Where health meets politics: examining the pressure to restrict
vaping and THR in order to protect the smoking economy
Electronic cigarettes: fact and faction
Prof Robert West introduces an interesting new concept: his personal measure of the scale of the potential reduction in smoking mortality due to ecig take-up. This figure does not appear to align with Britton's figure (5 million deaths preventable just among UK smokers alive today); though all such numbers are simply guesses about hypothetical situations in any case. West thinks that there will be a reduction of 6,000 deaths per year per million smokers who switch (presumably after a circa 25 year timelag, although this isn't stated).
This indicates that with a smoker population of about 10 or 11 million in the UK at present (2014) and 100,000 deaths a year (reportedly), then if all smokers switched, the reduction would be of the order of 66,000 deaths; leaving 34,000 deaths a year from vaping. I feel this number is rather difficult to support, since 1,000 deaths a year in a vaping population of 10 or 12 million would be a significant number given that there are few if any disease factors apparent; and uncommon genetic predispositions, rare intolerances, pre-existing morbidities and occasional serious product contamination issues would be required to produce even that number. The huge number of deaths West potentially attributes to vaping (which apparently equals only about a 66% reduction compared to smoking-related mortality if the currently-accepted smoking-related mortality figure of 100k per year is used as the base figure) is apparently predicated on the time it took to associate lung cancer with smoking, and the variability in vaping technologies and practice. Perhaps playing safe to this extent is unwarranted.
However: another completely different interpretation of this is as follows - if West does not believe that UK smoking causes 100,000 deaths a year, and perhaps only (say) 70,000 deaths a year: then his projected vaping mortality rate looks a great deal more practical: fairly close to other projections that assume that, if there are no toxins in the inhaled aerosol observable in morbidity-creating doses, then the mortality rate that can be expected is extremely low.
Even so, there would need to be new diseases created by very low concentrations of toxins, since the smoking-related diseases caused by much higher doses of these toxins are considered to be all but impossible with the tiny amounts present in ecig aerosol. The balance of current opinion is that ecigs are about 1,000 times less toxic than cigarettes (see UK NHS for example). There is no reason why new fatal diseases cannot appear; indeed, we might consider this quite likely in future gen pop projections, considering the growth in new toxins in the environment and the food chain - just that attributing large numbers of deaths to currently unknown diseases newly created by vaping is not seen as a reliable position at this time.
In the end, West's position on the possible mortality rate directly attributable to vaping, as against his stated opinion on the potential reduction compared to smoking, is dependent on his exact, and unstated, figure for current annual smoking-attributable mortality per million smokers - perhaps a rather clever position to take. It has been suggested that this is a bit of a cop-out, since he doesn't say either how many people he thinks smoking kills, or how many people vaping will kill; but many of us will forgive him for this. Going up against the public health industry and its funders is professional suicide.
There are few enough honest public health professionals, since truth and honesty in public health is a route to vilification - it always has been, ever since John Snow - and we need the few honest ones to keep their jobs where possible. You have to make a personal decision about West's approach: is it acceptable to say what the potential gains might be, without rocking the boat? On balance I'm OK with it because it means he'll keep his job and his funding. The implication is that vaping will kill a lot of people, of course - if you believe the tobacco control industry's figure for current smoking mortality. On the other hand, if you believe anything originating from mainstream tobacco control, you need your head examined.
[this post was transferred across from the old blog system here, and the comments are reproduced below]
I have been suspicious of Prof West's numbers since being intrigued by his 'smoking pipe' model.It appeared in the Smokefree funding proposal showing a decrease in prevalence for calendar year 2011 of 0.02% - approx 8,600(Para 3.5)
The next version is on his website for mid 2011 to mid 2012 and shows a decrease in the no. of smokers of 445k.With an adult population in England of ~43m,this is a prevalence fall of 1%
So,we have gone from 8,600 to 445,000 in 6 months - the world of TC should have been descending on his dept to find out why - but perhaps they already knew.
