dominant in the tobacco control movement even then.

History will not look favourably on the dangerous idiots who banned snus in the EU - especially those who still support the prohibition now that the facts are clear. There were rational voices thirty years ago which went unheeded.

One of Russell's co-authors for the Lancet letter was Martin Jarvis. Today, Jarvis is a trustee of ASH. ASH is truculent, devious and unreliable on almost every matter on which they claim to have expertise. None of their pronouncements of the last fifteen years has not involved at least a half-lie, but their failure to speak out against the EU ban adds cowardice, hypocrisy and gross negligence to the charge sheet.

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Offering your scorn

Many years ago I read an interview between Matt Groening (the creator of The Simpsons) and Frank Zappa. The interview doesn't seem to exist online, but I recall them both agreeing that their job was to 'offer their scorn'. No one had to accept the scorn. They didn't even have to acknowledge it. It probably wouldn't make any difference if they did acknowledge it, but it was the artist's job to offer it all the same.

Several years later I saw the greatly under-rated film Election, in which a school teacher (played by Matthew Broderick) spots a bad egg running for student president and recklessly tries to sabotage her campaign because he knows that a victory will set her on course for a life of making other people miserable. The teacher is exposed, Tracey "pick" Flick wins the election and he is ruined. By the end of the film, he has lost his marriage and his job, his nemesis has won and he has nothing. In the final scene, he comes across her by chance—she is now rapidly ascending the greasy pole of politics—and in a futile and impotent gesture, he hurls a milkshake at her car. The end.







If I was to tell you that this scene and the aforementioned quote regularly come to mind as I write my books, speeches, articles and blog-posts, you would get a glimpse of the hopelessness with which I view the pursuit of liberty and tolerance in the second decade of the twenty-first century. To be candid, I do not see myself on the winning side. As I hinted at in yesterday's post, the forces of reason are no match for the forces of ignorance, avarice and fear which outgun us.

With the odds stacked against you, all you can do is offer your scorn. With that in mind, I point you to Carl V. Phillips' recent testimony to the US Food and Drug Administration. Dr Phillips is an honest scientist, too rigorous for the public health movement he represents and too measured for the e-cigarette and smokeless tobacco industries whose products he implicitly or overtly endorses. The FDA committee on tobacco harm reduction, meanwhile, is ostensibly interested in public health but, as Carl writes, is actually "dominated by dedicated anti-tobacco extremists who are opposed to harm reduction, and its external scientific advisory group (TPSAC) is stacked with extremists and junk scientists". For financial and ideological reasons, it exists to promote pharmaceutical nicotine products at the expense of more effective alternatives.

A genuine harm reductionist cannot expect to change anyone's mind in such an environment. You can waste your three minutes' speaking time trying to win favour with a unwinnable audience or you can seize the moment to offer you scorn. Carl chose the latter...  

I speak today as an educator with an interest in the nature of science and its role in the functioning of our society, and from that perspective would like to say, "won't someone please think of the children?"

If an impressionable young mind stumbled across how science is often portrayed in this corner of our nation's government, he would be at risk of never becoming scientifically literate, let alone to wanting to be a scientist.

First, science is supposed to be an honest truth-seeking process that attempts to figure out the best possible answer to a question, often via methods that require innovative thinking. Our impressionable young mind, however, might come away:

-believing that science consists of just a few narrowly-defined recipes, rather than taking in all the information we have in myriad forms, available from many forums, and thoughtfully making the best use of it;

-believing that health science focuses on looking only under streetlamps and obsessing about easy but not directly informative work like chemistry, rather than trying to do the more difficult work to translate this and other information into what we really want to know about health effects;

-from today's session, he might believe that science involves such methods as manipulating children into giving the answers you want, speculation-laden anecdotes, limiting reviews of the evidence to exclude any evidence that you wish did not exist, and counting unsupported assertions by authors as evidence;

-and he would be taught that science it is not about identifying how we maximize our knowledge, but that it involves declaring that we just do not know anything, when in fact we know quite a lot.

Our impressionable young mind is not going to think very highly of science, and he might reasonably conclude that the best way to get involved in America's version of science is to go to law school. And, yes, that means that misguided ways of looking at science may be a gateway to more dangerous behaviors.

Second, this poor child would get the impression that a hypothetical cardiovascular condition or cancer 40 years from now will be just as harmful as a near-term case in a current smoker, a case that was caused because smokers are discouraged from switching to low-risk alternatives. Do we really want to tell that child that we expect so little of him, that his generation's health science will be so lousy that the 40-year-out cancer will be no more treatable that it would be today?

Finally, at the very least, I would urge this committee and Center to make sure that any such anti-scientific writing is kept in child-proof packaging, rather that being left laying around on the internet where anyone could stumble across it and damage their developing minds.

Go over to Ep-ology to read the background of this story and the various references to which the good doctor alludes.

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The murderous insanity of the War on Drugs

A batch of Ecstasy pills in British Columbia has been contaminated with a dangerous substance called PMMA which is similar to PMA, also known as Death, Dr Death and Chicken Powder, and is five times more toxic than MDMA.

You might infer from their names that Death is not such a nice drug as Ecstasy. You would be right. PMA has been linked to a number of fatalities in the past and PMMA appears to be causing similar carnage.

A batch of ecstasy believed to be behind a spate of recent deaths in Calgary may have been tainted with a lethal chemical never before found in the street drug, according Alberta’s chief medical examiner.

Five people have recently been found dead with PMMA in their systems. All had taken tainted Ecstasy. The police know what batch is contaminated and they know what it looks like. They know what colour the pills are and they know what the stamp is. So what are they doing to prevent more fatalities?

Absolutely nothing.

Police in British Columbia are reluctant to tell the public what unique, colourful markings are on ecstasy pills suspected to be packed with a lethal additive linked to five deaths in the province over concerns users will believe they're sanctioning the rest.

Lisa Lapointe said while some police agencies have been voluntarily handed samples of the suspect pills, they've decided against putting photos online.

"We don't want to give the impression that these are the tablets that are risky, and other tablets are safe," she told reporters.

"At any time, any tablet can be contaminated with anything."

RCMP and police in Vancouver and Abbotsford have all promoted the message that no drugs are safe, while shying away from providing specific details around tracking the substance's source or revealing what stamps the pills bare [sic].

This is just appalling. In their desire to 'send a message' that all drugs are bad, these negligent imbeciles are prepared to conceal information from people that might save their lives. Why is there PMMA in the Ecstasy supply in the first place? Because of the War on Drugs. Why won't they give users health information that will drastically reduce their risk? Because of the War on Drugs.

This is, of course, the same quit-or-die mentality that allows snus and e-cigarettes to be banned because they may or may not be a 100% safer alternative to cigarettes. It is harm maximisation in action and it is utter madness.

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Snus and e-cigarettes work

Two studies have recently been published testing the efficacy of snus and e-cigarettes in smoking cessation.

In the Harm Reduction Journal, Joksic et al. report their results from a randomised, placebo-controlled, double-blind trial in which 158 smokers were given snus and 161 smokers were given a placebo. Smoking status was verified throughout with carbon monoxide tests and 81% of participants enrolled because they wanted to quit smoking.

The results show that the snus-users were three times more likely to reduce their cigarette consumption by more than 75% and were two to three times more likely to quit smoking entirely.

An interesting feature of the study is that it was conducted in Serbia, which has no history of snus use. It is sometimes said that snus is a quintessentially Swedish habit that could never take off in the rest of the world. This seems to me a rather odd and slightly xenophobic view (see Alan Blum's quote in The Art of Suppression!) but this success in Eastern Europe shows that the 'Swedish experience' can indeed be exported.

