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Tobacco Harm Reduction - An Explanation

Summary
Tobacco Harm Reduction or THR is a consumer-driven process whereby safer consumer products are chosen by a purchaser, for continued and ongoing use, to replace cigarettes. The primary aim is removal of the smoke and THR has not been achieved in any form if smoke is still consumed. Substitution is the core factor: consumption of acceptably safe consumer products as a substitute for cigarette smoking. Such products obviously need to be very attractive to consumers otherwise the process does not work and cannot work.


Contents:
Principles of THR
THR - what it is
The Aims of THR
The THR Success Formula (the 3 Factors)
THR theory
The money problem
The practical effects of THR
Some basic facts about THR
What we should do in the UK
Harm Management
Electronic cigarettes
Why vaping works
Nicotine - the myths and the facts
The Swedish Miracle
The 20% Prevalence Rule
Why has no one heard of the Swedish Miracle here?
What exactly is Snus?
Snus and the mouth cancer non-issue
The implications of the Snus data
THR can reduce smoking prevalence by 1% per year
Dual use
Other consumer approaches
ULR consumer products for risk reduction
Opposition to THR - who benefits?
Tea harm reduction
The Malignant Circle
Money - or life?
Notes
What the experts say


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Principles of THR

1. Remove The Smoke
#Substitute some form of smokeless consumer product for cigarette use.#
Because the smoke causes most of the health risk, removing the smoke is the main aim. There is no THR if the smoke remains: the whole point of THR is to avoid smoke [1]. The definition of THR includes removal of the smoke as a core factor.

2. Improve The Quality Of ST
If smoking is avoided and ST (oral tobacco), for example, is chosen as the substitute, risk will be reduced by >90% even in the worst circumstances. There is some residual risk with low-quality modern products and especially highly-adulterated products such as South Asian STs. Even though no form of ST has more than 10% of the health risk of cigarette smoking (e.g. for oropharyngeal cancer), improving the quality of the product can reduce risk to below measurable levels [2].

3. Acceptably Safe
Consumption of nicotine has no clinical significance [3]. Consumption of high-quality oral tobacco such as Gothiatek-standard Snus has no clinical significance [4]. These products can rightly be referred to as 'acceptably safe' because consumption of them has no clinical significance.

Note that it will not be possible to make any technically-correct statement about the measured risk of vaping until at least 20 years of data is available at 2026 (consumption in the West began in 2005 and was established by 2006). Until that time, estimates can be made based on the low risk of the refill ingredients and other factors; but the reason why we know that nicotine and Snus consumption is acceptably safe is because we have multiple decades of data that clearly show consumption of these products has no clinical significance.

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THR explanation

Tobacco Harm Reduction or THR is a consumer-driven process whereby safer forms of tobacco or nicotine consumption are chosen by a purchaser, for continued and ongoing use, to replace cigarettes. When capitalised as Harm Reduction, a consumer purchase choice of a consumer product for ongoing use is specifically and only referred to. Harm Reduction (as a proper term, when capitalised) excludes by definition:

a. Medical interventions or licensed products (as it is the precise term for consumer purchase of consumer products)
b. Cessation of the activity entailing the risk (since it means continuation of the activity)

Tobacco Harm Reduction therefore is defined as the consumer purchase of consumer products for substitution of cigarette smoking, with the removal of smoke as the primary aim, for ongoing use and without cessation as the target (although it is not excluded). In fact it is a misnomer since it should be termed Smoking Harm Reduction or SHR, since tobacco is not the problem: smoking it is the problem.

 

The Aims of THR

The consumer side of THR
1: Replace cigarettes totally with a consumer product that is significantly less harmful.
2: If you can't (or don't want to) initially replace all smoking, then replace some cigarettes, and gradually increase the quantity of cigarettes replaced if you can, and if you wish to.
3: Quit totally if you want to - but don't worry about it.

The public health side of THR
1. Reduce harm to the individual, of any/all kinds, by all THR actions (so this will encompass physical, social and economic harms).
2. Ensure an overall public health gain results from any THR action (a gain for some individuals and a loss to others is not ultimately acceptable).
3. Offering the smoker better alternative choices in products and tangible financial benefits are the only forms of inducement; compulsion is never contemplated.


Therefore THR aims to reduce harm from smoking by supporting smokers in a move to less harmful products. The more cigarettes that can be replaced the better; but force is not supported, better solutions are the answer. The less harmful the substitute is, the better; but the important thing is to reduce the risk of relapse, so that the more acceptable, efficient, effective, available, and inexpensive the replacement is, the better the end result will be, both for the individual and for public health. In most consumer products but especially this type, a key issue is variety of choice: a one-size-fits all solution does not work; a very large choice is the only workable solution.

THR Success Formula

There is a simple formula that defines the success or failure of a THR product:

In order to work, THR products such as EVs (electric/electronic vaporisers) need to be:
Available - Affordable - Effective

 

This is the 3 Factors for THR Success principle. Products that do not comply 100% with the above requirement will not work for substitution of cigarettes and the end result will be failure. The degree of failure will equal the shortfall in any of the three factors above, and will vary from suboptimal take-up through to complete failure to reduce smoking prevalence significantly.

  • Available: this means people have to be able to easily buy the products they like. The products must be advertised and sold in stores and on the web. A full range of products is required by definition; where EVs are concerned and with ten years of experience at 2015 we know that an enormous variety of choice is the best route to success.
  • Affordable: using the products must cost less than smoking or the system simply won't work. Smoking is hugely expensive in many countries, and artificially inflating the cost of substitution products for some reason (obviously unrelated to risk) reduces the success of the system in proportion. EVs for example work so incredibly well partly because of the significant cost savings compared to smoking. Smokers first try out the products because they reduce risk and they are cheaper.
  • Effective: this means the products must work and must be desirable. So, effectiveness relates to any/all factors related to attractiveness, effectiveness for smoking replacement, variety of choice, fashion, satisfaction, convenience, perception of risk reduction, similarity to the smoking experience, and any other factor that influences the 'workability' of the solution.

These '3 Factors for THR Success' are the best way to measure the potential success of a solution, and the best way to measure the impact of possible restrictions.

Various other factor aggregations are seen, such as: satisfaction, convenience, affordability, safety. None are as accurate as the Three Factors for THR Success outlined above.

THR theory

The perfect substitute products would theoretically be a wide range of different, highly attractive, universally-available consumer products at low cost that all smokers can choose from to select a replacement preferable to cigarettes, and which are completely harmless, and ideally tax-free in order to encourage switching. Since this solution is not available at present, efforts should be directed toward enabling better access to existing products for consumers, removing barriers to availability, and improving the products.

There are ethical, economic and health considerations in THR:
- Solutions should not involve force but instead utilise desirability factors to encourage switching;
- Unless the alternative products are attractive to consumers and financially beneficial they are unlikely to succeed;
-The intended result is a gain for individual health and public health in all circumstances.


The money problem
This all sounds wonderful, but there is a very important problem: multiple giant industries, organisations and government revenue channels depend on smoking. Smoking generates enormous funds (at least $1 trillion a year globally), and the pain of their loss ensures that barriers to THR can be found at every stage. Therefore, public health is as much a matter of large-scale economics as anything else: money is far more important than health, at policy level. Until those who benefit from smoking are stopped from protecting it, real benefits will be hard to achieve.
 