ChrisPrice4 > dodderer1
Perhaps there are too many unknowns in all such figures to come to any conclusion. However, we do know this:
1. Smoking prevalence remained unchanged at ~20% after 2008.
2. Since the population grew strongly, so did a 20% slice of it (unless some other factor operated to prevent growth - and nothing did so for smokers).
3. A fag-packet calc then indicates that the number of UK smokers grew by 0.5 million between 2008 and 2013.
4. At some point after 2010, the number of smokers started to be reduced by the switch to ecigs.
5. By late 2013, we are told that the number of ex-smokers due to ecigs was 0.7 million.
6. By late 2013 smoking prevalence was showing its first fall in 5 years.
It doesn't look too hard to reconcile all these figures (including perhaps the numbers you give), although that is a known trap as the easy answer isn't necessarily right... Fairly soon we'll be seeing 1 million UK ex-smokers due to ecigs, though, and that number is significant: somewhere around 10% of smokers will have quit, voluntarily and without any medical, public health, industry or state support. Despite it, in fact.
This is one of the problems, no doubt...
Norbert Zillatron > ChrisPrice4
And we will probably see a drastic increase of smokers again, when the EU and the planned WHO defacto prohibition run amok in national laws and exterminate all the working devices and the variety of flavours. Not later than 2016.
I'm wondering what sanctimonious excuses they are already preparing to explain this predictable disaster. Probably they'll blame "BigVape" for boycotting their glorious plans and not providing good, compliant devices ...
Ignoring that this is an oxymoron. Morons.
ChrisPrice4 > Norbert Zillatron
As you say Norbert, once the US and EU restrictions come in, smoking will get a big boost. That's what is designed to happen of course.
ChrisPrice4 > Norbert Zillatron
West has now released an update and I've re-blogged about it:
Update Sept 9th
The previous blog post outlined Prof West's estimate of smoking vs vaping mortality risk. The numbers are for the UK but could be extrapolated for other locations:
There were some woolly edges in this, which invited comment from the ecig community and some of his peers. Prof West has now clarified his statement regarding the number of smokers who die from smoking and the number of vapers who might possibly die from vaping:
A quote from the update article, referring to UK numbers:
At current smoking prevalence of around 19%, the 9 million smokers will correspond to a long term death toll of 60,000 per year, or about 6,670 premature death per year for every million smokers. Even if e-cigarettes were to carry a significant risk of death, say 1/20th that of cigarettes at the upper end, this would reduce to 330 premature deaths per year for every million smokers saving more than 6,000 lives. This is a conservative estimate, as Professor West explains: “It's very conservative because the main toxins from cigarette smoke are either completely absent or in much lower concentrations than 1/20th.”
- R West, J Brown
To make these points clearer, what he is saying is:
- Smoking deaths will reduce anyway by 40% after the timelag required, from 100,000 per year today (the figure usually quoted for an estimate of smoking-related mortality, in the UK, in 2014, by public health sources) to 60,000 per year, which is 6,670 per million smokers per year (this is 0.67% smoker mortality per annum - the percentage of all smokers who die in any given year).
- This 40% reduction in the smoking death toll will (presumably) be due either to the reduction of the number of smokers to 9 million from a figure previously 40% higher, or West's opinion that the currently-popular figure of 100,000 deaths per year is too high; or a combination of the two.
- And then, further to that, for every million smokers who switch to ecigs, more than 6,000 deaths will be avoided.
- For every million vapers, there will be at most 330 deaths. West states this is likely to be an upper figure as there are few if any toxic materials of significant quantity in ecig aerosol. In fact it looks a very conservative figure indeed (i.e. higher than some others might give), as some other form/s of fatal disease/s would be needed to reach even this scale of mortality given the absence of high-quantity high-potency toxins.
Therefore if there were to eventually be 10 million UK vapers, there would be at most 3,330 deaths per year (cf 100,000 a year, the most common figure quoted for smoking currently; thus about 3.3% of the usually-quoted smoking mortality rate for 2014).