The e-cigarette trial had a smaller sample (of 40) and no control, but if its results are replicated elsewhere, things look very encouraging. At the end of the six months, 22.5% of participants had given up smoking entirely. Amongst all participants, average cigarette consumption fell from 25 a day to 5 a day. As Michael Siegel says, this compares very favourably with pharmaceutical nicotine products. The special point of interest in this study is that none of the participants expressed any particular desire to quit smoking at the outset.

You might think the anti-smoking movement would be jumping for joy at the prospect of having two effective smoking-cessation products to offer the public. As I write this, ASH Wales is holding a conference in Cardiff (with the temperance lobby, natch). It would be nice to think that they are celebrating the news that there are efficacious nicotine products to compete with Big Pharma's 'nicotine replacement therapies', but somehow I don't think they will be.

I wonder why?

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Being realistic about harm reduction

This story from the Daily Mail raises one or two questions:

Free morning-after pill fails to cut teenage pregnancies

The drive to give free morning-after pills to teenage girls has failed to cut underage pregnancies.

Schemes to offer over-the-counter emergency birth control to girls under 16 have simply encouraged youngsters to have more unprotected sex, damning research found.

In doing so they have fuelled a rise in sexually transmitted diseases.

The study in question looks sound enough and (according to its authors) its findings are in line with the majority of other research on the same topic. But the fact that this story has not been widely reported outside of the right-of-centre newspapers in Britain suggests that some people are not comfortable hearing such news.

I don't have a strong view on whether or not the morning-after pill should be given to under-age kids, but having the government hand out free contraception to the under-16s obviously sends out a signal that is at odds with sex being illegal for the under-16s. Likewise, giving free needles to heroin addicts. But that's how harm reduction works—we don't approve, but we recognise that it goes on and we try to reduce the risks.

The point of this post is not to pontificate on the rights or wrongs of needle exchanges and free contraception to teenagers, but only to point out something that any honest person working in harm reduction will tell you: if the government facilitates an activity, it will be seen to have at least tacit approval and that activity is likely to become more common. Social stigma is an effective means of controlling behaviour. We've seen it with drink-driving and we've seen it with smoking. If you remove that stigma and give a nod and a wink that something's okay—by, for example, handing out the morning-after pill in schools—you can expect to see more of it.

This is pretty basic behavioural economics and the apparently controversial study above does nothing but prove an obvious point—harm reduction policies increase uptake. But it isn't uptake that is the problem. Liberal opinion is less worried about people taking drugs and having sex than by the unintended consequences of these activities. I feel the same way. The problem with the free contraceptive scheme isn't so much that it is increasing the frequency of underage sex, but that it seems to be increasing frequency of visits to the STD clinic while not reducing the frequency of visits to the maternity ward. It is having an unintended—albeit predictable—consequence while failing to deal with the real problem. (Arguably, the wrong contraceptives are being dished out. Condoms would be a better way of preventing unwanted babies and unwanted diseases, but perhaps that would be putting too much power and responsibility in the hands of teenage boys.)

Harm reduction policies should be judged by the overall effect on public health. If it was about morality and behaviour, we wouldn't be attempting harm reduction in the first place.

So it is with tobacco harm reduction. If people were given access to less hazardous products such as snus or e-cigarettes—and if this was accompanied with honest information about how much safer they were than combustible tobacco products—we should recognise that this will inevitably lead to some people trying these products who would not otherwise be attracted to nicotine. Quite obviously, more people would use snus if it was legalised than if it wasn't. But the number of people using tobacco/nicotine isn't the issue, unless we have some moral objection to people using a mild addictive drug. The issue is whether enough people quit the very hazardous product in favour of the less hazardous product to make it worthwhile from a public health perspective.

In the case of tobacco, the hazardous product (cigarettes) is so harmful that very few smokers would have to switch to make a net saving in lives lost. Conversely, the less hazardous alternatives (snus/e-cigarettes) are so very much less harmful that a vast number of previously uninterested nonsmokers would have to be drawn towards them before this gain was cancelled out.

In terms of overall prevalence, it is likely that the total number of nicotine users would remain steady or rise, when compared to a scenario in which safer products were illegal and smoking was made less and less socially acceptable (although considering the failure of anti-tobacco to reduce smoking prevalence in recent years despite using every trick in the book, even that prediction may be suspect).

Whether or not you have a few more, a few less, or about the same number of people using nicotine products, if they are doing so using products which are 90%+ safer, the overall effect on public health can only be positive. If they are 90% safer, you would need more than ten previously uninterested people to start using these products for every smoker who uses them to quit. If they are 99% safer (and this is the more scientifically probable estimate), you would need more than 100 previously uninterested people to start using these products for every one smoker who uses them to quit.  Common sense tells us that this is simply not going to happen and only a delusional fruitcake could possibly think otherwise.

Coming up tomorrow: I discuss Stanton Glantz's belief that encouraging harm reduction would lead to more people smoking and more people dying of tobacco-related deaths.

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Prohibitionists march on in New York

When the hysteria about Skoal Bandits set the wheels in motion for the banning of snus back in the 1980s, Ann McNeill wrote an editorial for the British Journal of Addiction in which she said:

“Some find it hard to justify the ban on oral snuff when cigarette smoking, which is undoubtedly more dangerous, is still permitted. The answer is simple. Prohibition is only feasible if relatively few people use a product.”

This was unusually candid, and true. The resulting ban on snus turned out to be a public health disaster since it prevented smokers from switching to a product that is at least 90% safer than cigarettes (and quite probably 99% safer). Not all anti-tobacco campaigners have admitted they got this one wrong but, to her credit, Ann McNeil is one of them and she has publicly stated that snus should be decriminalised.

Still, it is easier to ban a niche product than it is to ban a widely used product. No wonder, then, that those with a prohibitionist mentality went after snus and are now going after e-cigarettes. The fact that both of these products are excellent substitutes for cigarettes and are virtually harmless seems not to enter into it. As the American Council on Science and Health said in its Top Ten Unfounded Health Scares of 2010:

The chemical components found in e-cigarettes pose little danger to human health, and should not be considered toxins or carcinogens. It is irresponsible for public health organizations such as the CDC and the AHA to denounce the use of e-cigarettes as an effective smoking cessation method. In doing so, they only continue to promote the use of regular cigarettes for the majority of smokers who failed to quit using traditional approved cessation methods.

And yet, the prohibitionist crusade marches on in New York City. Some day someone will write a book explaining how New York went from being a world-wide symbol for liberty to being the pitiful nanny state it is today. The unsavoury, bloated, authoritarian figure of Michael Bloomberg will no doubt loom large in the story, but even he can't be held directly responsible for this insanity:

A01468 Summary:

BILL NO: A01468

Prohibits the sale of electronic cigarettes to minors; prohibits distribution or sale of any item containing or delivering nicotine that is not defined by law as a tobacco product or approved by the United States food and drug administration for sale as a tobacco use cessation or harm reduction product.

The above comes from a Bill to ban e-cigarettes. I understand that it will be voted on tomorrow. The justification for this legislation is...

Given the unregulated nature of this product, there is no way of knowing the amount of nicotine in each cigarette, the amount that is delivered with each inhalation, or the contents of the vapor created in the process.

Gee, if only there was some way of dealing with an unregulated product without having to ban it. Of course—and this comes completely out of left-field—you could just regulate it, thereby guaranteeing the quality of the product whilst guaranteeing that e-cigarette users don't have to go back to smoking a proven health hazard.

Call these people anything you want. Just don't call them health campaigners.

(Vapers Club has the links if you want to let the NY authorities what you think of banning e-cigarettes.)

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How harm reduction works

A little story from Iceland tells a bigger story about how tobacco harm reduction could, and does, work in practice...