The practical effects of THR
From the Swedish experience, we see that:

  • THR can reduce smoking prevalence dramatically, where all other solutions fail after the 20% Prevalence Rule operates
  • The positive effect on public health is unprecedented (Sweden's national health statistics are unique)
  • Smoking-related mortality and morbidity rates fall through the floor
  • Long-term population-level health statistics show that users who have completely switched to modern THR products are equivalent to non-smokers in terms of disease or death rates
  • Any objections are revealed as irrelevant: there is no gateway effect from THR products to cigarettes, or any other such hypothetical effect - because male smoking prevalence in Sweden falls at 1% per year, will be 5% by 2016, and at some point will be close to zero, and no health impact can be measured, it is obvious that any objections are irrelevant

Any/all objections to THR are revealed as groundless and most probably commercially or ideologically motivated, since there is no relevance to any public health issue.

Some basic facts about THR

THR works. Not only that, it works spectacularly well.

It is extremely effective at saving life and reducing disease, especially compared to interventions based on pharmacotherapy.

It is somewhere between 100 and 1,000 times more effective than government health service smoking cessation programmes such as the NHS Stop Smoking Services when such services do not employ consumer THR, since the best THR results show a reduction in smoking prevalence of about 1% per year (within certain demographics e.g. Swedish males [5]), whereas the NHS SSS (in traditional mode, based around pharmaceutical interventions) probably reduces smoking prevalence in the UK by 0.01% to 0.001% per year.

Only THR has any significant effect on redction of smoking prevalence once the 20% Prevalence Rule operates. After this point, the standard methods such as education and high taxes have such a reduced effect that in practical terms they no longer work.

THR is incredibly good value for money, since it can reduce smoking prevalence by 1% per year in some circumstances and at zero cost, compared with an invisible effect from the NHS SSS at around £200m a year (for example, not only was there no reduction in smoking prevalence in the UK between 2008 and 2013, but the number of smokers actually increased). If properly supported at national level, correctly-presented THR might be able to reduce smoking prevalence by 1% per year across the population as a whole, leading to massive reductions in mortality and morbidity at very low cost. A 50% saving of life (the prevention of half of current smoking-related deaths) is the target for unsupported consumer products, given time - but proper support could improve even this dramatic figure, and more importantly reduce the timescale considerably. Reducing the time to full uptake of THR products by the smoking population would mean a significant saving of life.

From the national heath statistics / epidemiology in Sweden, we can see that a switch to THR products directly translates to a massive fall in smoking-related disease and death. Although this is accurately referred as the 'smoking-related mortality rate', some refer to this as the 'tobacco-related mortality rate'; however the Swedish data points up very clearly that tobacco is not the problem. Referring to a problem caused by smoke as being caused by tobacco is inaccurate.

A population-level switch to THR products has a dramatic and unequalled effect on public health. The effect is so substantial that it equals or outperforms the benefits of major medical advances: the current forecast is that, globally, 1 billion people will die from smoking-related diseases this century, with the worldwide death toll rising to 8 million people annually by 2030; but this could be cut by half if THR became a globally-supported strategy, leading to a saving of millions of lives a year. Current measures are not just far less effective, they cannot even scratch the surface in comparison.

In practical terms, it means that THR is the most important discovery since antibiotics due to the proven saving of life already demonstrated, which could be replicated and multiplied if THR was properly supported. It certainly doesn't make a lot of sense to ignore THR; in fact to deny its existence or to resist it is inexplicable in terms of the health issues (but not the financial issues).


What we should do in the UK
To illustrate the potential saving of life:

1. About 0.75% of all smokers are reported to die each year as a result of smoking-related disease. This is said to be 80,000 in England, the rest being in NI, Wales and Scotland, totalling around 100,000 people who die annually in the UK as a result of smoking. This number is essentially static year on year; no clear reduction is taking place.

2. Current methods to reduce the level of disease and number of deaths no longer work due to the 20% Prevalence Rule. Sterling work has been done to reduce smoking prevalence to its current level of around one-fifth of the adult population; but the reduction ceased many years ago in 2008 and current methods have included more and more force, at higher and higher cost, for zero result. This is unethical, pointless, and a serious waste of taxpayers' money. It is not totally inaccurate to describe this as fraud, since many are aware there is no progress and that there can be no further progress, but no one in the Public Health industry stops taking the money. Taking money for no result while blocking methods that will produce results but remove funding is, morally at any rate, fraud.

3. A full THR implementation policy with State support would reduce the current mortality rate by half, saving 50,000 lives per year eventually. Consumer purchase of e-cigarettes and Swedish Snus should be strongly promoted.

4. No one knows why the current situation persists, but clearly it has nothing to do with public health. Current policies jointly protect pharmaceutical industry and cigarette industry incomes, together with tax revenue and jobs in government departments and NGOs, and are massively detrimental to public health.

5. The pharmaceutical industry earns more from smoking than the tobacco industry does, in the UK (e.g. when tobacco industry income is £2bn then  pharma's is £3bn and possibly as much as £4bn). This is very easy to demonstrate. It means that two powerful industries have a great deal to lose - about 50% of their sales in this area, in fact - if THR is successful. This is the core issue, since it is the reason behind 99% of resistance to e-cigarettes and virtually all of the pointless regulations that have been proposed.

6. In practice, zealots provide the workforce stopping THR uptake, although funding by giant transnationals keeps them in play. Government collusion is required at some level, whether at federation, national or regional level. The smoking-generated money machine therefore relies for its survival on a tripartite arrangement: funding by industry, pressure from zealots in the Public Health industry, and facilitation by government. It is probable that removal of any one of the three legs of this arrangement would topple the smoking money machine and open the way for THR to destroy smoking; but the machine is a $1 trillion giant and stopping it appears impossible at this time.

7. The fantastic volume of propaganda ensures that public perception is always skewed in favour of the machine. This provides the foundation that enables resistance to THR to be maintained, and keeps the cigarette-pharma transnationals in play and protects the massive government tax revenues (and MSA funds in the USA).

Harm Management

The equivalent medical process is correctly termed Harm Management, and this involves medical management of the process by use of licensed pharmaceuticals that include some element or elements of the original material. Thus NRTs, nicotine replacement therapies, are Harm Management products because they contain an element of the original, and are medically licensed products designed to cure, treat or manage a medical condition. Psychoactive drugs for smoking cessation are not, because they contain no element or analogue of the original. Harm Management is generally seen as a process leading to eventual cessation, which must by definition take place after the Harm Management phase concludes. Neither Harm Reduction nor Harm Management include cessation, by definition.

The term 'harm reduction', uncapitalised, may be correctly used as a generic term to refer to all activities in this area: both Harm Reduction and Harm Management, in a general sense. Again, it excludes cessation, and it includes only products that contain some element of the original, or a way of replicating the original substance with a less harmful effect. Where harmful drugs are concerned, these may be replaced with less harmful equivalents (e.g. heroin >> methadone); but since nicotine is a normal dietary ingredient with very little potential for harm, it is not necessary to replace the nicotine but the delivery system, which is the harmful part of the product.

So, harm reduction of any type connected with smoking usually maintains the nicotine delivery and replaces the delivery system; an arrangement which may be opposite to that for other materials.

  • Because the facts from Sweden are indisputable: modern THR products have no measurable impact on health;
  • Because e-cigarette uptake is beginning to displace cigarette smoking in many countries such as the UK, where there has been a ~9% switch at Q3 2013 (11% according to ASH);
  • Because pharmaceutical interventions for smoking cessation have an average 9 out of 10 failure rate (much worse for some NRTs), then:

...it is obvious that THR is far more effective than any medical interventions when measured in terms of the saving of life and reduction of the burden of disease.