This is a useful figure for comparisons because we can see what West's estimate of the scale of mortality is for UK all-smokers or all-vapers; and we know from Brad Rodu that there are about 8 million US ST users, for which it may be possible to estimate an equivalent figure for comparison and which would be interesting as the group size is similar; and we can compare it with the mortality rate per million within Snus users in Sweden - my fag-packet calc is 1.6 million Snusers (Swedish gen pop = 10m and ~20% of adults are Snusers).
The mortality rates for all these low-risk THR products are probably impossible to calculate accurately since:
- they are all going to be below reliably statistically-identifiable levels (1% or so);
- the effect of confounders will be greater for these very low numbers;
- low mortality rates are going to be intrinsically poorly-identified and reported;
- stats in many countries are political property and may be 'massaged' before release.
West's figure for ecig-related mortality is about 0.03% per annum, which is obviously far too small to identify by any statistical method, and could only be seen by very careful collation of individual death reports (the equivalent figure for UK smokers is about 0.75% per annum, if current numbers are given credence). Given this is his estimate of the highest likely number, it seems clear that ecig-related mortality is not, in his view, a big issue; compared of course to smoking, as all comparisons or caveats related to ecigs must be. You can either have smokers, or ST users, or vapers. You can't have zero - that is a fantasy.
Note about theoretical mortality rates
West's figure for possible ecig-related mortality is for a theoretical 'vacuum' situation where people have never smoked and where there is no timescale - in other words it applies after 20 or 30 years vaping, to never-smokers.
Note about timescales
When discussing smoking-related mortality it is necessary to point out that this must apply after about 25 years or so. Smokers who die prematurely as a result of smoking do so after 20, 30 or 40 years' smoking . So a timepoint has to be chosen where you are going to apply any nominal effect in a statement such as, "smoking kills x% of smokers". The minimum realistic timepoint would be at least 25 years down the line.
I'm only pointing these things out because of the application to vaping. Because West states that vaping might possibly result in the premature deaths of up to 330 people per million per year, it needs to be pointed out that this is (a) a 'vacuum' theoretical situation, where no one ever smoked and there are no other factors affecting the mortality rate , and (b) after 25 years or so when possible diseases resulting from vaping have had a reasonable chance to operate. Vaping is not going to kill large numbers of people in the near future: after 8 years there has not been a single confirmed death.
 Doll showed that - statistically, that is to say, on average - smokers lose 10 years of life; and that smokers who quit by the age of 35 will - statistically, that is to say, on average - lose none of those 10 years (if they quit by 35 then on average they suffer no lifespan loss). This raises all sorts of interesting questions; and Doll is regarded as an unimpeachable source.
 As an example of this, oropharyngeal cancers (mouth cancers) associated with smoking are believed to be accelerated by drinking, and especially by heavy drinking. So, other factors can operate to promote / mitigate disease effects.
An analysis of the first two sentences of an article in a medical journal:
Commentary “Electronic Cigarettes”, and the psychobiogical problems of continued nicotine dependency in E-cigarette ‘vapers’.
Starting with the title: there appears to be a typo - a missing "on" after Commentary, or a colon perhaps. Then, getting past the first couple of words, a fleeting acquaintance with the topic would reveal that vapers routinely reduce their nicotine consumption as the final smoking event recedes in time. Cigarette smoking causes cigarette and nicotine dependency and tolerance to nicotine. Consumption of pure nicotine, as in vaping, does neither; so vapers have to reduce the strength consumed, regularly, in order to avoid OD, as tolerance gradually reduces with time.
Shame the author doesn't have a clue about the subject; but this appears almost compulsory in social sciences these days, so let's move on.