The sale of cigarettes has decreased significantly this year compared to 2009. According to the State Alcohol and Tobacco Company of Iceland (ÁTVR), sales dropped by almost 13 percent in the first nine months.

However, at the same time the sale of snuff and chewing tobacco has increased by 9.2 percent—at the end of September almost 18.8 tons of snuff and chewing tobacco had been sold in Iceland, Morgunbladid reports.

Cause and effect? Coincidence? Who knows? But if cigarette smokers are happy to switch to snuff and chewing tobacco, what would happen if they had access to snus, which is both less hazardous and—so many people say—more pleasurable than either?

Alas, the sale of snus remains illegal in Iceland, as it is in the whole EU (Sweden excepted).

Way to go, public health prohibitionists!

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E-cigarettes look set to be banned

So it looks like they're going to ban e-cigarettes in the UK. The fools.

Michael Kitt at ecigarettedirect.co.uk has received a letter from a Trading Standards Officer who has (apparently) been told by the Medicines and Healthcare products Regulatory Agency (MHRA) that they  will be opting for what they always said was their preferred option and banning all nicotine products. There are are—of course—two major exceptions: the most hazardous nicotine products (smoked tobacco) will continue to be on sale, as will the least effective smoking cessation aids (pharmaceutical nicotine).

From the letter:

I have been in discussions with other Trading Standards authorities and have found out that the consultation is almost complete. The outcome will be that as of a date (yet to be announced) there will be a 21 days period and then these products will be outright banned in the UK, unless the traders apply for certification as a medical device from MHRA. This process could be complicated and costly so it is expected that many traders may cease trading.

What this means for vapers like Leg-Iron is that it's back to the cigarettes. The least harmful nicotine delivery device is to be withdrawn in favour of the most harmful. And in the boardrooms of Pfizer and Philip Morris there was much rejoicing.

How has it comes to this? As I said at the International Harm Reduction Conference back in April, I think it comes down to a combination of fanaticism and pharmaceutical pressure.

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.”

Five years ago, when I began researching Velvet Glove, Iron Fist, I was wary of making too many claims about the influence of the pharmaceutical lobby. Although Big Pharma (or, more accurately, the pharmaceutical companies who happen to make nicotine products) have funded the anti-smoking movement lavishly over the last twenty years, there were anti-smoking fanatics long before they got involved and, for the most part, the movement's prohibitionist agenda has remained unchanged. While it is important to be aware of the conflicts of interest, especially when nicotine replacement products (NRT) are being touted, people like John Banzhaf and Stanton Glantz were going to be saying the same things with or without Big Pharma's cash.

But I have been saying for some time that the anti-smoking movement's attitude towards the e-cigarette would be the litmus test of pharmaceutical influence. There is no doubt that Big Pharma is seriously worried about the e-cigarette's impact on their sales, as an industry report suggested:

E-Cigarettes Will Revolutionise the Face of Tobacco Smoking and Could Pose a Threat to the Smoking Cessation Market

In February, the Department of Health (of which MHRA is a part) went further than ever before in pushing pharmaceutical nicotine, not just as a smoking cessation aid but as a long-term substitute. Needless to say, this change of emphasis suits the makers of nicotine products just fine. 

In the e-cigarette, we have a product that is—at the very least—99% less harmful than cigarettes. In all probability, it is 100% safe (because, as MHRA say, nicotine is "a very safe drug"). Furthermore, there is considerable anecdotal evidence that e-cigarettes are more effective as smoking cessation aids than anything sold by Big Pharma. It is certainly reasonable to say that they require some regulation, if only to prevent contaminated or substandard products going on sale, but to ban them entirely is sheer madness. As Paul Bergen says over at Smokles:

There is good reason for some sort of standards for any widely used product. This is just a very bad way of going about it.

If cigarettes did not exist and e-cigarettes were some unique nicotine delivery device then this approach would not be entirely out of sorts. It would still be unusually demanding in its short time frame for compliance but the worry would center more around commercial concerns than concerns of health.

However we have been repeatedly reminded by national authorities that too many people are dying from smoking, implying that these same authorities think this is not a good thing, and also implying that they would support actions that would bring down those mortality figures.

Quite simply, the ban on e-cigarettes—like the ban on snus—is going to result in more people dying of smoking-related diseases. It is a victory only for those with a bone-headed prohibitionist mindset, it is a victory for the precautionary principle and it is a victory for big business. No organisation that supports the ban can seriously claim to be working in the interests of public health.

If and when this ban is confirmed, will we hear objections from ASH? After all, ASH claims to support harm reduction. There must be some amongst their number who joined the movement because they wanted to help people quit smoking and save lives. Will they speak out or will they keep quiet in deference to the companies who pay for their conferences?

H/T: Kate at Vapersnet.org 

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Tobacco Harm Reduction book 2010

Make a pot of coffee, take the phone off the hook and put the kids in the fridge—the Tobacco Harm Reduction 2010 yearbook has been published and is free to download here. Edited by Carl V. Philips & Paul Bergen (who also run the Smokles blog, which I often link to), it includes presentations from the International Harm Reduction Conference in Liverpool and much else besides.

It would be less than candid of me to say that I have read the whole thing, but I intend to get stuck in this weekend. If you want a serious discussion of the issues pertaining to snus, e-cigarettes and smokeless tobacco, written by people who actually know they're talking about, you should do the same.

The contents are...

1. Introduction
Carl V. Phillips & Paul L. Bergen 

2. Tobacco – the greatest untapped potential for harm reduction
Carl V. Phillips, Karyn K. Heavner & Paul L. Bergen 

3. Still fiddling whilst cigarettes burn?
Adrian Payne 

4. Switching to smokeless tobacco as a smoking cessation
method: evidence from the 2000 National Health Interview
Brad Rodu & Carl V. Phillips 

5. Why do anti-smoking groups oppose tobacco harm reduction?
A historical perspective
Christopher Snowdon 

6. A tobacco-free society or tobacco harm reduction: Which
objective is best for the remaining smokers in Scandinavia?
(excerpts)
Karl Erik Lund 

7. The implicit ethical claims made in anti-tobacco harm
reduction rhetoric – a brief overview
Catherine M. Nissen, Carl V. Phillips & Courtney E. Heffernan 

8. Debunking the claim that abstinence is usually healthier for
smokers than switching to a low-risk alternative, and other
observations about anti-tobacco-harm-reduction arguments
Carl V. Phillips 

9. Systematic review of the relation between smokeless
tobacco and cancer in Europe and North America (abstract)
and
The relation between smokeless tobacco and cancer in
Northern Europe and North America. A commentary on
differences between the conclusions reached by two recent
reviews
Peter N. Lee & Jan Hamling 

10. University student smokers’ perceptions of risks and
barriers to harm reduction
Karen Geertsema, Carl V. Phillips & Karyn K. Heavner 

11. Comment to the U.S. Food and Drug Administration
summarizing the rationale for tobacco harm reduction
Brad Rodu 

12. Public comment regarding tobacco harm reduction to
the U.S. Food and Drug Administration from
TobaccoHarmReduction.org
Carl V. Phillips. Paul L. Bergen, Karyn K. Heavner
& Catherine M. Nissen 

13. Submission to the UK Department of Health from British
American Tobacco: The role for harm reduction within
tobacco control
David O’Reilly 

14. Comment to the U.S. Food and Drug Administration from
Phillip Morris USA and US Smokeless Tobacco Company
regarding harm reduction
James E. Dillard 

15. An analog visual comparison of best, current and worst case
scenarios in (tobacco) harm reduction; numeracy-aiding tools to
get the message across
Paul L. Bergen & Courtney E. Heffernan 

16. The fluid concept of smoking addiction
Stanton Peele 

17. Electronic cigarettes are the tobacco harm reduction
phenomenon of the year - but will they survive?
Paul L. Bergen & Courtney E. Heffernan 

18. Vapefest 2010: A report from a conference of electronic
cigarette supporters
Bill Godshall 

19. Electronic cigarettes (e-cigarettes) as potential tobacco harm
reduction products: Results of an online survey of e-cigarette
users
Karyn K. Heavner, James Dunworth, Paul L. Bergen,
Catherine M. Nissen & Carl V. Phillips 

20. Two petitions to the U.S. Food and Drug Administration from
the American Association of Public Health Physicians
Joel L. Nitzkin

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What would a bad public health policy look like?