Unfortunately, THR is disastrously ineffective at providing large incomes for government departments, giant industries and their front groups, thus reducing its overall attractiveness considerably.

Electronic cigarettes

The EV (electronic vapouriser) or 'e-cigarette' is a modern solution to the harm caused by smoking. It is a nebuliser specifically designed to replicate the smoking experience in a multitude of ways. A binary system composed of hardware and refill, it is engineered to have significant differences to a medical nebuliser and designed to be sufficiently attractive to consumers to be a practicable solution for cigarette substitution.

The many thousands of possible hardware and refill combinations contribute to the success of a consumer product of this type, since a suitable option can be found by all smokers in order to provide a viable permanent replacement for cigarettes. It is important to note that there is no one-size-fits-all solution with e-cigarettes: the system must be precisely tailored to the user, not the other way round; attempting to make the user fit a specific solution will result in a large reduction in success rates. Consumer products of this type are like clothes: a shirt available only in one size and one style and one colour will not be a popular and successful choice: it can only have very limited appeal.

This area of public health is referred to as Tobacco Harm Reduction or THR, and involves the use of consumer products that are available as alternative purchases for 'substitution'. Substitution is the basis of THR: a replacement for cigarettes that is not just acceptable but desirable.

The replacement product must be desirable or it will not be attractive to consumers. The reason that e-cigarettes are successfully replacing smoking is because they are desirable to consumers. If they were not desirable, they would not work.

Twenty years ago the Royal College of Physicians published a report that said what we need is a better nicotine delivery system that does not employ smoke. As it is the smoke that kills, if the smoke is removed then automatically some 98% of the risk is removed; risk can then be reduced further by processing of the tobacco or by selecting a clean nicotine delivery system. Modern THR products have about 1% or less of the risk of smoking; since statistical effects at population level below 1% cannot be reliably identified, it is not possible to determine any effect with confidence.

Today we have the system envisaged by the RCP all those years ago: it is called the e-cigarette. The consumer inhales a water-based mist of flavoured nicotine vapour, instead of smoke, and therefore we can immediately see that virtually all the potential for harm has been removed. We are probably only left with normal intolerance issues or very small-scale potential for minor morbidities, except in the case of those with lungs already severely compromised by smoking; such persons should choose an alternative solution.


Why vaping works
There are currently at least 5,000 possible practical solutions in terms of the combination of hardware (battery unit, head unit) and refill (glycerine or PG-based, variable strength, variety of flavours) easily available almost instantly to any consumer. This is the reason for the immense success of the system.

As an example, one vendor alone offers more than 7,000 possible choices of refill when the different bases, strengths and flavours are multiplied out - there is something to suit everyone (and this is just refills, not hardware). In terms of the actual number of possible options (combinations) on the market, the number is incalculable, as there are thousands of vendors; it must approach a million and may be higher. We use the figure of 5,000 options as it represents the number of options that any consumer can quickly and easily find available to try within 20 minutes research on the web [6]. Regulation automatically removes 99.999% of these options (as that is what it is designed to do).

Nicotine - the myths and the facts

Nicotine is an extremely low-risk material, and this statement can be supported by the facts, together with a very large amount of scientific evidence; this is in direct opposition to the myths and propaganda.

  • Nicotine is a normal part of the diet, everyone consumes it, and everyone tests positive for it.
  • The Snus data from Sweden clearly shows that ad lib consumption of nicotine over decades is not statistically harmful, never mind clinically significant. Nicotine consumption has no clinical significance.
  • No one has ever demonstrated that nicotine consumption is any more significant to health than coffee (caffeine) consumption; not only that, but we know from the hundreds of clinical studies of Snus in Sweden that long-term ad lib consumption of nicotine over several decades cannot be shown to reduce life expectancy on average by more than 6 weeks. This is in the same range as may be expected for equivalent consumption of coffee; indeed recent research on the health impact of coffee consumption indicates that coffee may be significantly more harmful than nicotine [7].

Prof CV Phillips, an authority on the science basis for THR, says this: "Consumption of nicotine has about the same implication for health as coffee and fries".

Everybody tests positive for nicotine in large-scale blood plasma nicotine tests. To date, there has never been a large scale clinical trial in which anyone tested negative for nicotine, since it is a normal and natural part of the diet, and all test positive; a 'background' level of 2ng/ml was seen in historic tests. Smokers typically register from 10ng to 25ng/ml (in the modern era - past levels were considerably higher, but cigarettes generally contain less nicotine now), which means that they commonly boost their dietary level by around 10x.

Many vegetables and other foods contain nicotine and its sister compound nicotinic acid, aka vitamin B3 or niacin. Some contain a significant amount: for example one portion of aubergine (eggplant) contains the same amount of nicotine as would be absorbed by being in a room with tobacco smoke for 30 hours. It should be noted that no one has ever suggested that drinking tea (which contains five active alkaloids including nicotine) and eating aubergines is in any way harmful; the problem is that because nicotine consumption has been conflated with smoking, it has been forgotten that nicotine is a natural part of the diet and everyone consumes it in small quantities.

Some people need a dietary supplementation of nicotinic acid (vitamin B3) of 2,000mg per day in order to resolve issues with cognitive function, memory, work capacity or stress. These are also areas where nicotine is reported to be of benefit to many.

The large amount of data from Sweden also shows that increased nicotine consumption is of such low risk that negative implications for health cannot be measured statistically. This data originates from the national health statistics, the large quantity of epidemiologic data, the hundreds of clinical trials and studies over thirty years, some of which are large-scale studies with cohorts of tens of thousands of subjects, and most especially from the giant-scale meta-analyses of these studies, as the risks can be isolated and identified (see citations). Sweden has about twice as many Snus consumers as smokers, and the data is both substantial in volume and easy to isolate.

It might even be said that there is little need for further studies of either Snus or nicotine consumption [8]: neither the epidemiology nor the clinical data can benefit greatly from further additions; we have all the data we need now.

Snus consumption (that is to say, long-term ad lib consumption, in Sweden, of the Swedish specially-processed pouched oral tobacco with high nicotine availability that has had most of the carcinogens removed by steam treatment) has no statistically-demonstrable implications for health at population level. Snus cannot be shown to elevate risk for any disease. Smokers who totally quit all tobacco or those who switch to Snus have the same expected health outcomes, from a statistical perspective.
(NB: we refer to population-level data here, but individuals need to consider their own personal circumstances, since a genetic predisposition to vascular disease may mean that choices are more limited.)

See also: Nicotine consumption issues

In the next section we look at Snus in detail, as it provides a close parallel with the electronic cigarette situation. The vast amount of data now available means that THR is no longer a theoretical issue, but a proven solution with benefits on a unique scale. Indeed, it is no longer necessary to even speak of 'irrefutable evidence', since the facts of Sweden's national health statistics are unique. It is no longer necessary to consider the evidence, since we have the facts.

The Swedish Miracle

Because we already have the national health statistics from Sweden as a foundation for all discussion in this area, there is no need for a debate; we already know the outcome for public health if smoke is removed from the tobacco consumption equation. Sweden is the world leader in reducing disease and death related to smoking or tobacco consumption. They have a real prospect of being able to reduce smoking mortality to insignificant amounts - a prospect absolutely out of the question for any other country.