The giant clanger (or clangers?) in the title is followed by two mistakes in the first fairly brief sentence. This doesn't bode well for the success of the rest... [No, old son, ecigs were invented so the inventor and his tens of millions of beneficiaries now and hundreds of millions in the future could keep on 'smoking' but without the death sentence; and whether something works or not determines its ultimate survival since every consumer product has an ultimate regulator: the market. If it's not fit for purpose it dies.] No one cares about your artificial, expensive and very silly attempts at measuring 'success' as it's far simpler and harsher than that in the real world.
Reading on, sentence #2 has three errors in its brief but spectacularly erroneous existence. Error #1: vaping does not facilitate continued tobacco smoking, because (a) the vast majority of ecig use is dual-use since most people don't quit on day 1 and it might take weeks (or months) to quit smoking; (b) therefore dual-use is the norm; (c) it leads to smoking cessation as vaping is a highly successful route to smoking cessation and QED this means dual-use; and (d) since vaping is currently the leading route to smoking cessation, it follows that dual-use is the most successful way to quit smoking (in the UK anyway). These points may or may not hold true in the California lie factory - it's hard to tell due to the volume of manure issuing from that direction. On the other hand, these lies come from Swansea not San Francisco.
Luckily we are very poor in the UK so the temptations of corruption are far less prevalent than in the USA, resulting in our public health liars lying less. At least that's what I think the reason is. However since this concerns a UK liar (or plank-thick f***wit) we must bite our tongues and soldier on. In fact this article reveals an interesting avoidance of the best, most current and most honest (real) science on vaping and smoking, which comes from the UK; it appears based on the best lies instead, which originate in the American lie factory. The mighty dollar has a lot to answer for.
Tell me, is it a principle of science that if you can't find any local facts to back your argument, despite the best in the world currently being available there, and everything available in your own country refutes every single point in your argument, you go to Calcutta or California to dig up some propaganda that suits your case? Ah - this explains a lot.
Mistake #2 in sentence #2 is that (in the UK) we don't have any child or youth vaping problem, as measured by honest and efficient statistics. The US may be different in many respects, one of which is the continual claims that significant numbers of children are regular vapers, partly because the stats are owned by the least reliable people. It seems unlikely that the data confirm the claims, made by equally unreliable people, that there is an epidemic of youth vaping without prior smoking. And if such an epidemic does exist in the USA, and it's almost exclusively in youth smokers, prior smokers, or those who would have smoked if they hadn't found vaping - then it's a Good Thing by any normal person's definition of the term. No smoking = no disease and death and poverty related to smoking and no addiction (you can't become dependent on nicotine without tobacco). Vaping is cheap and harmless by comparison.
Mistake #3 in sentence #2 is the spurious claim of nicotine dependency, with its twin implications that dependency can exist without tobacco and that such dependency is or will be caused by vaping. Since there isn't even a single clinical trial that demonstrates a single person has become dependent on pure nicotine unless they have consumed tobacco, we can strike this claim as well.
Why isn't there even a single published clinical trial of nicotine's potential for dependency with never-smokers? Because there is no such thing as clinically measurable nicotine dependency without tobacco consumption. It's easy enough to measure, after all - but no one has ever found any.
Numerous published clinical trials of nicotine's benefit for multiple medical conditions exist, but since they have to use never-smokers and non-smokers (duh - of course) and no one ever showed the slightest sign of dependence, despite the administration of large doses of nicotine - equivalent to 15 cigarettes a day - for up to 6 months, we can strike nic dependency off the record unless it is delivered in a tobacco vehicle; the 9,600 other compounds in tobacco and its smoke identified to date clearly play an important role in the brain chemistry change. Without tobacco, there is no such thing as nicotine dependency.
The first two sentences were such horrendous crap I couldn't read any further. It was impossible to complete the first paragraph, never mind the whole steaming pile of manure.
Is this what science has become? A catalogues of lies, misrepresentation and propaganda on such a scale that two sentences are enough to make anyone vomit.
I couldn't read any further - perhaps you are tougher than me and can eat any amount of excrement without severe and paralysing emesis, figuratively speaking.