An excellent article at the Tobacco Harm Reduction blog poses the hypothetical question of what a pressure group would do if it wanted to maximize cigarette sales. The answer looks remarkably like the current approach of the anti-smoking movement, particularly in the USA.

If public health organizations had as their mandate to maintain the present levels of disease and death associated with smoking (and even though their funding derives from the continuing sales of cigarettes I will not even mention in passing that that could possibly be a factor), what would their policies look like?

I imagine they would:

1. discourage any alternatives (like smokeless tobacco products or electronic cigarettes) that might make nicotine use safer

2. if they cannot make them illegal make sure that people think they are no safer

3. support regulations that do not conform to any other product information guidelines and demand that producers describe their products as more dangerous than they are.

And in this regard, they have been quite successful in making sure that little headway is made while at the same time giving the impression that they are valiantly fighting on our behalf.

Go read the whole article. You will not find a more concise and logical summary of the issues at stake.

It is time for us to rebrand these organizations. By their actions, they can no longer be identified as anti-smoking or anti-tobacco (since they fight solutions that would reduce smoking and tobacco use); they can only really be described properly as anti-social.

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Big Pharma versus Big Tobacco

The Washington Examiner hits the bullseye when it says that the regulation of nicotine products comes down to a straight fight between Big Pharma and Big Tobacco. The situation in America is now so messed up that the interests of neither liberty nor public health (however defined) are being served.

It's a full-fledged regulatory rumble between Big Tobacco and the even bigger Big Pharma -- the sort of ugly influence game that will become the norm as government sticks its arms deeper into the economy.

So says Timothy P. Carney, the newspaper's lobbying editor. And lobbying is the name of the game. Big Pharma's problem is that other industries keep producing better nicotine products which, given time, may turn out to be more effective stop-smoking aids. Whether it's the e-cigarette or Camel Orbs, alternatives to Big Pharma's 'medicinal nicotine' are making up market share and the drug companies want the government to stamp them out. 

All these products deliver, for all practical purposes, nothing but nicotine. Big Pharma's approach is to claim that the nicotine in their products is safe (which is true), but that nicotine becomes magically harmful when it is delivered in the products of their competitors.

Their other line of attack is to claim that their competitors' products are marketed to—or at least might appeal to—children. RJ Reynolds, for example, have committed the crime of designing reasonably attractive packaging for Camel Orbs.

Would this appeal to children? Who knows? But if it does, then surely so will this Nicorette product.

Camel Orbs have been accused of having a "candy-like appearance, added flavors, and easily concealable size"—all of which apply equally to Nicorette's Mint Mini Lozenges. They have been accused of having "a very minty taste and seemed to deliver a jolt of nicotine". Ditto. It is said that very young children could die if they eat a whole pack of Camel Orbs. Ditto again.

Either both of these products should be banned or they should both be legal. The group that will advise the FDA on what do is the Tobacco Products Scientific Advisory Committee (TPSAC), and that's where the conflict of interests come into play.

Jack Henningfield is one of nine voting members on the TPSAC, and he is also one of eight patent holders of a cutting-edge nicotine chewing gum that has not yet been commercialized.

Henningfield is also vice president of health policy at a consulting firm that counts drug maker GlaxoSmithKline as a client. Glaxo holds the license for Nicorette, the leading nicotine gum currently on the market.

Camel Orbs may or may not be a real health risk, but they are certainly competition to Nicorette's gums and lozenges -- and Henningfield's patented gum. Yet our government will count on Henningfield and others in the pay of Nicorette's maker for counsel on how to regulate Camel's product.

And it doesn't stop there...

Neal Benowitz, another committee member, has also worked as a consultant to Glaxo as well as Pfizer, the Wall Street Journal has reported. Pfizer makes the quit-smoking drug Chantix.

Boston University professor Michael Siegel has reported on his blog that the committee's chairman, Dr. Jonathan Samet, "has received grant support from GlaxoSmithKline. In addition, the organization that he directed -- the Institute for Global Tobacco Control -- is funded by GlaxoSmithKline and Pfizer."

Finally, committee member Dorothy Hatsukami has been paid by a small drug maker to study its proposed nicotine vaccine.

Michael Siegel, who remains the go-to man for these issues, writes...

The last individual in the world who you would want to serve on such a panel would be a Big Pharma consultant, especially one who consults specifically in the area of smoking cessation medications. The fact that this individual also has a personal financial interest in such medication and who also has testified in court on behalf of Big Pharma simply adds insult to the public's injury.

Pharmaceutical funding has been one of the key developments in the story of the anti-smoking movement in the last 20 years. Many millions of dollars have been spent financing groups who have campaigned for smoking bans, higher cigarette taxes and other tobacco control measures that have pushed smokers towards pharmaceutical nicotine. 

I have never been one to see the anti-smoking movement as a pharmaceutically led enterprise. The money has helped enormously, no doubt, but anti-smoking campaigners were around long before the drug companies got involved and their prohibitionist aims have not changed significantly.

Until recently, it could be said that the interests of public health and the pharmaceutical lobby merely happened to coincide. That is no longer the case. Big Pharma's attempts to use regulation to prevent its competitors from selling virtually identical, safe and probably more effective nicotine products is the final proof that this is all about money. As Carney concludes:

It's an ugly game, this use of regulation to kill competitors and guarantee business, and conflicts of interest are unavoidable. The Pharma-vs-Big Tobacco scrum shows that Obama's project of increasing government control is at odds with his talk of cleaning up government.

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GlaxoSmithKline lie about smokeless tobacco

From the Nicorette website:

A lot of people believe that taking smokeless tobacco is safer than smoking cigarettes. This is not true.

This is an outright lie. Smokeless tobacco is far safer than smoking cigarettes. Perhaps Glaxo's justification for this statement is that there are still health risks associated with smokeless tobacco. And so there are, just as there is a risk involved with most things in life, but they are tiny compared to the risks associated with smoking cigarettes. Glaxo might just as well say:

A lot of people believe that eating chocolate is safer than smoking cigarettes. This is not true.

Or, indeed:

A lot of people believe that using Nicorette is safer than smoking cigarettes. This is not true.

We have seen this kind of fabrication before from the US Surgeon General (amongst others). Under the Data Quality Act, his office finally had to retract the lie that smokeless is not safer. I covered this in an article entitled The Untouchables back in 2008.

In 2004, the National Legal and Policy Center complained about a statement in a booklet produced by the National Institute on Aging which read: "Some people think smokeless tobacco (chewing tobacco and snuff), pipes, and cigars are safer than cigarettes. They are not." This was, of course, false. Smokeless tobacco is known to be around 98% safer than cigarettes. The complaint was upheld and as a result, the US Government is no longer allowed to pretend that the health risks associated with smokeless tobacco are as great as those associated with cigarettes*.