In Sweden, the number of smokers has been reduced by 50% compared with similar countries such as the UK, since at 2013 only about 12% of the population smoke, and only 8% among men (therefore male smoking prevalence is 64% lower than in the UK). Smoking was replaced by consumption of their local version of oral tobacco called Snus. This locally-available product is usually supplied in mini-pouches for placement behind the upper lip, and is specially processed to remove most of the carcinogens. Snus has a provable near-zero elevation of risk for any disease including oral cancer. Snus is virtually invisible in use as it does not produce extra saliva, there is no spitting or chewing; because it is used by more men than women it also allows more reliable isolation of the data.

The consumption of Snus in Sweden has been studied intensively for 30 years, and the volume of both epidemiology and clinical data is substantial (more than 150 clinical studies).

A country that fully embraces this solution appears able to reduce tobacco-related disease and death to insignificant levels. Other countries, for economic reasons, appear to be strongly supporting the status quo, and the reduction of smoking prevalence is essentially static around the 20% average mark; the reduction in smoking prevalence has stopped at around one-fifth of the population. This can be referred to as the 20% Prevalence Rule as no country is an exception to this Rule once it operates (see below).

By contrast, Sweden has a current smoking prevalence much lower, and the figure for men is still falling steadily at around 1% per year. When Sweden reaches 5% of the male population smoking in 2016, other developed countries are likely to still have nearly 20% smoking.

Sweden now has the lowest tobacco-related mortality rate of any developed country by a wide margin; a smoking-related death rate about half the EU average; and the lowest male lung cancer and oral cancer rate in the EU.

  • Sweden is the world leader in reducing smoking prevalence
  • Sweden is the world leader in reducing smoking-related mortality
  • Sweden is the world leader in reducing smoking-related morbidity

This is the crux of the matter. THR is proven to work and proven to have a massive benefit for public health - unequalled perhaps by any other development since the invention of antibiotics, since the potential is there to save tens of millions of lives (or more: Prof Britton states that 5 million could be saved just in Britain just among those alive today). All other approaches to reduce smoking have stalled around the 20% smoking prevalence point, and only THR provides any realistic prospect of reducing the figure significantly.

As we can clearly see from Sweden, the disease and death rate is dramatically reduced; this means that any and all arguments about the details are pointless. If smoking prevalence can be reduced to 12%, is still falling by about 1% per annum for men, and since tobacco-related morbidity and mortality fall in parallel - then any debate about the risk/benefits is clearly irrelevant. When there is no smoking, there is no smoking and no smoking-related disease: the hypothetical objections to THR are clearly irrelevant.

Indeed, much of the debate has some sort of commercial agenda and has no relevance to public health except to preserve the status quo and maintain smoking at current levels. It is an especially unfortunate fact that some medical professionals appear to have financial conflicts due to accepting funding from industries that benefit substantially from preserving the status quo.

The 20% Prevalence Rule

Once the number of smokers in many countries has been reduced to about one-fifth of the adult population, the fall in numbers slows down, then sticks at around 20%. No further significant reduction is possible using the same methods. This can be stated in the following way:

"Once smoking prevalence is reduced to around one-fifth of the population - 20% of adults - in a developed country where efforts are made to reduce smoking from the typical level of 40% or higher, no further significant reduction occurs by continuation of use of the methods generally used for reduction to that level."

After this point, only unhindered access to consumer THR products has a significant effect on smoking prevalence.

Although this is referred to as a rule, it may simply be an empirical fact [9]. For a more complete explanation, see: The 20% Prevalence Rule

Why has no one heard of the Swedish Miracle here?

Sweden reduced their smoking prevalence by 50% at no cost to the taxpayer by free and unhindered access to Snus, and as a result is the world leader in reducing smoking mortality. Smokers switched en masse to Snus, once it was generally realised how safe this option is - essentially, this is a zero-cost proven way to cut smoking deaths by half (or more): smoking prevalence is still falling and disease/death rates fall in parallel.

Smoking was reduced more among men more than women, by 64% compared to UK levels for men, as only around 8% of Swedish men now smoke (at 2012). Traditionally, more men than women smoke in most if not all countries, and therefore Sweden may also be unique in its achievement of reducing male smoking to lower than the female level.

Sweden is the only country in the world that now has a realistic prospect of reducing smoking-related death and disease to very low figures, perhaps even to insignificant levels; a goal absolutely impossible for any other country.

Unfortunately, this situation has serious implications for several major industries and all governments. If repeated elsewhere, the impact on the cigarette industry, the pharmaceutical industry, and government tax revenues would be significant: all existing revenue streams in related areas would, essentially, be cut by at least 50%. This may help to explain why Sweden's national health statistics are something of a well-kept secret, and why THR is actively opposed.

When the funding sources of those opposed to THR are examined, most have clear links to industries that will suffer as THR becomes more popular. It is likely that considerable funds have been expended in order to try and keep THR from becoming popular: a 50% cut in cigarette sales, drug sales for the treatment of sick smokers, and tobacco tax revenues is not going to make everyone happy. It is not a question of there being winners and losers: there won't be any big winners because THR is a cheap way to reduce smoking death and disease, and you can't tax a harmless product - there will only be losers. Big, big losers; and that is where the problem lies.

The pharmaceutical industry earns as much from smoking as the tobacco industry does in some countries (such as the UK); and the government earns considerably more.

There is obviously a moral issue here - and it comes down, quite simply, to profits versus public health.

What exactly is Snus?

The word 'snus' in Swedish means snuff, but is now used to refer to the local smokeless tobacco for oral use. The term 'smokeless tobacco' is generally used to mean any kind of tobacco product that is not smoked, and can be applied to chewing tobacco, dissolvable tobacco, snuff and Snus for example.

In Sweden, their local variant of oral tobacco is not chewed, but instead is placed behind the lip; in other words they place their snuff in the mouth instead of the nose. In the past, use of a pinch of the loose, moist version was more popular; but more recently there has been a strong move to the mini-pouch version. This type is a moist, ground-up, specially steam-treated and flavoured processed tobacco product that comes in a small, flat mini-pouch that is placed behind the upper lip, between the upper lip and the upper gum. Most of the carcinogens have been removed by the special processing. It is more or less invisible in use as there is no chewing or spitting. Unlike older forms of oral tobacco, it does not create significant additional saliva and is therefore not chewing tobacco or 'spit tobacco'.

It works because it delivers all the active alkaloids in tobacco, and has an especially effective nicotine delivery mechanism; it is flavoured and therefore far more acceptable to more people than the basic or sometimes bitter tobacco flavour; it is invisible in use; it is clean in use; and it doesn't cause harm in any statistically-identifiable numbers, never mind having any clinical significance.

These advances in the product presentation are important, but not nearly as much as the carcinogen removal. A steam-treatment process was discovered that removes most of the carcinogens, and is sometimes referred to as pasteurising. A Snus product that complies with certain quality standards including the level of carcinogens is a Gothiatek standard compliant product, and this applies to modern Swedish Snus products. Such products can be referred to as acceptably safe since consumption of them has no clinical significance, as clearly demonstrated by both the facts and the vast data resource.

Together with the presentation (flat mini pouches of flavoured moist tobacco with high nicotine availability), this provided a unique solution to the smoking problem: you can have your cake and eat it. Tobacco, with such significant quantities of nicotine that some Snus products outperform some cigarettes for nicotine delivery, can be consumed without measurable health impact.

Today we have more than thirty years of epidemiology on this unique consumer cohort. They consume tobacco, with no health impact of any clinical significance. Although it is not strictly correct to say that every smoker who switches to Snus walks away from tobacco-related disease, since there is always a latent but reducing risk from previous smoking, and because individuals are not cloned population units, the point is clear enough.