Let me know if things improve or you have to commit suicide rather than dig any further into this steaming pile of faeces (caution: anyone on Chantix should not proceed further into the article) - hardened coprophiles only past this point.
[Originally published 2013-08-09, now re-published in a more prominent position.]
A recent article here discussed how smoking is being radically affected by a technology change, and how this factor is far more important than any other such as regulations or resistance from established players (which is essentially the same thing).
Why e-cigarettes can't be stopped
It could be argued that a technology change from inhalation of burning vegetable matter to electronic nebulising is so unimportant that it has little effect on anything else, or that it affects such a small market that the impact will not be significant. This might be true if the market is small enough; but since the smoking economy is at least $1 trillion annual value, it's not that small; and an important factor is the number of other markets it affects. For example a quick calculation shows that smoking generates at least 10% of all pharmaceutical industry income ; this is one of many significant contributions to the smoking economy, and a route by which a change in smoking habits affects other industries and eventually many other things too.
Even something that appears to be a very small technology change can end up dramatically changing the world. What follows is an example.
In 1956, Malcom McLean of N Carolina  invented the modern version of the shipping container. He had a trucking company, and for long-distance journeys that could be done cheaper by putting the truck on a ship and taking it around the coast, he wanted to ship the trucks intact - but there was too much wasted space and other costs, so he started thinking about just shipping the truck bodies, and this would benefit from standardisation. At the same time, loose cargo was problematic for international shipping as costs were too high, and too much got damaged in transit (which was another reason he wanted to ship his trucks intact); and he also saw that the shipping system was a bottleneck, as trade volume was being massively restricted by dead slow cargo handling and the artificially high cost. So he had several good reasons for finding an alternative cargo transfer method.
In order to make a new form of boxed cargo system more prominent, and have it take as much of the cargo trade as possible, he gave the patents for the container to the industry - he made it open-source, if you like . He figured this would expand the market much faster, and his company Sea-Land was positioned to do extremely well from the business in any case. It was a good decision because in order for his company to do well, he needed a lot of changes: he needed loose cargo handling ('break-bulk cargo') to change over to containers, he needed the ports' design and operation to change, and ship design ideally had to change as well - most ships could carry some containers as deck cargo already, but ideally they would need to be designed from scratch for this purpose.
Going open-source, as we call it now, was the best answer to the problem. We now know that a mix of open-source and commercial involvement is the best way to supercharge any market; but at the time, McLean was a visionary in multiple respects.
At first, everyone ignored the box. No one believed it would catch on; loose cargo had been the way of trade for 3,000 years since the Phoenicians and it had worked OK for all that time. Hardly anyone thought that the huge changes to cargo handling, ports and ships required by a changeover to boxes would ever come about: it was impossible; and clearly the people backing the change were crazy and/or had their own distorted commercial motivations.
But despite the perceived negatives, some trade did move to the boxes. Those who used the new system liked it.
Then, people started to ridicule the container. Who needed ships with boxes? All ships had cargo holds, that's what ships were for. They'd always been like that and it worked fine. Boxes were silly and would cost too much. Nobody needed them and it was madness. Look at all the jobs that would be lost, for a start. And who was going to rebuild all the ports? How could they, in any case, because ports were in cities, and there was simply not enough space for the vast box yards needed. It was impossible and no one needed it, things were fine as they were. So what if ships were held up in port for days or weeks while cargo was unloaded in bits and bobs and processed slowly through customs. This was the way it had always been and the world had worked fine up till now, hadn't it?
But soon enough there were ships built for boxes and ports built for boxes. At that point the dockers and their unions knew they were in a fight for their very survival. And fight they did: they fought as hard as they could, any way they could, for as long as they could. Others joined the fight against the boxes because their livelihoods were threatened: shipowners with old ships, most of the existing ports, all the politicians owned by the existing industries and unions, and many more.