The upshot is that the National Institute on Aging now says: "Some people think smokeless tobacco (chewing tobacco and snuff), pipes, and cigars are safe. They are not." And former Surgeon General Richard Carmona - whose 2006 report into passive smoking is one big DQA complaint waiting to happen - had to subtly change his tune from "smokeless tobacco is not a safer substitute for cigarette smoking" to "smokeless tobacco is not a safe substitute for cigarette smoking" (my italics). 

A slender difference indeed, but an important one, because at least now these statements are not outright lies. What has replaced them may still be misleading - they do not hint at how much safer smokeless tobacco is - but, as Jacob Sullum asked sardonically in Reason magazine, "Why lie about smokeless tobacco when a misleading half-truth will do?" Demanding half-truths rather than outright lies from the anti-smoking lobby might be the most that can be hoped for in this day and age. The Data Quality Act may be the only way to get them.

* Anti-smoking groups, websites and charities who are not publicly owned remain be free to lie about smokeless tobacco and frequently do. For example: "The fact is, chewing tobacco is every bit as dangerous as smoking it." or "There's a widely held myth that smokeless tobacco is a safe alternative to cigarettes, when actually it's just as dangerous as smoking."

Thanks to Bill Godshall for the tip.

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Talking sense on smokeless

Several recent news articles have flagged up the madness of prohibiting less hazardous tobacco products like snus, dip and (if you can call it a tobacco product) the e-cigarette.

From Forbes:

Antismoking crusaders treat all tobacco products as equally lethal. They aren't. The smokeless varieties--nicotine strips, lozenges, snuff, chewing tobacco and the like--are dramatically less harmful than traditional cigarettes. Yet Washington prohibits companies from marketing smokeless products as a safer alternative. This is murderously foolish.

It's difficult to argue with this, but that doesn't stop the intensive care contingent of the anti-smoking lobby trying. The usual cliche is to say that switching from cigarettes to safer alternatives is like jumping from the 30th floor of a building instead of the 35th. This is garbage. In the case of smokeless tobacco products, it's more like climbing out of a ground-floor window. People who know much more than me about these things say that these products are at least 99% safe. 

From the Wall Street Journal:

The experience of another effort to induce American smokers to switch clouds the picture for Terry Pechacek, associate director for science in the Centers for Disease Control and Prevention's office on smoking and health. He recalls that many smokers switched to low-tar cigarettes beginning in the 1960s, under the mistaken belief they were safer. "We need to be careful not to repeat this experience," says Dr. Pechacek. Public-health officials, he adds, are reluctant to advocate any form of tobacco use. "We do not need to make the American public guinea pigs."

But the American public already are guinea pigs, Mr Pechacek. They are guinea pigs in an experiment to rid the country of a plant that has been used as a extremely popular recreational drug for thousands of years. No one knows how such an experiment is going to end, but the omens from history are not good.

The comparison with low-tar cigarettes is, in any case, a dubious one. Apart from the fact that there is ample evidence that the high-yield cigarettes of the 1960s were more hazardous than today's brands, there is no knowing how many people would have quit if tar yields had remained high. I suspect not too many. More importantly, cigarettes of whatever strength are not analogous to snus, smokeless and e-cigarettes—there is a vast difference in risk.

The New York Times Freakonomics blog gets to the nuts and bolts of the issue in characteristic style. 

Offer a life raft and more people will jump off a sinking ship. Many will be saved, but some will drown off the life raft.

Mandatory seat belts do this—lives are saved, but people also drive faster and more accidents occur.

Sex education does this—there are fewer pregnancies per sexual encounter, but more sexual encounters are undertaken.

Unemployment insurance does this—it is a life raft for the working, but it attracts people into the workforce who are more likely than others to be unemployed.

I’ll bet that snus, like the other examples, will reduce the total damages of the risky behavior, but more people will engage in the behavior because they expect its costs to be lower.

As Carl V. Philips said in Liverpool two weeks ago, reducing risk is likely to increase usage. Let's not pretend otherwise. The question is what the overall impact on public health? Smokeless tobacco reduces risk to the individual and it reduces the risk in population terms. So what's not to like?

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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.”

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E-cigarettes - safe for now

Last month I posed the question of whether British anti-smoking groups would follow in the foot-steps of their American cousins and call for e-cigarettes to be banned. 

As I mentioned, ASH (UK) has a remit of encouraging safer forms of nicotine use (they support the legalisation of snus, for example). Furthermore, the amount of money British anti-smoking groups receive from pharmaceutical companies is a trickle compared to the river of cash spent in the US by GlaxoSmithKline, Pfizer and Johnson & Johnson (the latter, via the RWJF).

This question has now been partly answered by an ASH (UK) fact-sheet [PDF] which states the organisation's position:

ASH supports a harm reduction approach to tobacco, that is, we recognise that whilst efforts to help people stop smoking should remain a priority, many people either do not wish to stop smoking or find it very hard to do so. For this group, we believe that products should be made available that deliver nicotine in a safe way, without the harmful components found in tobacco.

Most of the diseases associated with smoking are caused by inhaling smoke which contains thousands of toxic chemicals. By contrast, nicotine is relatively safe.

Therefore, e-cigarettes, which deliver nicotine without the harmful toxins found in tobacco smoke, are likely to be a safer alternative to smoking. In addition, e-cigarettes reduce secondhand smoke exposure since they do not produce smoke.

This is level-headed stuff and is good news for smokers who wish to quit. There is an abundance of evidence (albeit anecdotal) that the e-cigarette is the most effective smoking-cessation device yet invented. Banning it would be madness from a public health point of view. 

ASH (UK)'s assertion that e-cigarettes do not create secondhand smoke is a statement of the obvious, but is nonetheless welcome since their American namesakes have been making laughably hysterical claims to the contrary, such as this, from the ASH (US) website:

A new device for addicted smokers who want to be able to get their nicotine fix by “smoking” in places where smoking is prohibited, and do so by exhaling a cloud of “smoke” made up of a chemical which is both toxic and addictive.

This new product, already being sold and used in many U.S. cities, is called an e-cigarette...

If you don’t want people sitting next to you – in a waiting room, restaurant, bar, or any other area where smoking is now prohibited – using one of these devices to get around smoking bans, and forcing you and your loved ones to inhale deadly nicotine – please help now!

We should be thankful that ASH (UK) haven't sunk to this level of fear-mongering. Nonetheless, they have three reservations about e-cigarettes.

1. Most deliver a low dose of nicotine which may not give a typical smoker a sufficient ‘hit’ to satisfy cravings, discouraging smokers from continuing to use them.

2. Because the products are unregulated there are some concerns about their safety since few manufacturers disclose the ingredients of their products.

3. So far, there have been no clinical trials to prove that they can help people to stop smoking. In the absence of such evidence, ASH therefore recommends that people who want to quit smoking should use nicotine replacement therapy or other proven pharmacological aids such as Champix (varenicline) or Zyban (bupropion).

I don't believe that the first point is valid. E-cigarettes offer high, medium, low and zero nicotine cartridges and I haven't heard users complain that the high nicotine cartridges are insufficient. Besides, users can take as many drags as they need to increase the dose. ASH's criticism could more accurately be aimed at pharmaceutical nicotine devices like patches and gum.

The second point is moot. Already, we are getting a clear indication that there are very few ingredients in the devices and that none of them - nicotine included - are harmful at the doses found. Nevertheless, regulation is required and is welcomed by the e-cigarette industry. As ASH points out: 

...e-cigarettes are subject to general consumer protection laws and it is the responsibility of trading standards officers to rule on their safety.

That should be sufficient regulation.

The third point is also questionable. It is true that clinical trials have not yet shown e-cigarettes to be effective as smoking-cessation devices, but then they are not being marketed as such. On the other hand, they have not been shown to be harmful. The same cannot be said for Champix and Zyban which, between them, have been linked to 317 suicides or attempted suicides. 