Snus has no statistically-demonstrable elevation of risk for any disease. The giant-scale meta analyses of multiple Snus studies by PN Lee, and Lee & Hamling, show that:

  • Snus has no elevation of risk for any disease, including any cancer
  • The expected health outcomes for smokers who totally quit or for those who switch to Snus are as close as makes no difference
  • There was originally thought to be a very small increase in elevation of risk for stroke and pancreatic cancer that was not considered statistically relevant; however these concerns were eliminated with the increase in size of the clinical data resources, as no such risks are identifiable when viewing all of the data in total

We also see that:

  • As Snus consumption rose substantially in Sweden, oral cancer rates fell dramatically
  • Sweden has the lowest male lung cancer rate and oral cancer rate in the EU
  • Sweden has a tobacco-related mortality rate lower than any other developed country by a wide margin
  • Sweden's tobacco-related death rate is about half the EU average


Snus and the mouth cancer non-issue

"Snus cannot be shown to elevate risk for any disease, including oral cancer."
- Prof PN Lee, meta-analyses of Snus clinical studies

(Lee is a leading authority on the statistical interpretation of clinical data on tobacco consumption; see PN Lee; Lee, Hamling.)
 

"Modern epidemiologic studies reveal that the oral cancer risks from Snus use in Sweden and from moist snuff and chewing tobacco use in the U.S. in the modern era are so small that they cannot be measured with any precision."
- Prof B Rodu

(Private communication, 2013-02-04. Rodu is the leading authority on the oral pathology of tobacco consumption.)

The implications of the Snus data

The implications are simple, although revolutionary by our current standards. They require a new way of thinking about these issues:

It doesn't matter what questions are raised about flavours in tobacco; about the possibility of dual-use with cigarettes; about the possibility of attracting youth; or about any other hypothetical objections of this type. All such issues are proven irrelevant since the widescale use of a THR product is proven to reduce both smoking prevalence and smoking-related disease and death to exceptionally low levels in a population where this is embraced, and can be expected to eventually reduce it to insignificant levels given time and full support.

Any questions about dependence are thus shown to be equally irrelevant: if an addiction or dependence or habit is harmless, then it has no consequence. In addition if it has benefits, and no harmful consequences, then objections to it are less important. If additionally it replaces a deadly delivery method then objections are moving toward becoming irrelevant.

An addiction to coffee is not the same as addiction to heroin or alcohol; those may ruin your life, your health, and harm others around you, and it is more accurate to refer to habitual use of relatively harmless substances as 'dependence'. Addiction equals dependence plus harm.

Dependence on coffee or nicotine delivered via Snus is not the same thing as addiction, since it is likely to provide benefits not negatives. A harmless dependence is just that: harmless. In addition it provides multiple benefits for many people - or they wouldn't do it. Dependence on a substance that provides benefits and on average causes no harm is not a serious issue for public health. Smoking is.

We can assume the same applies to e-cigarettes at this stage, since no potential for harm has been demonstrated despite millions of user-years. We can see by comparison with drugs introduced at the same time that have caused significant mortality and morbidity that the timescale is certainly not too short to reveal issues (cf Chantix).

Please see this page (at foot) for relevant citations; also:
www.ecigarette-politics.com/why-snus-is-important.html
 

Some points of note
1. There have been more than 150 clinical studies of Snus, over three decades. No more evidence is needed, and no more trials of Snus are required.

2. There have been giant-scale meta-analyses of the Snus studies that provide extremely strong evidence as to why the disease and death rate from tobacco consumption in Sweden is so dramatically low.

3. There are one or two studies that show an elevation of risk for pancreatic cancer. Equally, there are one or two that show a decrease in risk (i.e. a protective effect). Such examples conflict with the greater volume of studies that report no effect (~4 studies vs 150 studies), and are therefore regarded as outliers and with no significance.

4. In addition, when PN Lee, the medical statistician and leading authority on the statistical epidemiology of smoking and tobacco consumption, looked at methods used for data collection and analysis in studies that appeared to show an elevation of risk for pancreatic cancer, during the process of importing studies for one of his large-scale meta analyses, he found that such studies could not be used due to reliability issues. One such study (sometimes quoted by pharmaceutical industry spokespersons), Boffetta et al 2008, was thoroughly discredited by Lee and others. See the literature: search 'lee boffetta'.

The small number of studies purporting to show an elevation of risk for pancreatic cancer cannot therefore be seen as reliable or valid; just as those that show the opposite effect are not considered reliable.

Occasionally we see press releases announcing that nicotine has 'been discovered' to 'promote cancer' (in animals). Since we already have hundreds of clinical studies that clearly demonstrate that nicotine does no such thing in humans - not to mention the real-world facts that show no such effect - then such new trials (and especially their lurid press releases) can be seen for what they really are: an irrelevancy, and possibly with some sort of agenda. As NICE, the official UK clinical guidance authority state very clearly in NICE PH45: nicotine has no association with cancer. This is the official guidance for all UK medical practitioners.

(This also means that any British doctor who treats a patient and provides any intervention based on an incorrect belief that nicotine is associated with cancer can be sued for medical negligence, since they are legally bound to treat patients within the NHS according to official guidelines. Thus, prescribing a psychotropic drug intead of NRT plus counselling, based on an incorrect belief that the risks are about equivalent, is straightforward medical negligence. NRTs have no measurable risk and indeed no known risk of any kind for any average patient, since they are in essence simply a nutritional supplement; this contrasts distinctly with psychotropic drugs, which do have significant risks.)

THR can reduce smoking prevalence by 1% per annum

Snus
Sweden can be estimated to have reduced smoking prevalence by about 1% per year, year on year, for a total reduction of about 50% (depending on what country it is compared with; here, we are referring to the UK). Although Snus has been used there for a very long time, it is only recently that use increased significantly; therefore we might take a liberty and amortise those two periods to end up with a 1% per year average. In recent years, the fall in male smoking prevalence is known to be around 1% per annum: male prevalence was 17% in 2003, and 8% in 2012.

A smoking prevalence of 12% for the male/female average is about 50% less than comparable countries, although the male prevalence at 8%, a comparative reduction of 64% with the UK, is even more impressive.

Snus is banned throughout the rest of the EU, by power of the EU Health Commission's Tobacco Products Directive. Sweden received a derogation from this (an exemption) when they joined the EU. In 1992, when this Directive was put on the statute, there were probably good reasons since there was at least a possibility of a genuine debate on the risks. By about ten years ago and certainly by five years ago, the epidemiology and volume of clinical data made the ban obsolete, since it had become obvious that something extraordinary was happening in Sweden.

Now that there is no scientific basis for such a ban - in fact a mountain of evidence that removing it would be the single largest public health benefit for countless decades - we can only assume it is kept in place for reasons that have no relation to health.


Electronic cigarettes
In the UK, at Q3 2013, about 8% of smokers have switched to e-cigarettes already. Ecigs have been available for 8 years and were first sold in the UK in 2005. More than 2 million smokers either use ecigs or have switched completely (ASH UK reported the figure as 310,000 in 2010, then 650,000 at Q2 2012, then 2.1m in Q1 2014).

Update Q2 2015
UK: there are now 2.6 million vapers in the UK, and more than a third are ex-smokers as a result. This route to smoking cessation is massively more successful than any other in the UK.
USA: two recent surveys showed that there are more than 15 million vapers in the US, and more than 4 million are now ex-smokers. Brad Rodu re-worked some survey data from the CDC to get a figure of just under 10 million vapers. A figure of 10 million also aligns with general values for market size vs consumer numbers that we know are correct from countries like the UK where the stats are not deliberately hidden or obfuscated, unlike the USA.