The battle raged for more than two decades. Eventually the boxes won, and the docker's unions had so few members in work they could fight no longer, and no one was using their old ports, and the public had finally realised that the dockers and the old ports were killing trade and that their argument was entirely self-centred compared to their protestations that the box was evil.
It took 25 years for the boxes to win and 40 years before the issue was clear enough that everyone could see the problem for what it was: the medieval age versus the modern world. Nowadays people think of loose cargo as madness: imagine suggesting now that cargo should move to a system where everything is loose, is loaded and unloaded in nets, it takes days or even weeks at each end, and it needs dozens of men per ship. Crazy? Yes - but it took a huge fight over several decades for that to be clear to everyone.
Loose cargo is still the way for local trade in remote areas: on the Nile, or between Polynesian islands; though in 2002 while I was living on the small island of Faial, way out in the Atlantic, the local harbour even built a container depot. The boxes got everywhere in the end; even an island a thousand miles from anywhere has a box depot. It's kind of bijou, like the little harbour of Horta it's in - but it's there.
What followed was a change to world trade and even people's basic living standards of such a scale that it would have been absolutely impossible to envisage at the time. In fact it changed the world.
Shipping costs had been 30% or more of product cost - this changed to under 1%, a reduction of more than 30 times in cost. Five container ships could be unloaded in the time it took to unload one loose cargo ship. As an example of the impact on just one product: 30% of all whisky shipped from Scotland to the USA disappeared in transit due to thefts and/or breakages, but this changed overnight to under 1%; whisky transit insurance fell by 90%. All transit insurance costs fell through the floor as there was no longer a 'tax' on cargo handling.
McLean convinced Grangemouth port in the UK to change over to container-only, with non-union labour; then Felixstowe in 1976; soon every port had to follow suit or die. Felixstowe became the UK's #1 port as a result; plus the fact it opens directly onto the sea unlike most of the old city ports, has a 1.4 mile long continuous quay, is dredged to take the world's largest ships, and has no real restrictions on the size of the container yards backing it up.
The old docks could not cope because large land areas were needed for the box storage facility, ship movements were now so fast that the old gated dock systems could not cope, the old city ports were often some way up a river, and finally ships became so large that pilotage in the rivers became problematic and they could not fit in the old docks anyway. Every dock in London gradually closed, one after the other; in the end the main dock area was flattened and became the Canary Wharf financial area, one of the world's largest financial centres. Because a large area very close to the city centre came free, and it was a brownfield site so that rebuilding was easier and cheaper than with open land, an area of entirely new office blocks and modern facilities was able to be created very close to the City of London financial centre; the financial services industry was able to expand massively, and eventually came to earn millions of times more than the docks did.
In the UK, there were previously 129,000 dockers; the boxes changed that to 11,000. From needing 30 dockers per ship, it changed to just one 1 docker, and on top of that ship handling speed increased by 5 times, and ships could carry double the cargo as well. The huge unionised workforce previously had a stranglehold on the country as essentially they controlled all international trade: when they had a dispute, the entire country was shut down. All that disappeared.
Let's look at the effect on UK life caused mostly by containerisation.
1. Because goods could now be transported rapidly and cheaply, it no longer mattered where the factory was. Additionally, long-distance transport was now so cheap, fast and efficient that different factories could build different parts of a product, ship the components, and the final product could be assembled in the end-user country; this also beat trade barriers and high import taxes on finished products because the destination country could now be the 'manufacturer' of any composite product.
2. As a result of cheap, fast shipping, manufacturing moved from the UK to Asia; the cheapest place to make something could now be used because economies that were previously masked by huge transport costs now became active. In effect, the factories moved from Sheffield to Shenzhen.
3. Before boxes, about 45% of the UK workforce were in manufacturing; this fell to 15%.
4. It caused a huge trade deficit as the UK no longer made all goods; they could be made anywhere in the world and be in Croydon within six weeks instead of three months, and cheaper. Due to reefer boxes (self-contained refrigerated containers) and very fast overall transit times almost all food could be produced elsewhere. As a direct result, the UK had to change from a manufacturing economy to a service economy.