In July, the FDA ruled that black-box warnings must be put on both these products:

FDA: Boxed Warning on Serious Mental Health Events to be Required for Chantix and Zyban 

The U.S. Food and Drug Administration today announced that it is requiring manufacturers to put a Boxed Warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs.

This leaves consumers with a choice between a product that has not been clinically proven as a stop-smoking device but is safe, and two products that have been proven to cause psychotic disorders. That ASH (UK) is recommending the latter may seem perverse, but at least they are still allowing a choice.

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Government to encourage smoking

Not the smoking of tobacco, of course, but the smoking of heroin...

Heroin addicts could be given free aluminium foil to encourage them to smoke rather than inject the class A drug under plans being considered by government advisers.

Few would disagree that injecting heroin is more dangerous than smoking it. As a harm reduction strategy, this proposal has a certain superficial logic to it, but as a practical matter it is - surely - a pointless waste of time. Heroin users inject the drug because it is the most efficient way of taking it, not because they can't afford a bit of tin foil.

But what I find particularly interesting about this story is the contrast between harm reduction policies with heroin, which is completely illegal, and tobacco, which isn't. In the field of tobacco there are various alternatives - snuff, snus, e-cigarettes or even pipes and hookah - which are known to reduce or eliminate the health risks associated with cigarettes, and yet it is fashionable to pretend that this is not so.

The article goes on to explain that health professionals are already able to give away free syringes to heroin addicts. Government policy regarding hard drugs has an element of realism. There is an acceptance that not all users will simply give up. There is an acceptance that there will never be a drug-free world and so we should minimise the health risks associated with them. In the field of tobacco, however, the quit-or-die approach still reigns supreme. It is a smoke-free world or nothing.

It is now almost 60 years since Doll and Hill published their first study showing the link between lung cancer and smoking and yet there are more smokers in the world than ever before. It is safe to say there will be more smokers in the world next year than there are now.

Despite this, the public health community acts as if the eradication of tobacco is just around the corner. Any attempt to reduce the risks from tobacco is verbatim verboten because it might 'encourage' people to keep smoking. They don't appear to worry that handing out free foil and syringes might 'encourage' people to keep taking heroin.

We accept that the war on drugs can never be won and we spend public money helping heroin addicts to take their drug more safely. At the same time, e-cigarettes are being banned, snus is illegal throughout most of Europe, smokeless tobacco is being unfairly maligned and hookah is the subject of hysterical news stories. 

Does tobacco have to be illegal before we look at sensible harm reduction policies?

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The plain packaging ruse

Every day, millions of tiny miracles happen in shops throughout Britain. Customers walk in and ask for products that do not exist and have not existed for years. The shopkeeper hands over these products, the customer hands over their money, and that is that. These non-existent products include such items as Marlboro Lights, Camel Lights and Silk Cut Ultra.

Since 2002, the EU has banned words like 'light' and 'low tar' from appearing on cigarette packs. And yet low tar cigarettes do exist. The shopkeeper knows it. The customer knows it. The side of the pack explicitly shows how much tar and nicotine are contained within. For the sake of propriety, however, we must all pretend that this is not so.

Everyone knows, for example, that Marlboros in a gold pack are really Marlboro Lights, and everyone knows that Marlboro Lights have less tar in them than Marlboro Reds. But this cannot be openly admitted and the BBC goes along with the game:

Marlboro packs with a gold label were rated as having a lower health risk by 53% of adults and easier to quit by 31%, when compared with the Marlboro packs with a red logo.

The BBC are reporting here yet more unpublished 'new research'. This time the research suggests that some customers believe Marlboro Lights 'Marlboro packs with a gold label' are less harmful to health than Marlboros with a higher tar content. Professor David Hammond, from the University of Waterloo, Ontario, says that this is a fallacy:

"The truth is that all cigarettes are equally hazardous, regardless of what colour the pack is or what words appear on it."

Well perhaps. Or perhaps not. The truth is that people have not been smoking ultra-low tar cigarettes for long enough for us to see if there is any reduction in risk. And by the standards of previous decades, all cigarettes currently on sale in the EU are ultra-low tar.

But there is some evidence that lowering tar yields has reduced risk in the past, such as in this study:

The tendency for the risk of lung cancer to increase with increasing tar content was consistent among men and women.

The results provide further support for the hypothesis that the tar content of cigarettes is directly related to lung cancer risk.

And even ASH have not always been fundamentalist in their opposition to lower yields. Here is Karen Williams, ASH's former campaign director, talking in 1995:

"There are no safe tar levels in cigarettes but basically the higher the tar the greater danger to health. It is nicotine which is addictive and the more nicotine there is in a cigarette the greater the chance there is of reinforcing the habit and making it harder to stop."

The EU appears to agree with this. After all, if they believe that all cigarettes are equally harmful, why did they set a maximum tar level of 15mg in 1992? As Man Widdecombe has pointed out:

Hold on a second, didn't the EU regulate the amount of tar and nicotine in cigarettes because of health reasons?

Directive 90/239/EEC established maximum limits for the tar yield of cigarettes marketed in the Member States with effect from 31 December 1992. The carcinogenic nature of tar makes it necessary to reduce further the levels of tar in cigarettes.

If high tar cigarettes are not more hazardous than low tar cigarettes, why would the EU bother to bring in this ban? Why, indeed, would they go on to lower the legal limit to 12mg (in 1998) and then to 10mg (in 2004)? Presumably because 12mg tar is better than 15mg, and 10mg is better still.

So by what magical process does reducing tar yields from 12mg to 10mg reduce risk when, as we are now being told, switching from a 10mg tar cigarette to a 1mg cigarette makes no difference? Either low tar cigarettes are less hazardous (in which case the government should not be pretending otherwise) or all cigarettes are equally harmful (in which case the EU ban is pointless and they should allow high tar cigarettes back on the market).

Like most 'new research' in the field of tobacco, this study has a political objective. In this instance, it is to persuade the government to force the tobacco industry to wrap their cigarettes in plain packaging with no logo, words or colours.

Subtle branding on cigarette packets is misleading smokers into believing some products are less harmful than others, research suggests.

Products branded "smooth", "silver" or "gold" are generally believed to be healthier and easier to give up, a survey of 1,300 people found.

But when shown plain packs the false beliefs disappeared, University of Nottingham researchers discovered.

How this plain packaging ruse will work in practice remains a mystery. The anti-smoking lobby are not calling for all cigarettes to have the same tar and nicotine yields, so 'light' cigarettes will still exist, even if they cannot be called that. And if they exist, they must surely still be identifiable as different products in some way, even if they have to be called something like Marlboro A and Marlboro B. And if they are identifiable, consumers and shopkeepers will still know that Marlboro B are really Marlboro Lights.

Perhaps, in the future, this information will be passed on from father to son and from mother to daughter. Perhaps the very existence of low tar cigarettes will only be confirmed by whispered conversations on street corners. How ever it is passed on, that knowledge will survive. Short of erasing the collective memory of the nation, it is difficult to see how this latest phase in smoking's denormalisation will achieve what it sets out to do.

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Pigeon amongst the cats

Now this should be interesting...

E-CIGARETTE COMPANY DONATIONS TO CANCER RESEARCH UK

UK Electronic Cigarette company cheapelectroniccigarettes.co.uk are today launching a scheme which will see 10p of every product sold being donated to Cancer Research UK.

Owner Michael Kitt stated, “We sell a lot of electronic cigarettes all over the world and feel that it is only right that we also support a charity which has the same vision as us – creating a smoke free environment around the world by offering clean smoking without tobacco, tar and the thousands of other chemicals found in traditional cigarettes.”