Dual use

'Dual use' means use of both cigarettes and EVs (electronic vapourisers). Most consumers will be dual-users since most do not switch on Day 1 of trying an EV.

- Some smokers will be able to immediately switch 100% to the e-cig
- Most smokers who are new ecig users will reduce their cigarette consumption but still be dual-users
- Most long-term e-cigarette users are likely to be exclusive ecig users

Therefore:

  • Dual-use is a normal and natural part of the process
  • Dual-use of ecigs and cigarettes is now the single most important route to smoking cessation, and outperforms every other

There is a timelag until most new e-cigarette users become non-users of tobacco cigarettes. In the ASH 2013 report, one-third of ecig users had ceased smoking - 700,000 out of the 2.1m ecig users were ex-smokers. This was the first time in the world that the proportion of ecig users who have quit smoking had been reported, and it was far higher than many critics had previously estimated (which was often around 10% or less). This process has been maintained, and we now know that more than one-third of UK ecig users quit smoking, and that this proportion is maintained year on year (as the figures for every year now show the same or better results).

When ecig users cease to be dual-users [10], as most do eventually, the full benefit is seen in the UK smoking prevalence figures, which show the full effect of the switch to e-cigarettes. Since the 20% Prevalence Rule tells us that no significant fall can now occur as a result of State-supported methods, it follows that any reduction in smoking prevalence now seen will be due to e-cigarette uptake; and currently we think that around a 2% to 3% fall in smoking prevalence overall is due to the switch to vaping.

Even though only a percentage of e-cigarette users have switched fully at any given time, that percentage is a significant number of smokers, and far more than could be gained by any conventional method of tobacco control. In addition, all e-cigarette users will have reduced the amount they smoke, and this itself is a public health gain (as harm is proportional to dose x time); a 6% fall in cigarette volume sales in the last two quarters is attributed by the tobacco industry to ecig takeup (@Q3 2013).

As research on these important effects is not being carried out, we have to guess at some of the implications. For example it looks as if the real reduction in smoking prevalence at any time point may be around 33% of the number of smokers who have become e-cigarette users. An 8% - 9% switch to e-cigarettes may therefore equal a 3% reduction in smoking prevalence.

It is expected that by 2020, 25% of smokers (at least) will have become e-cigarette users; this will - QED - equate to a reduction of about 8% in smoking prevalence. One of the benefits ecig use has over Snus is that e-cigarettes are acceptable to both sexes and all demographics, in contrast to oral tobacco variants, and therefore smoking prevalence reduction due to ecigs should balance across all sections of the population.

What is also now very clear is that any reduction in smoking prevalence reported in future UK surveys is entirely due to e-cigarette uptake and no other reason.

As more smokers switch, the population-level benefits will also start to emerge and the effect will become apparent, as is clearly seen in Sweden: we will start to experience the dramatic fall in smoking-related disease that the pharmaceutical industry is so afraid of. Rates of diabetes, high cholesterol and high blood pressure will all fall in parallel with the cancer and CVD stats. Unfortunately, the hugely profitable drug sales for treating these ailments will also fall in proportion to the number of smokers who switch; along with the huge tobacco tax revenues. This is the real problem facing THR products: they cut off the money supply, and that is the main issue - not of course any fabricated health concerns.

Other consumer approaches

There are a multitude of consumer substitutes for smoking that qualify as a THR approach.

HnB
If no smoke is produced, then basically it qualifies as THR. One such product range increasing in support is herbal vapourising, also known as HnB (heat-not-burn). More detail here:
http://www.ecigarette-politics.com/combusting-or-vapourising-tobacco.html

There are multiple types of tobacco vapour products and they have different risk profiles. Some use a fossil fuel and have only one air channel for the vapour and exhaust products, such as carbon monoxide, which are inhaled; some have dual channels so that the fuel exhaust products are not inhaled; some are electronic, so there are no fuel exhaust products at all. Therefore it is not possible to place them all in the same class as far as risk reduction is concerned. If there is no smoke then THR has been achieved; there is some debate about how to classify tobacco vapour exactly; and there is clearly a difference in elevation of risk between products.

Low-nicotine cigarettes
Low-nic cigarettes cannot be classed as THR since they produce smoke. In fact this approach is the reverse of THR: it leaves the harmful product in place and removes the harmless, beneficial product, the nicotine. It is tempting to describe this as the reverse of THR: making something more harmful than it needs to be, since people may smoke more in order to derive sufficient nicotine, and there appears to be no direct route to removal of the smoke, which is the only thing that qualifies as THR. It is in fact rather obvious that a safer cigarette will contain more nicotine, not less, so that people smoke less. The smoke kills, so reducing the smoke is the only route to reducing harm. A  THR product by definition has no smoke, since the whole point is to remove the smoke. It is possible that low-nic cigarettes improve public health if they lead to much faster and much increased cessation of smoking, but this result has never been confirmed or even suggested as a possible outcome in practice.

ULR consumer products for risk reduction

The term Ultra Low Risk is an informal categorisation for clean nicotine delivery consumer products or processed smokeless tobacco products that can show a history of safe use, or can reasonably be expected to do so in the future.

Snus falls into this grouping by virtue of its history: the unique national health statistics of Sweden show a reduction in smoking mortality proportionate to the number of smokers who switched, and the large volume of clinical data shows a risk so low as being almost impossible to see by statistical methods.

E-Cigarettes have such a simple ingredient profile that disease vectors are not apparent, and therefore a ULR classification is justified. The average number of ingredients is around six, all well-known and used safely for decades; contrast this with the 9,600 identified so far in tobacco and tobacco smoke.

All ecig refill materials are pharmaceutically licensed for inhalation, with the exception of the flavourings, and have no clinical history of harm. There is no reason to suspect that the flavours will cause harm on a wide scale. Intolerance issues will be seen but this is not the same as disease initiation.

A smoker who switches to use of a ULR product can probably expect the same health outcomes as one who quits totally. This article finishes with a quote from CV Phillips and it illustrates the risk potential quite well.

Opposition to THR - who benefits?

The cigarette market has created a vast money machine that has its tentacles in almost every facet of public life and administration. The sums of money involved are so gigantic that in practice it is probably impossible to remove its influence; what we might call 'the smoking economy' has at least a $1 trillion annual value. The list of those who benefit is almost endless and ranges from the tobacco industry through to government employees, the pharmaceutical industry, quasi-health organisations, and sections of the media.

The practical difficulties of changing this situation are almost impossible to countenance since so many people make so much money from cigarette sales: it is the world's biggest gravy train. The tobacco industry are just one among many, and even they only make a tiny fraction of what governments make from cigarette sales. You actually buy your cigarettes from the government because of their far greater stakeholding than even the tobacco companies. The UK government has an 86% stake in tobacco sales (receiving £12bn from the £14bn tobacco sales revenues in 2011/12), and a 90% or greater stake when all income and savings are calculated; the tobacco industry is strictly a minor partner [11].

Cigarettes are therefore, essentially, purchased from the government. Cigarette sales benefit the pharmaceutical industry more than the tobacco industry. Cigarette sales prop up the vast funding resources and gigantic salaries of a large section of the Public Health industry.

While that situation prevails, almost universal opposition to THR will be found since it is now the only practical threat to the gravy train.


Tea harm reduction
Let's consider a situation where, by a quirk of history, we smoke tea instead of drinking it. You may laugh - but it could easily have been this way; people in some countries smoked their plant matter of choice to derive nicotine, and in others infused it into hot water (tea of course contains nicotine as one of its five active alkaloids).