5. Before the boxes, UK consumers had very little indeed. The average household had little in the way of what we would describe as modern consumer goods, or the foods we now consider normal; it was simply impossible under the old system. The inside of an average British house in the 1950's probably resembled the average house in central Africa now. The UK consumer went from having very few consumer goods to a limitless choice.
So the consumer won, people's lives changed dramatically in multiple ways due to the changes in working and home life, several industries lost, new industries grew, old ways died and new ways were learnt, Britain moved from general manufacturing to service industries and high-quality manufacturing only. Even the cities changed dramatically because previously the cities were the ports but this was no longer the norm; and the entire country changed in one way or another.
It can now be seen that the change to shipping was about the smallest change that containerisation brought. Nevertheless, this is how it started.
Nobody foresaw any of this at the time the boxes were being introduced. In fact, if someone had guessed at any of these changes - and especially the scale of them - they would simply have been dismissed as a lunatic.
In 1975 when the boxes were taking over, it would have been far more believable and acceptable to state that man would be living on Mars by 2000 than to speak any of the above out loud.
The container changed the the world and it changed the UK beyond recognition. You might say, justifiably, that many other contemporaneous factors contributed; but the catalyst was the box. You might also have to take into account whether other changes could have occurred in any case without the box.
Malcom McLean is one of the people who changed the world.
In the late 1990s, a Chinese pharmacist named Han Li invented an electronic nebuliser that was designed to replace the cigarette . He patented it in 2003 but never really tried enforcing the patent; the device was cloned everywhere.
People initially didn't think it would have any effect on anything much; they ignored it.
After a time they could no longer ignore it, because a couple of million people were using it, and instead they began to ridicule it. After all, anyone knows that people really like inhaling a toxic bonfire that tastes grim and they always have done. These new electronic doodads with their strawberry flavours and such are just a gimmick, surely?
Well, eventually they had to give up on that because tens of millions of people were vaping instead of smoking. Then, they started to fight against it as hard as they possibly could: everyone had woken up to the fact that trillions of $$ and thousands of jobs and multiple other industries were threatened: the gravy train itself was under threat for the first time in centuries.
I wonder what happens next?
"All truth passes through three stages. First, it is ridiculed; second, it is violently opposed; third, it is accepted as being self-evident."
"First they ignore you, then they laugh at you, then they fight you, then you win."
 In 2008 global pharma income was estimated at around $500 billion. (Total tobacco sales including tax was about the same.) It is impossible that smoking did not generate at least 10% of those revenues ($50bn), due to the huge market for smoking disease treatment drugs and the overall boost to other drug sales. For example diabetes, cholesterol and blood pressure drugs all get a boost from smoking: smokers have a 44% greater chance of diabetes, 61% for 1 PAD smokers. It is more likely that smoking generates 15% of pharma's overall income.
Today, global annual turnover for the pharmaceutical industry is $1 trillion, and for tobacco sales overall, $850 billion (which is mostly tax, though, and the industry's receipts are estimated at around $50bn). Pharma revenues are taxed at a considerably lower rate.
 Malcolm McLean changed his name to the older version without the 'L', Malcom.
Han Li now spells his name this way in Latin script (see list of directors of Dragonite); it was previously written Hon Lik.
 Eventually the boxes were standardised to 10 foot, 20 foot and 40 foot units, with ships being built to carry ever more thousands of TEU's (twenty-foot equivalent units). They're still getting bigger as simple trans-ocean journeys (Asia - N America) don't need the canals, and the savings are starting to look as if they might even marginalise canal transit cost savings; political instability also affects the desirability of canal routes.
And now, even the canals are being expanded in size to allow passage of the enormous boxships of mega scale taking the millions and millions of boxes around the world.
It all started with one fruitcake wanting to ship his truck body intact.