What to make of this? As a commentator over at Smoking 2.0 says:

Are they mad?

Anti-tobacco want e-cigs outlawed too.

CRUK receive money from pharma companies who are in direct competition with e-cigs.

Anti-tobacco certainly want e-cigarettes banned in the US, and have already succeeded in Australia, but what is the situation in the UK? One of ASH's stated objectives is "harm reduction", of which they say:

One way of reducing the harm caused by tobacco may be to facilitate the switch from smoked tobacco products to the use of ‘clean’, non-tobacco, nicotine products.

For years, ASH have officially supported the legalisation of snus, saying (in 2004) "there is no logic to the banning of snus, when cigarettes, which are far more deadly, are on general sale".

ASH director, Deborah Arnott, said in 2006:

"We currently have a situation where the safest form of smokeless tobacco in the EU is banned, and that's the form on sale in Sweden [snus]."

More recently, she claimed that:

"ASH is not fundamentalist about nicotine.''

This year, ASH's Martin Dockrell reiterated the point that nicotine itself is not harmful:

"Think of cigarettes as the dirty syringe of nicotine addiction. If you could get heroin that didn't cause any harm, what would be the problem? If you could nicotine that didn't harm people's health, what would be the problem?

I think we would like to see faster, stronger nicotine delivery systems available to smokers."

The truth is that ASH (UK) have never been "fundamentalist" about nicotine. They were set up in 1971 with a mission to reduce harm and although it is one of their most low-key campaigns, they do want to see the EU ban on snus overturned. With their objective of tobacco harm reduction, it is difficult to see how they can oppose the e-cigarette which is, undoubtedly, a "faster, stronger nicotine delivery system".

ASH (UK) have not, so far, demanded a ban on e-cigarettes (unlike their American namesakes). Since ASH receives substantial funding from Cancer Research, these new donations from the e-cigarette industry should ensure that things stay that way. Or will pressure from American fundamentalists and Big Pharma prevail?

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1+1=11: The Untouchables (part 5)

In this series of articles we have looked at a number of clear-cut examples of the public being misled by false information based on shoddy data and faulty reasoning. It is not necessary to speculate on whether these scientific howlers were the result of simple incompetence or calculated dishonesty. It is enough to know that these untruths have been endorsed by major governmental and not-for-profit organisations around the world and consequently have filtered down to the public as facts.

Part of the problem is that powerful government bodies such as the Environmental Protection Agency have, over the last 25 years, become home to radicals and former activists who are instinctively antagonistic towards the private sector and any kind of perceived corporate interest.

Nearly all the big names in anti-tobacco activism in the past 40 years have managed to make careers of what was once their hobby. To name just three, James Repace - the subject of our first article - joined the EPA in 1979. Stanton Glantz - the founder of Americans for Nonsmokers Rights - currently runs the pressure groups SmokeFree Movies and TobaccoScam in addition to his work as the American Legacy Foundation's Distinguished Professor of Tobacco Control and the Director of the Center for Tobacco Control Research and Education. Simon Chapman, who founded the fanatical Australian anti-smoking outfit MOP-UP in the 1970s, is a correspondent for the British Medical Journal and editor of the international anti-smoking journal Tobacco Control.

Countless lesser names with similar extreme views hold posts in environmental and public health organisations around the world. There is no great surprise. We all aspire to having a job which combines business with pleasure and many of us prefer to work and socialise with those who share similar views and backgrounds. How often do we hear people say that they don't know anybody who disagrees with their point of view on a certain issue, even when opinion polls show that the public is deeply divided on it? But while it is attractive to work with people of the same mindset, it tends to mean that you are less likely to hear views that contradict with your own. The limits of debate become narrow and this is never a good thing for science.

One consequence of these institutions being dominated by former crusaders is that the peer-review process is often carried out by a self-selecting team of like-minded individuals with a shared agenda. If the studies examined in this series of articles are any indication, peer-reviewers are either not reading submitted papers properly or are so blinded by ideology that they will allow any rubbish to make it into print for the benefit of what they view as the greater good. Since these studies ultimately help to dictate policy, the agencies which finance and propagate research have become judge, jury and executioner on a whole range of health and environmental issues without ever being accountable to anyone but themselves. They are, in short, untouchable.

The infamous EPA report on secondhand smoke is a case in point. This wretchedly dishonest document (which James Repace's department, in his own words, "were able to convince EPA top management to initiate") will be familiar to many readers (if not, please see here.)

So biased and twisted was the EPA's conduct in fabricating the evidence for the passive smoking theory, that the tobacco industry took the agency to the District Court and won. The judge ruled that the EPA had decided from the outset that secondhand smoke was a killer and had bent the facts to fit the theory. The following extract from Judge Osteen's summing-up gives us an insight into how the EPA came to declare secondhand smoke a 'group A carcinogen':

"EPA publicly committed to a conclusion before research had begun; excluded industry by violating the Act's procedural requirements; adjusted established procedure and scientific norms to validate the Agency's public conclusion, and aggressively utilized the Act's authority to disseminate findings to establish a de facto regulatory scheme intended to restrict Plaintiffs, products and to influence public opinion. In conducting the ETS Risk Assessment, disregarded information and made findings on selective information; did not disseminate significant epidemiologic information; deviated from its Risk Assessment Guidelines; failed to disclose important findings and reasoning; and left significant questions without answers. EPA's conduct left substantial holes in the administrative record. While so doing, produced limited evidence, then claimed the weight of the Agency's research evidence demonstrated ETS causes cancer." (1)

This court case graphically illustrated how the EPA had manipulated data, ignored evidence, disseminated false information and abused its power and yet the court's ruling did nothing to stem the tide of legislation against smokers that the EPA had unleashed in the 1990s.

What happened next showed that even when you win against the EPA, you lose. In 2001, the EPA appealed the decision and won on an obscure but important technicality. The EPA protested that since it did not have the power to make laws, it could not be held accountable for any legislation its 'guidelines' might have instigated. The District Court did not, therefore, have jurisdiction to overrule it. Finding in favour of the EPA, the appeal judge declared:

"The consequences complained of by plaintiffs [eg. smoking bans] stem from independent actions taken by third parties. Even if other agencies have relied on the Report in imposing tobacco related restrictions, these regulations are not direct consequences of the Report, but are the product of independent agency decision making." (2)

The appeals court did not challenge a single word Judge Osteen had said in condemning the EPA's near-criminal abuse of power but was forced to concede that, in law, the EPA existed to carry out research and that there were no direct legal or regulatory consequences from anything they reported. This was technically true, even if it was laughable in practice, and the appeals court freely admitted that "The practical consequences of the EPA Report are great and affect the livelihood of thousands" - a reference to tobacco farmers, retailers, restaurant owners etc.

Everyone knew that the EPA's report had had an unprecedented influence on government policy and had played a huge role in persuading lawmakers in the USA and beyond to pass legislation to 'protect' nonsmokers from secondhand smoke. And yet the EPA remained untouchable. It could say anything it liked on any matter without fear of being brought to book in a court of law or be held accountable for the practical consequences of what it said. It could "make findings on selective information", it could "fail to disclose important findings", it could "disregard information" and it could "leave significant holes in the administrative record." It could, in short, do and say whatever it liked, knowing full well that its judgement would be trusted by lawmakers and that its recommendations would be turned into law. But even when its dishonesty and incompetence were exposed for all to see, it would never be held accountable for anything or be prosecuted by anyone.

A glimmer of hope?

It is something of an irony that environmental and health organisations so often complain about industry being "completely unregulated" when they are subject to virtually no checks and balances themselves. There is, however, one glimmer of hope, for Americans at least.