If that had been the case, then someone who suggested Tea Harm Reduction - by drinking it instead of smoking it - would receive exactly the same opposition, from the same quarters, as THR proponents receive today. Exactly the same and in every respect. Don't make the mistake of thinking otherwise.


The multiple beneficiaries
So, others benefit just as much as (or more) from smoking than the tobacco industry, who in reality are just one among many. The principal commercial example of this is the pharmaceutical industry, who in the final analysis make more from smoking than the tobacco industry does: about £3bn annually in the UK in a given year where tobacco industry income is £2bn. As NHS costs rise, and the annual cost of treating sick and dying smokers rises above the £3bn per year that this cost analysis is based on, the pharmaceutical industry will make considerably more from smoking than the tobacco industry (as 50% of the cost of smoking to the NHS is the drug cost, and because multiple other income channels benefit the pharmaceutical industry from smoking).

Globally, their income channel from the drugs to treat sick and dying smokers is so vast as to be almost incalculable: probably $100 billion a year at any rate, and certainly one of their most important markets. This translates to over 10% of pharma's global gross of around $1 trillion @2015.

The smoking cessation drug market (NRTs and psychoactive drugs) is just a fraction of this at around $3bn annually (2013). The huge profits from the sale of chemotherapy drugs, COPD drugs, cardiac drugs, vascular drugs and other treatments, and the massive boost to other drug sales [12], are what drives a significant proportion of the resistance to THR products such as Snus and e-cigarettes.

The largest single impediment to free and unhindered access to e-cigarettes is without doubt the pharmaceutical industry, who have more to lose than most in this scenario. Some of their largest markets (e.g. the treatment of sick smokers) will conceivably suffer such a huge shrinkage that eventually ecigs may cost them more than $60bn annually. They are using every device at their disposal to try to stop this happening, principally by attempting to remove a commercial competitor as they see it. This is a normal mode of operation for them in any case and used frequently.

The biggest problem with this industry is the tight control they have over legislative processes as a result of power within closely-connected government departments. The business methods employed are not those that should be employed by an industry with so much power within government: they are officially and legally the world's largest criminal fraudsters and criminal corruptors. In fact the pharmaceutical industry are legally-speaking the world's largest-scale criminals by virtue of the scale of criminal fines paid across almost the entire industry. In the specific areas of criminal fraud and criminal corruption, they pay world-record fines and damages.

It may sound like unjustified speculation to question this industry-government relationship, until the facts are examined:

  • It is vital to many powerful interests to keep smoking at its current levels.
  • Currently, all State efforts to reduce smoking have little or no impact, as the 20% Prevalence Rule is now operational (UK smoking is at about one-fifth of the adult population, and cannot be reduced further by conventional means).
  • The NHS smoking cessation services are reducing smoking prevalence by somewhere between 0.01% and 0.001% per year, about 100 to 1,000 times less effective than the THR approach. These services are based almost entirely around ineffective pharmaceutical interventions, and the taxpayer supports the costs.
  • It is impossible to show any better than a 1 in 10 success rate for pharmaceutical interventions for smoking cessation, and even such a figure would not be achievable in most circumstances. Indeed, the independently-verified success rate for NRTs such as nicotine-containing skin patches is about 2%; that is to say, a failure rate of about 98%.
  • This being the case, pharma has no need to fear that smokers will succeed in quitting by the use of their remedies. Indeed, there is a better than 9 to 1 chance they won't.

This creates a rotary money machine where everyone benefits - except the consumer.

The Malignant Circle

Smokers pay a fortune in tax (about 4 times more than the cost to the country for treating their disease burden) - then, they try to quit, using pharmaceutical interventions, which is a profitable sideline for pharma - they fail and return to smoking, boosting tobacco industry profits - they attempt to quit again and fail again - they return to smoking - they get sick, which provides a vast income for pharma - many die, enabling huge savings for government in pensions and care of the elderly due to reduced lifespans.

Smokers keep smoking, quitting, failing, and relapsing to smoking, until they die. Everyone makes money at every stage - it is a tremendously profitable money machine.

Here, then, is the opposite of a virtuous circle: it is a malignant circle that is immensely profitable for government, the tobacco industry, the pharmaceutical industry, government staff, pseudo-health pressure groups funded by pharma, the media, the retail industry, transport, health service providers, and others. The 'malignant circle' is heavily protected at all levels. The most obvious feature of the protection of the status quo is its sham respectability, carefully maintained by a prodigious amount of propaganda.

THR threatens the gravy train and must be resisted at all costs: smokers can escape if they have access to THR products, and no one (who counts) wants that.


Exactly how much could e-cigarettes cut smoking by?
Snus caused a 50% reduction of smoking in Sweden, at 2012. Because ecigs are generally more acceptable to smokers than oral tobacco (and even more so for female smokers), we could probably estimate, with some degree of validity, that e-cigarettes will outperform Snus - in time. It is anyone's guess what the exact reduction might be, and it is certainly going to be several decades before that figure becomes visible on the horizon; but if we looked at around 60% as a figure for discussion, then we would probably not be too wide of the mark.

It goes without saying that this would cause severe pain for several industries, for government tax revenue, and for government staff in certain areas - their jobs would go.

The continuing circle in the journey that a typical smoker takes leads to huge profits at every stage, for numerous interests. Less than one in ten who tries is successful in quitting. The circle continues and everyone wins, except the smoker, who has a substantial chance of ill-health, and a significant chance of early death. This is the opposite of a virtuous circle: it is a malignant circle. In effect the individual's rights are taken away, when government acts to support the status quo: the individual becomes a revenue-creation unit forced to pay through certain specific channels, and with a significant chance of illness and death as a result.


The impact on public health
Public health is not served by the continuation of current methods, as can be seen by a simple comparison with the situation in Sweden. Surely, it must be obvious that there is a simple and cost-free solution to the volume of disease and death caused by smoking, since no argument about the real-world effect of THR is tenable now. The problem actually lies with the fact that the solution is virtually cost-free: no one is going to profit by it and there will be significant losers.

Unfortunately, the potential losers are also those with the money or power to stop this revolution in public health.


The individual
Of course, at an individual level, everything possible must be done to assist any smoker who can be persuaded that their activity is harmful. There will be some individual wins, even if the scale is not impressive.

This does not detract from the fact that our national achievement level is nothing short of abysmally poor and even approaching a situation that invites accusations of fraud, given that we now know exactly how to reduce smoking prevalence by 50% or more and at zero cost to the taxpayer.

The proven efficacy of THR in Sweden shows that despite continuing tobacco or nicotine use, there will be no negative effect on public health but instead a dramatic fall in disease and death related to tobacco and smoking that eventually reaches the same proportion as the number of smokers who switch to ultra low risk products.

Money - or life?

This entire issue depends on one thing, and one thing alone:

Human life - or commercial and tax income

In actual fact the health issues are irrelevant, because all such policy decisions are governed by the financial pressures. This is especially true in the area of smoking, where a subgrouping of the population, smokers, are so hugely profitable for others that they can legally have their rights, their health and even their lives taken away, without recourse, for profit.

A situation hardly possible with any other group within society.


A memorable quote from Dr CV Phillips
Let's finish off with a pithy quote from Carl Phillips, the authority on the science behind THR:

"Three months of additional smoking poses a greater risk to someone’s health, on average, than a lifetime of using a low-risk alternative."