In 2000, an obscure law tacked onto an appropriations bill - the Data Quality Act (DQA) - went some small way towards redressing the balance. Under the DQA, more than 90 Federal agencies are required to publish guidelines for basic standards to ensure the "quality, objectivity, utility, and integrity of information (including statistical information) disseminated".

Affected persons can challenge the agency and request a correction if they can show the information to be false. If the agency refuses, that person can sue. Furthermore, all raw data produced by federally funded research must be made available to the public upon request. The idea is to allow the American taxpayer - who ultimately pays for such research - to see what they are getting for their money while making it possible to have demonstrably false claims retracted.

"It's the information age," said Jim Tozzi, the main instigator of the bill, "Now in the world's most powerful government you're going to have to issue information that's accurate." Who could argue with that?

As it turns out, quite a few people could argue with that. The left-wing journalist Chris Mooney called the DQA "the regulation to end all regulation" and the Washington Post's Rick Weiss dubbed it "the nemesis of regulation". These critics articulated a widely held fear amongst activists that the new emphasis on "objectivity" and "integrity" would make it difficult for environmental health laws to be passed. This says more about the standard of their evidence than it does about the DQA.

The bill was signed off in the last days of the Clinton administration but opponents depicted it as a typically Republican piece of legislation, sponsored by a former tobacco industry consultant and co-written by big business. At best, they said, it would slow the pace of regulation. At worst, it would bring it to a crunching halt. And yet, the requirements of the DQA were so modest that it was hard to see how any honest scientist could have anything to fear:

"'Utility' refers to the usefulness of the information to the intended users. 'Objectivity' focuses on whether the disseminated information is being presented in an accurate, clear, complete, and unbiased manner, and as a matter of substance, is accurate, reliable, and unbiased. 'Integrity' refers to security - the protection of information from unauthorized access or revision, to ensure that the information is not compromised through corruption or falsification. If an agency disseminates influential scientific, financial, or statistical information, that information must meet a reproducibility standard. Analytic results related to influential scientific, financial, or statistical information, must generally be sufficiently transparent about data, methods, models, assumptions, and statistical procedures that an independent reanalysis (or more practically, tests for sensitivity, uncertainty, or robustness) could be undertaken by a qualified member of the public." (3)

The fears of the likes of Chris Mooney have not been realised. Eight years after it was passed, most Americans are still unaware that the Data Quality Act even exists. Agencies have not, as some predicted, been tied up in interminable wrangling over arcane technicalities and important legislation has not been delayed. Government regulation has not slowed down and the bureaucratic machine has rolled on much as before. The DQA has been used in practice as it was intended - as a means of correcting blatantly false information. It just hasn't been used a great deal.

Predictably enough, the EPA have received the lion's share of complaints, with challenges to their data coming from everyone from the American Chemistry Council to the National Association of Home Builders. Altogether, only around 100 complaints have made under the new law in 8 years. Few are of much interest to you or me, but a few cases stand out.

Although it was predicted that the DQA would be used exclusively by right-wing industrialists, the left soon discovered that a law requiring accuracy and truthfulness could have its uses. The DQA has been used to challenge federal government's funding of family planning campaigns that emphasised abstinance-until-marriage (see here) and Public Employees for Environmental Responsibility, an environmental pressure group, has filed complaints against the Defense Department and the Fish and Wildlife Service.

Perhaps the most high profile petition has come from Americans for Safe Access, an organisation that campaigns for marijuana to be legalised for medical use. Since 2004, they have filed two complaints with the Health and Human Services (HHS) and the Food and Drug Administration (FDA), challenging its claim that "marijuana has no accepted medical value." Having got nowhere with their complaints, Americans for Safe Access filed a lawsuit and are now in the process of suing the FDA on the basis that the agency's "position on medical cannabis is incorrect, dishonest and a flagrant violation of laws requiring the government to base policy on sound science."

As this series of articles has shown, "sound science" is not always to be found in abundance in the anti-smoking movement. Most anti-smoking groups are not subject to the DQA because they are non-governmental organisations, even if they are granted very large sums of taxpayers' money. But while ASH and GASP are safe from the law, the FDA, the EPA and the Surgeon General are not.

The Data Quality Act has so far been used just twice in relation to tobacco. Philip Morris has employed it as a tool in their long-standing efforts to view the raw data of Elizabeth Fontham's secondhand smoke study of 1994. It is no surprise that the tobacco company is curious to see this data since the study remains, to this day, the only American study to have ever found a statistically significant association between secondhand smoke and lung cancer.

Fontham and her team have fought tooth and nail to suppress the data and anti-smokers have long feared that it may one day come to light. The Fontham researchers have explained their reluctance to allow the source material to be viewed by claiming that Philip Morris will manipulate it to show no risk. Commenting on Philip Morris's assumed motives, Fontham's co-author Patricia Buffler made a perceptive, if unintentional, remark about the problems of low-risk epidemiology, saying: "If you know anything about statistics, adjustments can be made to produce conflicting results." Quite so. And it is because of this - and because the Fontham finding was so unusual - that this data should be made public, available not just to Philip Morris, but to anyone who wishes to see it.*

In 2004, the National Legal and Policy Center complained about a statement in a booklet produced by the National Institute on Aging which read: "Some people think smokeless tobacco (chewing tobacco and snuff), pipes, and cigars are safer than cigarettes. They are not." This was, of course, false. Smokeless tobacco is known to be around 98% safer than cigarettes. The complaint was upheld and as a result, the US Government is no longer allowed to pretend that the health risks associated with smokeless tobacco are as great as those associated with cigarettes**.

The upshot is that the National Institute on Aging has removed one letter of one word from its statement, which now reads: "Some people think smokeless tobacco (chewing tobacco and snuff), pipes, and cigars are safe. They are not." Former Surgeon General Richard Carmona - whose 2006 report into passive smoking is one big DQA complaint waiting to happen - had to subtly change his tune from "smokeless tobacco is not a safer substitute for cigarette smoking" to "smokeless tobacco is not a safe substitute for cigarette smoking" (my italics). A slender difference indeed but an important one, because at least now these statements are not outright lies. What has replaced them may still be misleading - they do not hint at how much safer smokeless tobacco is - but, as Jacob Sullum asked sardonically in Reason magazine, "Why lie about smokeless tobacco when a misleading half-truth will do?" Demanding half-truths rather than outright lies from the anti-smoking lobby might be the most that can be hoped for in this day and age. The Data Quality Act may be the only way to get them.


* I have heard that PM have succeeded in obtaining this data but I cannot find official confirmation. If anyone has information please e-mail me. It is interesting to note, from Philip Morris's internal documents, that PM expected a 'best case' and 'worst case' outcome from obtaining the Fontham data. Either: "We get the data from the Fontham study and prove it does not show any association between ETS and disease" or "We do the reanalysis of the Fontham data and an association remains" (4). If it was PM's intention to manipulate the figures to its advantage - as Buffler suggested - the author of this piece would surely not have bothered speculating about the 'worst case' scenario.

** Anti-smoking groups, websites and charities who are not publicly owned remain be free to lie about smokeless tobacco and frequently do. For example: "The fact is, chewing tobacco is every bit as dangerous as smoking it." or "There's a widely held myth that smokeless tobacco is a safe alternative to cigarettes, when actually it's just as dangerous as smoking."



(1) http://www.tobacco.org/Documents/980717osteen.html (p. 80-81) (p.16)

(2) http://pacer.ca4.uscourts.gov/opinion.pdf/982407.P.pdf". (p 14)[pdf]

(3) http://www.thecre.com/misc/20040606_worms.htm

(4) http://www.ajph.org/cgi/content/full/95/S1/S20#T3 (see table 3)

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