See: http://antithrlies.com

This demonstrates two things:

  • Argument about the benefits of switching is fairly pointless
  • There is no time to waste, for an individual making the decision to switch




________________________________
Notes

[1] Reducing the amount smoked or modifying the product smoked in some way is not THR: it is a marginal reduction in risk that avoids THR. The principal aim of THR is to remove the smoke by use of alternative consumer products.

[2] Swedish Snus consumption in Sweden has no measurable risk for mouth cancer - see the work of Profs B Rodu and PN Lee for the numbers, and CV Phillips for the background.

[3] Lifetime nicotine consumption has no clinical significance. There is no published research that reports nicotine consumption has demonstrated harms for humans on average. Nicotine has no association with cancer or heart disease, and is not contra-indicated except in exceptional circumstances. (Obviously: without smoke, and without low-quality ST.)

[4] According to Prof Rodu, the principal risks for oropharyngeal cancers ('mouth cancer') are smoking, drinking alcohol in excess, and HIV (oral sex with an infected partner) - and especially a combination of them. Any risk from Snus and other high-quality STs including modern American products is invisible in comparison.
(Rodu is a pathologist specialising in the oral pathology of tobacco consumption, and the leading authority on tobacco and mouth cancer.)

[5] Male smoking prevalence in Sweden: 2003, 17%; 2012, 8%.

[6] Anyone can find 5,000 options almost instantly, with a few minutes' research. About 50,000 options can easily be found with less than an hour's research. It is actually hard to find as few as 5,000 options and you have to limit your research to a few minutes in order to keep to such a low figure: 5 battery holder options x 5 head unit options x 2 e-liquid base types x 5 strengths x 20 flavours = 5,000. Keep in mind there are vendors with 7,000 separate refill liquid options (200+ flavours), before you get to hardware choices. Regulation removes virtually all options and is designed to cripple the system in order to protect existing revenues.

[7] Reference page: Coffee, 1.

[8] There is no published clinical trial of nicotine. That is to say, no clinical trial can be located that involved the administration of pure nicotine to never-smokers for the purpose of examining dependence issues - despite the huge interest in this area. This inevitably leads to certain conclusions. We already know the factual implications to health of ad lib nicotine consumption in tobacco, without smoke, over many decades, by a large and isolated population (Swedish males): it is clinically insignificant. It would be useful to add a study or two looking at consumer pure nicotine consumption over decades, and this will be possible once e-cigarettes have been used for long enough. We already know the results, of course, by extrapolation from the Snus data: on average the health implications are insignificant.

[9] It should be stated, for a complete view, that Carl Phillips' opinion is that this may not be a rule, since it may have no rule-like properties and is just an empirical fact. He says that education can reduce smoking prevalence to around 25%, then tax rises on cigarettes get the figure down to 20% or so. After that, substitution is the only significantly successful route.

[10] Statements such as, "Most e-cigarette users are smokers / are no longer smokers", are inaccurate. This is because most new e-cigarette users will be dual-users for a time, and most long-term ecig users will be non-smokers. Therefore any statement regarding smoking status has to be qualified with some sort of time reference. It is correct to say: "Few long-term e-cigarette users are still smokers, though most new users are".

[11] UK tobacco sales @2011/12 = £14bn; tax = £12bn; tobacco industry takes £2bn; government takes £12bn; cost to government of treating sick smokers = £3bn; government savings from smokers dying early = ~£10bn (£7.5bn pensions, £2.5bn other savings such as NHS, care homes, social support); government net income therefore = £19bn. This makes government a 90% stakeholder in tobacco sales.

[12] Smoking drives a tremendous boost to many other drug sales, for example in the areas of diabetes, cholesterol and blood pressure. As an example, a smoker has a 44% greater chance on average of being a diabetic, and this rises to over 60% for a >1 PAD smoker.


 


What the experts say about THR

Please google for the published work of these experts on Tobacco Harm Reduction issues. There are innumerable examples of their work in the medical literature, and in court documents, national and State committee records, and conference presentations. A useful collection of quotes is here.

Dr CV Phillips is a public health scientist, an epidemiologist and economist with a speciality in tobacco-related issues, and a leading authority on the evidence base for Tobacco Harm Reduction. His work provides the basis for many of the statements we can make about THR today. For many years he has supported the use of smokeless tobacco (such as Snus) as a substitute for smoking, and advocates for smoking replacement by e-cigarettes. As the acknowledged expert in this area he is well able to refute much of the anti-THR propaganda published by commercial interests. He is renowned for regularly naming specific colleagues as liars, such persons having made deliberately inaccurate or misleading statements about the risks of THR products such as Snus and e-cigarettes. He has never been sued for libel, slander or defamation, probably because the science is entirely on his side and it would be impossible for the named offenders to prevail in court, no matter how much money they (or more usually their pharmaceutical industry funders) could throw at it.

Prof Brad Rodu is a Professor of Medicine at Louisville, Kentucky and a specialist in Oral Pathology. He is regarded as the leading authority on the oral pathology of tobacco consumption. He was one of the originators of THR, and says that smoking (plus drinking and the growing threat from HPV infection) has a much greater risk for oral cancer than modern oral tobaccos; and that the risk of Swedish Snus consumption is not just insignificant compared to smoking but so low as to be hard to determine. He supports a population-level move to e-cigarettes.

Prof G Stimson is a public health veteran with forty years of Harm Reduction experience, and was one of its original architects. He strongly supports e-cigarettes as a replacement for smoking.

Bill Godshall of Smokefree Pennsylvania is the world's foremost campaigner against smoking harm, and is an expert on tobacco-related legislation in the USA. His fight against the cigarette companies has lasted for decades, is legendary, and is without equal. His vital contributions to committee hearings concerning cigarette companies are almost without number, and he has had considerable influence on tobacco-related law in the USA. Above all else he is regarded as an honest and reliable spokesperson for the anti-smoking harm movement. He is a firm supporter of e-cigarettes, is frequently found on the community ecig forums, and even visits the large vaping events such as Vapefest in order to show support. (Vaping is a term popular within the e-cigarette community as a description for ecig use since it is not smoking or inhalation of smoke, but inhalation of vapour.) He has strongly stated that those who support measures to reduce smoking and reduce the harm from smoking must by definition support THR, and that those who do not do so are not working for public health.

Clive Bates is an ex-Director of ASH UK, the anti-smoking pressure group. He is a firm supporter of e-cigarettes and has probably helped to influence current policy at ASH UK, where their first 2013 position paper on THR issues, published on 14th January 2013, came out with strong support for e-cigarettes. He is an expert on UK and EU regulatory processes. His current work strongly recommends e-cigarettes.

Prof Michael Siegel is a professor of public health and tobacco control advocate whose testimony was used in the landmark case against the cigarette industry that achieved $145bn in damages. He is a long-term member of tobacco control. An authority on tobacco and public health, he fully supports e-cigarettes as a smoking replacement.

Prof Peter Lee of Sutton, London is a medical statistician, regarded as the leading authority on the statistical analysis of tobacco-related morbidity and mortality. His work and that of colleagues, as for example PN Lee or Lee and Hamling, is available in the literature. He has carried out giant-scale meta-analyses of the large volume of Snus clinical studies, in which he reports that there is no statistically-measurable evidence of any elevation of risk for any disease for a Snus consumer over that of a non-smoker, and that health outcomes for smokers who switch to Snus or who totally quit can be demonstrated statistically to be the same; meaning that consumption of Swedish Snus in Sweden has no statistically-identifiable impact on health and is of no clinical significance.

 

 


created 2013-06-21
last update 2015-10-09